Anal pain may occur in the anus or rectum during defecation, sitting or walking. In severe cases it may be accompanied by local swelling with a feeling of heat, bleeding, or even difficulty in defecation, difficulty in sitting and lying down or an uncomfortable feeling when walking. According to TCM theory, the anus is the place where the Directing and Governing Vessels meet, and it is the exit of the Large Intestine. Tlierefore a painful anus can be caused by disorders in one of these Vessels or by disorders of the Large Intestine, including accumulation of Toxic Heat or of Damp-Heat in the Large Intestine, as well as deficiency or stagnation of Qi and Blood. Anal pain may be attributed to any of the following disorders in Western medicine: haemorrhoids, anusitis, fissure in ano, anal fistula, perianal abscess, anal prolapse and rectum carcinoma.
Aetiology and pathology
Accumulation of Toxic Heat in the Large Intestine
Overconsumption of spicy, pungent or sweet foods or alcohol may cause internal Heat to form in the Large Intestine and may gradually damage it. Furthermore, overeating may cause accumulation and stagnation of food in the Middle Burner, which obstructs the circulation of Qi in the Large Intestine. In the long run this causes anal pain.
Accumulation of Damp-Heat in the Large Intestine
Drinking too much alcohol or eating too many pungent, sweet, fat or greasy foods may damage the Stomach and Spleen’s function of transportation and transformation, and result in the formation of Damp-Heat. Damp has the characteristic of downward flow, so when Damp combines with Heat, it may flow downwards to the Lower Burner, damaging the Large Intestine so that anal pain occurs. Accumulation of Damp-Heat in the Lower Burner can also cause stagnation of Qi, so that its movement in the Large Intestine slows or even stops, and anal pain follows.
Constitutional Qi deficiency of Spleen may also cause internal Damp to accumulate so that the Qi stagnates, and this causes the generation of internal Heat.
Stagnation and deficiency of Qi and Blood
Prolonged sitting or walking, a disharmony of Cold and Warmth, accumulation of Damp in the Lower Burner, excessive stress, anger and frustration and lack of sufficient movement may all cause a slowing down or a stagnation of Qi in the Large Intestine, resulting in anal pain.
Since the Qi guides the Blood, if Qi stagnation persists it may in turn influence the circulation of the Blood, leading to stagnation of Blood in the Large Intestine and causing anal pain. Furthermore, physical trauma or an inappropriate operation on the anus may directly damage the channels and muscles in this area, bringing about a local stagnation of Qi and Blood, and causing anal pain.
A deficiency of Qi and Blood can also cause anal pain. Excessive physical work or walking for long distances with a heavy pack consumes the Spleen-Qi. When the Qi is not sufficient to produce the Blood, this results in a deficiency of the Blood. Sexual hyperactivity, giving birth to several children and prolonged sickness may all cause consumption of Kidney-Essence, which indirectly leads to deficiency of Qi and Blood. Sinking of the Spleen-Qi may also cause a prolapse of the anus and pain in the anal region.
Treatment based on differentiation
Differentiation
Differentiation of acute and chronic anal pain
Generally speaking, anal pain is classified into acute type and chronic type.
— The acute cases are often related to invasion of Toxic Heat or Damp-Heat.
— The chronic cases are often due to stagnation of Qi and Blood, or deficiency of Qi and Blood resulting from chronic sickness.
Differentiation of character of the pain
— Acute anal pain with a burning or pricking sensation, constipation, blood in the stool, pyogenic anus, fever, or aversion to cold, is often caused by invasion of Toxic Heat to the Large Intestine.
— Acute or chronic anal pain with a burning and itching sensation, swelling and redness of the anus, tenesmus, or loose stools with a foul smell, is usually caused by accumulation of Damp-Heat in the Large Intestine.
— Chronic anal pain with a stabbing feeling, aggravation of the anal pain by pressure, stools with purplish blood, a history of operation or trauma in the anus, is usually caused by stagnation of Blood in the anus.
— Chronic anal pain with a bearing-down sensation in the anus, anal prolapse, lassitude, a pale complexion, cold hands and feet, or shortness of breath, is often caused by deficiency of Qi and Blood.
Treatment
ACCUMULATION OF TOXIC HEAT IN THE LARGE INTESTINE
Symptoms and signs
Pain in the anus with a burning or pricking sensation, which worsens during defecation, with blood in the stools, pyogenic anus, fever, an aversion to cold, a thirst, dark yellow urine, constipation, a red tongue with a sticky and yellow coating and a slippery and rapid pulse.
Principle of treatment
Clear Heat, eliminate Toxin and relieve the pain.
HERBAL TREATMENT
Prescription
XIAN FANG HUO MING YIN
Sublime Formula for Sustaining Life Bai Zhi Radix Angelicae Dahuricae 3 g Bei Mu Bulbus Fritillariae Thungergii 3 g Fang Feng Radix Ledebouriellae 3 g Chi Shao Radix Paeoniae Rubra 3 g Ήβη Hua Fen Radix Trichosanthis 3 g Ru Xiang Resina Olibani 3 g Dang Gui Radix Angelicae Sinensis 3 g Jin Yin Hua Flos Lonieerae 9 g Gan Cao Radix Glycyrrhizae 3 g Zao Jiao Ci Spina Gleditsiae 3 g Chuan Shan Jia Squama Manitis 3 g Ju Pi Pericarpium Citri Reticulatae 9 g Mo Yao Resina Myrrhae 3 g
Explanations
9 Jin Yin Hua and Gan Cao clear Heat and remove Toxin.
• Dang Gui, Mo Yao, Ru Xiang and Chi Shao invigorate the circulation of Blood and resolve stagnation in order to reduce swelling and to stop pain.
9 Chuan Shan Jia and Zao Jiao Ci promote the circulation of Blood and eliminate pus.
• Fang Feng and Bai Zhi remove Qi stagnation and expel Intestinal Wind.
• Bei Mu and Tian Hua Fen clear Heat and resolve swelling caused by Toxin.
• Ju Pi regulates the circulation of Qi.
Modifications
1. If there is a fever, add Lian Qiao Frudus Forsythiae 10 g, Pu Gong Ying Herba Taraxad 10 g and Jing Jie Hcrba Schizonepetae 10 g to clear Heat and to reduce the fever.
2. If there is constipation, add Da Huang Radix et Rhizoma Rhei 6 g and Mang Xiao Nutrii Sulfas IOg to eliminate Heat and to promote defecation.
3. If there is blood in the stools, add Bai Tou Weng Radix Pulsatillae 10 g, Sheng Di Huang Radix Rehmanniae Recens 10 g to cool the Blood and to stop the bleeding.
Patent remedy
Huang Lian Su Pian Coptis Extract Tablet
ACUPUNCTURE TREATMENT
GV-I Changqiang, BL-25 Tianzhu, BL-30 Baihuanshu, SP-9 Sanyinjiao, LI-2 Erjian and Ll-4 Hegu. Reducing method is used on these points.
Explanations
• GV-I, the Connecting point of the Governing Vessel, harmonises the collateral and relieves the anal pain.
• BL-25, the Back Transporting point of the Large Intestine, clears Toxic Heat in the Large Intestine and promotes defecation.
• BL-30 regulates the circulation of Qi in the Lower Burner and relieves the anal pain.
• SP-9, the Sea point of the Spleen channel, clears Heat and relieves the anal pain.
• LI-2, the Spring point of the Large Intestine channel, and LI-4, the Source point, remove toxic Heat in the Large Intestine, promote defecation and relieve the anal pain.
Modifications
I. If there is a fever, add GV-14, the meeting point for all the Yang channels, and LI-11, the Sea point of the Large Intestine channel, to clear Heat and reduce the fever.
2. If there is anal soreness and swelling, add SP-6 and LI-6 to relieve the soreness and reduce the swelling.
3. If there is constipation, add ST-37, the Lower Sea point of the Large Intestine, to clear Heat in the Large Intestine and promote defecation.
4. If there is blood in the stools, add BL-40 and BL-57 to clear Heat in the Large Intestine and stop the bleeding.
Case history
A 45-year-old man had been suffering from anal pain for 5 days. He complained that he always had a painful anus after eating hot foods such as peppers. Sometimes there was fresh blood in his stools when he strained during defecation. A previous diagnosis of ‘fissure in ano’ had been made. Besides anal pain, he had a bitter taste in the mouth, constipation, irritability and yellow urine, a red tongue with a dry yellow coating and a rapid pulse.
Diagnosis
Accumulation of toxic Heat in the Large Intestine and hyperactivity of Liver-Fire.
Principle of treatment
Clear Toxic Heat and relieve the pain.
Herbal treatment
XIAN FANG HUO MING YIN (modified)
Subirne Formula for Sustaining Life (modified)
Bai Zhi Radix Angelicae Dahuricae 3 g
Fang Feng Radix Ledebouriellae 3 g
Chi Shao Radix Paeoniae Rubra 3 g
Tian Hua Fen Radix Trichosanthis 3 g
Dang Gui Radix Angelicae Sinensis 3 g
Jin Vln Hua Flos Lonicerae 9 g
Gan Cao Radix Glycyrrhizae 6 g
Zao Jiao Ci Spina Gleditsiae 3 g
Ju Pi Pericarpium Citri Reticulatae 9 g
Zhi Zi Fructus Gardeniae IOg
Explanations
• Jin Yin Hua, Zhi Zi and Gan Cao clear Heat in the Large Intestine, reduce Liver-Fire and remove Toxin.
• Dang Gui and Chi Shao invigorate the circulation of Blood and resolve stagnation in order to reduce the swelling and stop the pain.
• Zao Jiao Ci promotes the circulation of Blood.
• Fang Feng and Bai Zhi remove Qi stagnation and relieve Intestinal Wind.
• Tian Hua Fen clears Heat and reduces swelling.
• Ju Pi regulates the circulation of Qi.
The patient took this herbal prescription daily. After 6 days his anal pain was under control. Upon follow-up 6 months later, he reported being free of the pain since the treatment.
ACCUMULATION OF DAMP-HEAT IN THE LARGE INTESTINE
Symptoms and signs
Biting pain in the anus with a burning sensation, which worsens during defecation, with oozing, swelling and redness of the anus, dark yellow urine, yellow leucorrhoea, constipation with tenesmus, itching in the anus, a sticky and yellow tongue coating and a slippery and rapid pulse.
Principle of treatment
Eliminate Damp and clear Heat.
HERBAL TREATMENT
Prescription
QIN JIAO FANG FENG TANG
Chin-Chia and Siler Decoction
Qin Jiao Radix Gentianae Macrophyllae 12 g
Fang Feng Radix Ledebouriellae 12 g
Dang Gui Radix Angelicae Sinensis 12 g
Chuang Xiong Radix Ligustici Chuangxiong 9 g
Sheng Di Huang Radix Rehmanniae Recens 12 g
Bai Shao Radix Paeoniae Alba 10 g
Fu Ling Poria 12 g
Lian Qiao Fructus Forsythiae 10 g
Di Yu Radix Sanguisorbae 12 g
Zhi Qiao Fructus Aurantii 12 g
Huai Jiao Fructus Sophorae 10 g
Bai Zhi Radix Angelicae Dahuricae 9 g
Cang Zhu Rhizoma Atractylodis 12 g
Gan Cao Radix Glycyrrhizae 6 g
Explanations
• Qin Jiao, Fang Feng and Bai Zhi expel intestinal Wind and eliminate Damp in the Large Intestine.
• Dang Gui and Chuan Xiong remove Blood stagnation and relieve the pain.
• Sheng Di Huang, Lian Qiao, Huai Jiao and Di Yu clear Heat and cool the Blood.
• Fu Ling and Cang Zhu strengthen the Spleen and eliminate Damp.
• Zhi Qiao regulates the circulation of Qi and removes the Qi stagnation.
• Bai Shao and Gan Cao relieve spasm in the Large Intestine and stop the anal pain.
Modifications
I. If there is constipation, add Da Huang Radix et Rhizoma Rhei 6 g and Mang Xiao Natrii Sulfas 10 g to eliminate Heat and promote defecation.
2. If there is itching in the anus, use a warm lotion obtained from Huang Bai Cortex Phellodendri 10 g, Ku Shen Radix Sophorae Flavescentis 10 g and She Chuang Zi Fructus Cnidii 10 g to wash the anus in order to clear Heat, remove Damp and relieve the itching.
3. If there is swelling and redness of anus, add Jin Ym Hua Flos Lonicerae 10 g, Lian Qiao Fructus Forsythiac 10 g and Xuan Shen Radix Scrophulariae 10 g to clear Heat and remove Toxin as well as relieve the swelling.
Patent remedies
Huang Lian Su Pian Coptis Extract Tablet San Miao Wan Three-Marvel Pill
