What causes sharp and sudden rectal pain that lasts seconds?

Sharp, Sudden Rectal Pain Lasting Seconds

This is most likely proctalgia fugax, a benign condition characterized by sudden, severe rectal pain lasting seconds to minutes that requires no treatment beyond reassurance. 1, 2, 3

Clinical Diagnosis

The diagnosis of proctalgia fugax is made when the following features are present:

• Episodic, sudden, sharp pain in the anorectal area lasting several seconds to several minutes 2, 3
• Pain occurs irregularly by day or night with no predictable pattern 2
• Completely normal physical examination including digital rectal examination 3
• No fever, bleeding, or visible external findings which would suggest other pathology 1

The pain results from dysfunction of the internal anal sphincter, though the exact mechanism remains unclear 2.

Critical Red Flags to Exclude

You must urgently evaluate for serious conditions if any of the following are present:

• Fever suggests anorectal abscess, which presents with throbbing (not sharp) pain, fever, and tenderness on digital rectal examination 4, 1, 5
• Persistent pain (not episodic) indicates possible abscess, fissure, or other structural pathology 1
• Visible swelling suggests thrombosed hemorrhoid or abscess requiring examination 1
• Bleeding makes anal fissure or hemorrhoids more likely than proctalgia fugax 1

Key Distinguishing Features from Other Conditions

Anal Fissure

• Causes sharp, tearing pain specifically during and immediately after defecation, not isolated spontaneous episodes 6, 5
• Pain pattern is predictable and related to bowel movements 4

Thrombosed Hemorrhoids

• Present with visible thrombosed tissue on external examination 6
• Cause constant discomfort rather than brief episodes 4
• No fever present 4

Anorectal Abscess

• Produces throbbing pain (not sharp, brief episodes) 5
• Associated with fever and tenderness on digital rectal examination 5
• Pain is persistent, not episodic 4

Levator Spasm

• Causes chronic, cramping rectal pain rather than brief, sharp episodes 6
• No fever, swelling, or tenderness on examination 6

Management Approach

Reassurance is the most useful therapeutic option once the diagnosis is established 3.

• No expensive imaging (CT, MRI) is required when the clinical picture is classic 2
• No laboratory testing is needed in the absence of red flags 2

If Attacks Are Frequent and Severe

• Consider trial of calcium channel blocker such as nifedipine if episodes are numerous and significantly impact quality of life 2
• This addresses the internal anal sphincter dysfunction underlying the condition 2

When to Pursue Further Evaluation

Obtain imaging (MRI or CT) only if:

• Diagnosis remains uncertain after history and examination 6
• Atypical presentations that don't fit classic proctalgia fugax 6
• Concern for deeper pathology such as intersphincteric or supralevator abscess 5
• Suspicion of inflammatory bowel disease or malignancy based on patient history 4

The key clinical pitfall is failing to recognize this benign condition and subjecting patients to unnecessary invasive testing. The uniform clinical picture—sudden, brief, severe rectal pain with completely normal examination—makes diagnosis straightforward once you're familiar with the entity 2, 3.