Excruciating Pain in Lower Body Leads to ER Visit
A 38-year-old female, weighing 165 pounds and standing 5 feet 8 inches, leads an active lifestyle and follows a vegetarian diet. She has been diagnosed with ADHD and underwent a surgery two years prior to replace a torn L5/S1 disc. In addition to using a copper IUD, her medication regimen includes Vyvanse, fluoxetine, trazodone for sleep, magnesium threonate as advised by her doctor, Claritin, and a multivitamin with omega-3s. While she has experienced general gastrointestinal issues throughout her life, none have been formally diagnosed as chronic. A persistent cough prompted her to consult two ear, nose, and throat specialists and undergo lung function tests, all of which yielded normal results. Post-surgery, she developed mild hemorrhoids and sought the opinion of a gastroenterologist regarding suspected acid reflux, wherein she tried doses of up to 80mg omeprazole without success. Following a colonoscopy and endoscopy in early 2025, the GI specialist confirmed small hemorrhoids, deeming them too minor for surgical intervention. Approximately two weeks ago, she observed blood on the toilet paper following a bowel movement characterized by mild constipation. This occurrence harks back to her surgery recovery phase, prompting her to use an over-the-counter hemorrhoidal suppository containing phenylephrine HCl. The insertion was surprisingly painful compared to her previous experiences, during which discomfort was manageable. Although bleeding was not excessive, she noted mild to moderate pain during bowel movements and coincidently began her menstrual cycle shortly afterward. Fast forward eight days, and the pain localized around the anus and rectum escalated to the point where regular activities became infeasible. A small, white, pea-sized bump at the top of the anus became increasingly bothersome. Sitting became challenging and squatting amplified the pain, a natural stance due to her back issues. Following up with her gastroenterologist, she received a prescription for hydrocortisone cream, although the pain felt largely internal. The suppositories were discontinued due to intense discomfort upon application, akin to experiencing a blockage. A gentle exploration with a clean fingertip revealed no significant abnormalities within the first inch. The pain predominantly manifested on the left side near the upper body, and the GI physician instructed her to visit the emergency room if the agony reached an unbearable level. While bowel movements remained uncomfortable, they weren't incapacitating, allowing her to walk albeit without engaging in rigorous exercise. Nevertheless, she began to experience nerve pain traveling down her legs along with a growing sense of physical irritation. Yesterday morning, after an uncomfortable bowel movement at around 9 AM, she encountered a surge of intense pain by 11 AM, reaching a severe level of 10. The pain rendered her incapable of sitting or standing, causing shaking, tears, and dizziness. The discomfort radiated throughout her pelvis and down her hips, likened to an overwhelming cramp—more intense than any menstrual cramps she’d previously endured. At this stage, her mobility dwindled to a mere 0.25 mph, with sensations akin to a giant needle constantly piercing her rectum. Neither Tylenol nor a 600 mg dose of ibuprofen provided relief. She experienced considerable abdominal pain and backache, feeling as if the sheer intensity might be fatal. Pain surged in rhythmic waves, with significant cramping intervals lasting from 10 to 90 seconds. She spent the remainder of the day in the emergency room due to the unbearable pain, where a brief examination of her anus was performed alongside urine samples, blood tests, and a CT scan. She was administered an anti-nausea medication (though she hadn't complained of nausea) and received pain relief through an IV. Unfortunately, the results remained inconclusive, showing only minor signs of a potential bladder infection; she was prescribed antibiotics and tramadol before being sent home, urged to follow up with her primary care physician or return to the ER if the pain persisted. Given her pain level had not dipped below 9 out of 10 for the past two days, she felt disheartened by this advice. Although she had previously suffered from bladder infections and hemorrhoids, the current pain severity was unprecedented. The IV pain relief did alleviate some discomfort, enabling her to find sleep with the help of mild THC, noted for its efficacy in dulling pain. Upon waking today, her pain was a moderate 6 out of 10. After rising, a bowel movement proved excruciating, though devoid of blood. The tightness around the small white bump at her anus continued, with persistent pain also felt in her lower abdomen and back, intensifying through her kidney region to another 9 out of 10 rating. It felt as though the sensation in her rectum had swollen and transformed to a fiery agony, maintaining a constant pulse of pain punctuated by sharper stabs. Additionally, she suffered from widespread nerve pain, further accompanied by bodily aches and chills, along with severe cramps throughout her back and abdomen. Checking her IUD strings confirmed they were intact, and she assumed the CT scan would reveal any displacements. After taking tramadol about an hour earlier, the broader pain persisted. At this juncture, she seeks assistance or suggestions for unearthing a resolution to her suffering. It's Saturday, and, truthfully, her current GI doctor seems uninterested in investigating her ongoing condition (though other providers are booked with long wait times). She has a follow-up with a colorectal physician in two weeks, the earliest appointment available. Her primary care provider advised pain management and consultation with either the GI or colorectal specialists, while the GI's counsel directs her back to the emergency room. Caught in this frustrating cycle, her pain only continues to amplify. If someone were to suggest that a malevolent entity had pierced her with hot iron instruments within her body, particularly on the left side, addressing both her psoai and pyriformis regions, alongside her kidneys, she would find this explanation quite fitting. She's inquiring what actionable steps she might consider next. Should she return to the ER? What specific inquiries should she present? What differential diagnoses could she explore? Any guidance would be immensely appreciated!
Answers (1)
7/12/2025, 4:40:43 PM
OpenHealth AI
I'm truly sorry to hear about the severe pain and discomfort you’re experiencing. Given the intensity and persistence of your pain, it’s crucial to prioritize finding relief and getting the necessary medical evaluation.
Main Points:
- Return to ER if Pain Persists or Worsens: Your pain level is dangerously high, and you have already consulted multiple medical professionals without an adequate resolution.
- Specific Presentation to Medical Staff: It’s important to communicate your symptoms clearly, including new and specific pain locations, and any changes since your last ER visit.
Explanation:
You’ve described a combination of concerning symptoms, including:
- Severe, localized rectal pain, possibly exacerbated by a recent bowel movement.
- A noticeable bump near the anus, which raises the suspicion of several issues, such as external hemorrhoids, anal fissures, or other potential conditions like an infected cyst or abscess.
- Radiation of pain down your legs and overall lower body, which might indicate nerve involvement related to your back surgery or other underlying conditions.
Given the inadequate response from previous consultations and the dire nature of your pain, the situation warrants an urgent reassessment. It’s common for complex gastrointestinal and pelvic issues to require thorough investigation with possible imaging studies or referrals to specialists who can provide more dedicated attention.
Next Steps:
- Return to the ER: If your pain remains at a level of 9 or above, do not hesitate to return to the emergency room. Being persistent may help ensure you're taken seriously.
- Prepare for Your ER Visit:
- Document Symptoms: Keep a record of when your pain escalates, its intensity, and new symptoms (like the bump, nerve pain, etc.).
- Ask Specific Questions:
- Could this be related to an anal fissure or a possible diverticular issue?
- What further imaging or examinations can clarify the bump's nature?
- Is there a possibility of nerve compression from your previous surgery affecting your current pain?
- Follow-Up Options:
- Maintain close communication with your colorectal specialist about your symptoms and express the urgency of your pain.
- Ask about the possibility of a referral to pain management specialists who can help with medication adjustments, physical therapy, or other interventions.
Coping Strategies at Home:
- Pain Management: In addition to tramadol, consider discussing alternative pain relief options that may be more effective, considering your current medications.
- Hydration & Diet: Staying hydrated and eating a high-fiber diet can help ease bowel movements and potentially reduce pain associated with constipation.
- Gentle Movement: If possible, try gentle stretches (consulting instructions online or through a physician) to alleviate any muscle tightness, particularly in the back and pelvic regions.
Summary:
Your priority is to effectively manage pain and understand what is causing this distress. Utilizing both ER resources and follow-up specialists strategically can lead to better insights and treatment options. Please take care, and seek help promptly as it’s essential for your well-being.
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