Rectal Pain in a Runner

The following is an an unedited question received via Runner Triathlete News. The question, and response, appeared in the June 1998 issue of this magazine.

Question:

I read the info on Pelvic rotation, etc. and thought it might relate to me, so I'm writing with a bit of information on myself.

I am a female 64 years old and have been running 30 years with little or no injuries. I do compete and run short races and half-marathons. Last October I began having a little discomfort in the rectal area and went to my physician where he said I had a fecal impaction (probably from dehydration). I followed his instructions and on return visit I was ok.

But the problem continued and a barium enema and proctoscope was (sic) ordered and both were negative. Spastic colon was his diagnosis; later went on to gastroenterologist who suggested I stop running for two to three months, which I did. Discomfort semed to be gone until I played a little raquetball and problem came back, only with an ache in sacroiliac and sacral area.

Finally went to physcal therapy and now am in my sixth week -- seems to be helping but everytime I do a little something strenuous the problem pops up. And sometimes it is only after a bowel movement.

1. Why should it take so long to heal?

2. Why does it seem to be better but when trying to run or something it comes back?

3. Does it sound like I'm doing the right thing or should I have an MRI?

4. Have you ever heard of such a condition? I have been to two doctors and a couple of sports injury clinics and no one has actually given me a good diagnosis, so I guess I'm really frustrated.

Answer:

I can certainly understand how frustrating this must be for you. The best way to approach the problem of rectal pain in a runner is to divide it into two main possibilities; musculoskeletal, and non-musculoskeletal. In the former, I am of course referring to conditions directly related to bones, joints, spine, ligaments, and muscles used in exercise.The latter encompasses conditions related to the organs, smooth muscle, nerves, etc...

In the musculoskeletal group, problems in the lower part of the spine, the sacrum and coccyx (tailbone), may give rise to pain in the rectal area. These conditions can be identified on physical exam and with radiographic studies, such as x-ray and MRI. Sometimes, deeper hip/pelvis muscles, such as the piriformis, can lead to pain in this region as well. An assessment of strength, and range of motion of the hip (e.g., external and internal rotators) may assist in diagnosis.

The non-musculoskeletal group accounts for most people with rectal pain. The smooth muscles (non-exercise muscles) which make up the pelvic floor, can become weaker with age. Weakness in these muscles means that organs in the pelvis may press downward and cause pain. Conditions involving the pelvic floor muscles are more common in women -- especially in post-menopausal women and in women who have several children -- and in people who have had previous abdominal or pelvic surgery. One consideration is a partial prolapse of the rectum, in which a small part of the interior surface of the rectum is transiently pushed out. This would occur in circumstances of increased intra-abdominal pressure, such as having a bowel movement or exercise. This can be identified by having the physician examine the area during straining.
The irritable bowel syndrome is a poorly understood phenomenon in which patients experience alternating bouts of constipation and diarrhea, and lower abdominal pain. Rectal pain can also occur in this condition. Running is a well described stimulus for a variety of gastrointestinal complaints, including diarrhea, abdominal cramping, and tenesmus (rectal pain and urge to defecate). Some patients with rectal pain are thought to have spasm of the muscles around the anus. This may be due to an obvious cause such as hemorrhoids or an anal fissure. Sometimes there is no obvious cause and the condition may result from irritation of the nerves which go to the rectal area. Other conditions of the rectum deserve mention. Ulcerative colitis, cancer, and infections can all present as rectal pain. The evaluation that you have had to this point should have identified these more serious diseases. Finally, in some patients no definitive cause for the pain can be found. Biofeedback and other techniques may be beneficial in relieving pain in these patients.

If you have not already done so, it would be a good idea to have a gynecologic examination. This would help identify any disease of the pelvic organs and could determine if there is weakness of the pelvic floor muscles. I wish you the best in finding the cause of your pain, and the cure, so you can get back to the activities which you clearly enjoy.

Mark A. Jenkins, MD

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