Pain when pooping: fissures vs. hemorrhoids vs. proctitis

Pain during bowel movements ("pain when pooping") is common and can arise from several anorectal conditions. Three frequent causes are anal fissures, hemorrhoids, and proctitis. Knowing the key differences helps you recognize warning signs, seek appropriate care, and ease discomfort. If you experience chronic or recurring bowel pain accompanied by changes in bowel habits, you might consider using a free AI symptom checker for Irritable Bowel Syndrome (IBS) to help identify potential underlying conditions.

Anal fissures

An anal fissure is a small tear in the lining of the anus.

Causes

• Passing hard or large stools
• Chronic diarrhea
• High anal sphincter pressure reducing blood flow to the anoderm (Schouten et al. 1994)

Symptoms

• Sharp, severe pain during and after defecation
• Bright red blood on toilet paper or stool surface
• A visible "crack" or skin tag near the anus

What happens?

• Increased resting anal pressure injures the anoderm and impairs blood flow.
• Reduced blood flow delays healing, leading to a chronic fissure.

Diagnosis

• Physical exam: gentle inspection of the anal margin, often with a slight spreading of the buttocks.
• Digital rectal exam is avoided if pain is intense.

Treatment

• Stool softeners and high-fiber diet to prevent straining.
• Warm sitz baths (10–15 minutes, 2–3 times daily) to relax the sphincter.
• Topical nitrates or calcium-channel blockers to lower sphincter pressure.
• Botulinum toxin injections or lateral internal sphincterotomy for chronic fissures.

Hemorrhoids

Hemorrhoids are swollen veins in the anal canal or around the anus.

Prevalence

• Affects about 39%–45% of adults (Riss et al. 2012).

Types

• Internal: above the dentate line, usually painless but can bleed.
• External: below the dentate line, can be painful, thrombosed, or itchy.

Causes

• Straining during bowel movements
• Chronic constipation or diarrhea
• Pregnancy and childbirth
• Prolonged sitting

Symptoms

• Internal hemorrhoids: painless bright red bleeding, a feeling of fullness.
• External hemorrhoids: sharp pain when thrombosed, perianal swelling, itching.
• Mucus discharge or soiling.

Diagnosis

• Anoscopy to visualize internal hemorrhoids.
• Physical exam for external hemorrhoids or thrombosis.

Treatment

• Dietary changes: increase fiber and fluid intake.
• Topical creams or suppositories containing hydrocortisone or lidocaine.
• Warm sitz baths to reduce swelling and discomfort.
• Rubber band ligation or infrared coagulation for persistent internal hemorrhoids.
• Surgical hemorrhoidectomy for large or unresponsive hemorrhoids.

Proctitis

Proctitis is inflammation of the rectal lining.

Causes

• Infectious: sexually transmitted infections (e.g., gonorrhea, chlamydia, herpes).
• Inflammatory bowel disease (ulcerative colitis, Crohn's disease).
• Radiation therapy to the pelvis (Marks & Farnell 2005).

Radiation-induced proctitis

• Acute: occurs weeks after radiation, with mucosal inflammation and diarrhea.
• Chronic: months to years later, with fibrosis, ulceration, telangiectasias.

Symptoms

• A constant urge to have a bowel movement (tenesmus).
• Rectal pain during and between defecation.
• Bleeding, mucus discharge, cramping.
• Possible fever if infectious.

Diagnosis

• Anoscopy or sigmoidoscopy: reveals inflamed, friable mucosa.
• Stool studies and swabs if infection is suspected.
• Biopsy for chronic or unclear cases.

Treatment

• Infectious proctitis: targeted antibiotics or antivirals.
• IBD-related proctitis: mesalamine suppositories, steroids, immunomodulators.
• Radiation proctitis: sucralfate enemas, formalin application for bleeding telangiectasias, hyperbaric oxygen.
• Pain control with topical analgesics.

Key differences at a glance

Feature	Anal Fissure	Hemorrhoids	Proctitis
Pain	Sharp, tearing with BM	Usually painless (internal); acute, severe (external thrombosis)	Burning, constant ache; urgency
Bleeding	Bright red, scant	Bright red, may drip	Can be mixed with mucus, variable
Itching/discharge	Rare	Common (mucus, soiling)	Mucus, possible pus
Visual exam	Tear in anoderm, sentinel tag	Bulging veins, bluish lumps	Inflamed mucosa, ulcers, telangiectasias
Onset	Linked to hard stools/strain	Gradual, worsened by strain	May follow infection, radiation

When to seek medical attention

Although many cases improve with home care, immediate medical attention is needed if you experience:

• Severe rectal bleeding (soaking pads or pooling blood)
• Unintentional weight loss or fever
• Signs of infection: redness, warmth, pus, high fever
• Inability to pass stool despite urge
• New or worsening pain that disrupts daily life

Always speak to a doctor about any concerning or persistent symptoms.

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Pain when pooping can usually be managed with dietary changes, sitz baths, topical treatments, and lifestyle adjustments. However, proper diagnosis ensures targeted therapy and prevents complications. If you're experiencing ongoing symptoms like abdominal discomfort, bloating, or changes in bowel patterns alongside your pain, try the free AI Irritable Bowel Syndrome (IBS) symptom checker to better understand what might be causing your symptoms, or speak to your healthcare provider for personalized advice. If you notice any life-threatening signs—such as heavy bleeding, high fever, or severe unrelenting pain—seek urgent medical care.