Pain in a, ah, sensitive place
March 15, 2016 6:35 PM   Subscribe

My father has overwhelming, debilitating, excruciating rectal pain that seems to be getting worse. Nobody seems to know what to do. More inside.

This is going to be blunt and TMI. Don't read if you don't like detailed descriptions of pooping.

It started with a, ah, difficult bowel movement. He deals with chronic constipation from a surgery he had a few years ago, and this particular bowel movement got stuck in his rectum. So he used a tissue to pull it out. This was probably six weeks ago, maybe more. Cue problem.

Since then he's had terrible pain. It started out as quite painful but also something that was largely just an annoyance. He thought it was a hemorrhoid. He'd go, have pain for a while, then recover. He could still do things. He shoveled the driveway during a snowstorm. He had pain afterward, but he was still able to do it. But since then it's gotten steadily worse, to the point where he could barely walk around without setting off excruciating pain that left him lying on the ground, hyperventilating. It lasted for hours after a bowel movement. He saw a colorectal surgeon, expecting to have hemorrhoid surgery. But they didn't find anything on examination, so two weeks later they did a sigmoidoscopy, where they found a "small" fissure in his rectum. In those two weeks it got so bad that he ended up in the ER, where they found nothing noteworthy.

To note: he got a nerve blocker during the procedure and he was still having pain. They also gave him two shots of botox.

After the procedure the pain exploded. He was up at 2am the next morning crying because it was so severe. The colorectal surgeon refuses to see him before eight weeks after the procedure, saying they won't know if the botox worked until then. She told him to take oxycodone in that time and go to the hospital if it gets too severe. (Thanks, asshole.)

He has a doctor he sees for chronic pain, who was baffled and gave him a muscle relaxer (or antispasmodic? Not sure which one it is) because he thinks he's having spasms after a bowel movement. This is consistent with what I understand about fissures. But THIS bad? He's screaming. He's hyperventilating. I'm afraid he's going to pass out.

He's taking MANY fiber supplements; consul and a lot of miralax and he's eating bran cereal and extra fruit and generally a TON of fiber. When his BMs are soft, it's better but still there.

Right now he's also taking: vicodin, oxycodone, and a muscle relaxer. He's also doing sitz baths and using heat when he can. The muscle relaxer helped, but he's been having bizarre side effects, so he switched. It made the attacks of pain shorter. However, it's still so bad that he can barely walk. Brushing his teeth sets off the excruciating pain. Sometimes he can barely make it up the stairs.

The first muscle relaxer was making him feel agitated, so he switched, and today he took none. He's also trying to slow it down with the oxy (5mg, 6-8 a day). The pain was SO BAD just now, five hours after a BM, he was SCREAMING louder than I've ever heard him scream. My mother called the doctor. I don't think they're doing an adequate job communicating the severity of this to the various doctors, but anyway.

Here's the thing. He sees a pain doctor already for a bad back. The pain doctor is confused as to how a fissure could be THIS debilitating. His GP is baffled. The colorectal surgeon is largely absent, and it's getting worse. He had the clean colonoscopy a few months ago.

YANMD, etc.

What would you do?
posted by Amy93 to Health & Fitness (23 answers total)
I'd see a neurologist, because they usually deal a lot in pain and will recognize weird signs like him standing in a slightly strange way. I mean, it could be anything and he'll have to fire that surgeon no matter what. But that's where I'd start. The GP's office should be able to help get an earlier appointment.

Also, in my experience neurologists love challenges and know lots of people in other specialties. It sounds like the surgeon is deeply uncurious, which is bad when your problem isn't obvious.
posted by SMPA at 6:44 PM on March 15, 2016 [5 favorites]

Hospital. If his doctors won't address the literal screaming pain, he needs the ER. I know he's been already, but he needs relief NOW.
posted by Ruki at 7:09 PM on March 15, 2016 [8 favorites]

I have no advice but I read this article yesterday about a man's unexplainable (but then explained) pain.
posted by Thella at 7:09 PM on March 15, 2016 [1 favorite]

Just a data point in case you aren't aware: one of the common side effects of opioid analgesics is constipation.
posted by googly at 7:11 PM on March 15, 2016 [10 favorites]

Doesn't sound like this could get any worse. Could either of his doctors order pelvic floor physical therapy for him? He may need to see a MD who specializes in rehab medicine.

baclofen (muscle relaxer) suppositories are a thing too, hopefully that would lessen side effects.
posted by txtwinkletoes at 7:23 PM on March 15, 2016 [1 favorite]

Screaming pain is unacceptable. Call his GP and every other person involved in his care! he needs to be seen What if the fissure leaked bowel into his system, blood? Who would take care of that? Something is wrong. Someone needs to see him and figure this out properly. Gastroenterologist?
posted by Riverine at 7:30 PM on March 15, 2016 [1 favorite]

I think it is hospital time.
posted by Riverine at 7:31 PM on March 15, 2016

It could be so many things. Diverticulitis? Fistula?Maybe a gastroenterologist should be the next step. Send the results of the sigmoidoscopy. If youre dealing with diverticulitis it may have occurred past the sigmoid colon (although that is rare) and further tests might be necessary.

Also your dad may not be taking the right kind of fiber for his constipation. All the bulk forming fiber may be making the situation worse. If he has hard stools with the fiber supplements something is off. I would tell the gastro about his vicodin, oxy use,plus all the fiber supplements he is taking. All the opiods increase constipation. I dont know why that would prescribed for a constipated person with rectal pain, but Iam not a doctor.

I would take anti spasmodics, stool softeners, drink water, take magnesium supplements or drink an epsom salt solution, keep up fruit intake and exercise.
posted by charlielxxv at 7:33 PM on March 15, 2016 [5 favorites]

Screaming unrelenting pain is right up there with poking out bones and heart attack symptoms for great reasons to go to the ER. He's not overreacting by going. I hope he finds relief soon!

PS- too much fiber can really constipate. The hospital may suggest a stool softener instead.
posted by cecic at 7:37 PM on March 15, 2016 [1 favorite]

Response by poster: Quick update. The screaming pain stopped. No hospital. My father is stubborn and refuses to go to the hospital often. In his defense, we live in a city with a busy ER, so the wait times are absurd. Last time he was there for 10 hours. As an added data point, he took three oxycodone and still ended up in that pain.

The doctor on call called in a prescription for a numbing cream that also has an ointment-type thing in it. I've heard of it when I've read about anal fissures and it's a very common line of treatment; not sure why he's JUST getting this prescribed, but anyway.

I've tried talking to him about fiber, but he's wildly stubborn and won't listen. The fiber supplements simply don't work. The bran cereal is ridiculously high fiber (13g) so that helps.

The pain doctor told him to call GI so he's doing that tomorrow. Exercise would be great (when he's not screaming from rectal pain, he does yoga regularly) but he can barely move right now. I'm urging him to send a detailed note to his GP saying just how bad this is, but again, wildly stubborn.
posted by Amy93 at 7:46 PM on March 15, 2016

The vicodin and oxy are probably contributing to the problem. Painkillers of that level always cause severe constipation for me. Since they aren't helping anyway, he should drop them. I concur with the advice to see a GI.
posted by peanut_mcgillicuty at 8:00 PM on March 15, 2016 [2 favorites]

Response by poster: Ahhhhh hold on hold on. When I wrote this I was exhausted from listening to him. He is NOT taking Vicodin. He's ONLY taking oxy. Not sure where that came from. He's taking Tylenol with the oxy.

They do constipate, which has made it worse, but it's such a toss-up between dealing with the pain and dealing with the constipation risk.
posted by Amy93 at 8:03 PM on March 15, 2016

Does he realize that he's putting a ton of effort into trying to make his stools softer, then taking narcotics which are incredibly constipating? These two things are at odds with each other. On preview, what peanut_mcgillicuty is saying. And he's taking a lot of narcotics, and that's not a good thing for many reasons.

I agree with the topical cream. Narcotics are not the answer for this. And there is very little that can be done for this in the emergency department unless he has new or different symptoms. If he's already got Vicodin and oxycodone I sincerely hope no one is going to give him more or stronger drugs. In fact, I don't think whoever prescribed those meant for him to continue to take both.

The fact that he was still having pain despite having a nerve block could mean one of two things: 1. The nerve block failed to block the nerve 2. The pain isn't coming from the area covered by that nerve.

Seeing GI is a good idea. Surgeons are generally only interested in things they can do surgery on.
posted by treehorn+bunny at 8:05 PM on March 15, 2016 [9 favorites]

Has he had a CT scan? an MRI scan? If not, please insist on one or the other.
It is possible that this pain is generated from something in the pelvis and not it the colon and would not be seen by scoping at all.
posted by SLC Mom at 9:15 PM on March 15, 2016 [2 favorites]

Wow, sounds miserable! Poor dad! A topical cream with lidocaine in it sounds like a great idea, also there is a branch of pain medicine that is specific to nerve pain which this may be, gabapentin and lyrica are in that family. Also fiber supplements will only soften the stool if he's staying very well hydrated. A better road may be colace which is less bulking (still need to stay hydrated) and senna which is a laxative to help move the stool through which is what you need to combat the opiate (oxycodone) constipation. Fiber alone may be worsening the problem rather than helping. Good luck!
posted by eggkeeper at 10:32 PM on March 15, 2016

Holy fuck do anal fissures hurt. The nitroglycerin cream works but it takes a couple of weeks. Give the cream time.
posted by crazycanuck at 10:33 PM on March 15, 2016 [1 favorite]

The doctor who is giving him muscle relaxers may be on the right track. Your description of your father's pain made me think of Piriformus Syndrome. The page I linked to refers to a "dull ache in the buttocks", and then makes vague reference to nerve pain. Don't let that fool you; that nerve pain can be excruciating! I had to be taken to the hospital in an ambilance, and I was also screaming. Note that it can be caused by prolonged sitting - such as you might do on a toilet if you were constipated.

There are stretching exercises that can help. The one that works for me is sitting on a chair, and putting your left foot on your right knee, as if you were trying to assume the Lotus position. Then bend your torso gently towards your left knee while also pressing down on that knee with your hands. You'll feel stretching on the opposite side. Then reverse everything and do it again. You have to do this regularly to keep it from happening again.
posted by MexicanYenta at 12:34 AM on March 16, 2016 [1 favorite]

If he is in that much pain after taking the oxy and tylenol, then it could be that his pain management doctor has failed. It could be that he has developed a tolerance to the medication- the same medication that has caused his current poop problems. Can he try a different pain management therapy for his back?
posted by myselfasme at 6:38 AM on March 16, 2016

Could it be a severe case of Proctalgia Fugax? Since they've tried nerve blockers and botox I wonder if that's what they were attempting to fix.
posted by saladin at 6:50 AM on March 16, 2016 [2 favorites]

In the last year, I developed a fissure that sounds very similar. It felt like pooping glass shards, and then the pain stayed most of the day. It was really painful. After a lot of oat bran (3 tablespoons in a bowl of applesauce), the fissure healed. HOWEVER, months later it left behind an infection that turned into a pararectal abscess. That's the one that sent me to the ER in some of the worst pain I've ever experienced -- I've passed multiple kidney stones and they were a walk in the park compared the the abscess.

The ER doc sent me right to a surgeon who lanced and drained the abscess. I was back to normal in a few days!

Just my experience, but maybe it'll help.

My surgeon has this printed *right on the back of his business card*:
Oat Bran
3 Heaping Tablespoons Daily
-Mix into cereal, yogurt, applesauce or other soft foods
-For best results, do not heat or cook
-Remember to increase your intake of fluids
-Take oat bran every day for the rest of your life
posted by PSB at 7:43 AM on March 16, 2016 [3 favorites]

Please read this!!

hyperalgesia = can occur when on oxy/vicodin etc. for a length of time. This is a super increase to pain sensitivity. The body stops making its own pain killers.
This can be 'cured' by STOPPING the oxy/vicodin etc, completely, but it takes a bit of time. I had debilitating abdominal pain every morning until I had a bowel movement. (I cried too)
Perhaps you could read up on it or suggest it to the doc?
My doc was not familiar with it at first. It is horribly painful to just stub a toe. Mine went away and I was able to resume a lower dose of pain helpers for chronic spinal pain. Of course IANYD
posted by donaken at 3:14 PM on March 16, 2016

Could it be unrelated to his rectum, other than that he's feeling pain in that area? I had terrible pain -- not as bad as his! -- that I thought was a broken tailbone and was fixed with physical therapy. I remember describing it to my PT as "it feels like I a sat on a steak knife."
posted by The corpse in the library at 10:42 AM on March 17, 2016

Response by poster: Thanks for the replies. Didn't mark a best answer because they were all helpful.

His stool is soft. We've known for years that oxy causes constipation, but it's so severe he has no other choice right now. But... it's soft. And he's not taking THAT much. Going off the oxy is not an option right now. He's seeing GI tomorrow so maybe they'll have other ideas.

I'm starting to think a secondary infection is forming. The pain was AWFUL before, like end-up-in-the-ER awful, but now it's honestly worse. None of us knew it could get worse but it did. He can barely move. He can't walk around. He can't even walk down the steps without triggering it off. And now he thinks the area MAY be swollen. He didn't have an infection when he had the procedure two weeks ago, nor did he three weeks ago in the ER, but things change. It is so bad. I've never seen anything like this before.

We got information for a physical therapist who specializes in this area.

I'm at such a loss. I feel so helpless and watching a family member go through this is harder than I will ever be able to describe. It's at the point where he's not even talking that much anymore. It's horrible.

Anyway. Venting. Sorry. Thanks again for the replies.
posted by Amy93 at 8:50 PM on March 17, 2016

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