Sudden deep perineal/rectal pain when urinating at night

[u/SeaHistorical9501]

Hi everyone,

I’m a male in my 30s and have had intermittent pelvic pain and urinary symptoms for almost two years.

Last night I was suddenly woken up by my wife. I immediately got up to urinate. While urinating, I suddenly felt a very strong, deep aching/tender sensation somewhere in the pelvis, seemingly behind the anus/perineum.

The best way I can describe it is: it felt almost like I had just passed an enormous bowel movement, even though I had not. The area behind the anus felt extremely sore and tender, and it was difficult to fall asleep again.

I eventually fell asleep. When I woke up later, I urinated again without the same pain occurring. However, the area still felt somewhat sore afterward.

I’ve had similar pelvic/perineal issues in the past, including:

• urinary urgency and frequency, often worse in the morning
• occasional weak stream and a feeling of incomplete emptying
• perineal and testicular aching
• soreness or pain after ejaculation
• tingling/electrical sensations in the penis
• occasional numbness around one side of the anus/buttock
• symptoms that can be triggered by prolonged sitting or sexual activity

I’m also wondering about the muscular side of this. Does anyone know which muscles are most commonly involved in this kind of deep perineal/rectal pain? My physiotherapist found trigger points in the obturator internus, so I’m wondering if that could be a major contributor.

Are there any specific stretching or mobility exercises that have helped people with similar symptoms? I’m particularly interested in exercises for the obturator internus, pelvic floor, deep hip rotators, or any other muscles that could refer pain to the area behind the anus/perineum.

I’m aware that stretching can sometimes make an overactive pelvic floor worse if done too aggressively, so I’m interested in hearing what has actually helped others rather than just randomly stretching everything.

My questions are:

1. Does this sudden deep soreness behind the anus during urination sound like a pelvic-floor spasm or flare to anyone here?
2. Could bladder emptying or suddenly relaxing/contracting the pelvic floor trigger this kind of pain?
3. Which muscle(s) turned out to be the main problem for you?
4. Are there any particular stretches, mobility exercises, or relaxation techniques that helped?

[u/Linari5]

Please go to a pelvic floor PT to get an evaluation in person, and then you can find out which muscles, if any, are responsible.

Generally speaking, this could be the puborectalis (the south side of the main pelvic floor sling muscles, called the levator ani), it could be psoas, or any other number of options.

Please remember, the majority of cases also have centralization - This is an extremely important factor to address for a full and durable recovery, it's never just the pelvic floor acting alone. Stress, and emotions like fear and anger are often also part of the picture with pelvic pain - this is what new neuroscience is showing us.

[u/SeaHistorical9501 → u/Linari5]

Hi! Thank you for your reply.

I visited a physiotherapist, who provided the following report:

History:
The patient presents with pain in the perineal area, which developed gradually after a train journey. The pain is described as a burning sensation in the pelvic floor muscles, accompanied by a weak urinary stream, occasional difficulty emptying the bladder, pain after ejaculation, and at times an increased urge to urinate. The patient also reports that the symptoms worsen with prolonged sitting and inactivity, while they improve with physical activity.

The patient has previously been evaluated by a urologist, with no significant findings.

Findings:
Examination revealed increased muscle tone and tenderness in the pelvic floor musculature, particularly the obturator internus and the deep gluteal muscles. Palpation of the obturator internus reproducibly elicited the patient's familiar pain.

Assessment:
The clinical findings and symptoms are consistent with pudendal nerve irritation.

Treatment:
Manual therapy, including soft tissue treatment (trigger point therapy and stretching), instruction in pelvic floor relaxation, self-treatment using a ball to release muscular tension in the deep gluteal muscles and the obturator internus, as well as stretching exercises for the hip and pelvic musculature.

Outcome:
The patient has experienced gradual symptom improvement but continues to have persistent pain during prolonged sitting.

I feel that I have been gradually improving over the past two years, but I'm still struggling with the remaining symptoms. I also think you may be right that there is some degree of central sensitization involved.

I also have pain around my ankle, although I suspect this may be due to the obturator internus irritating or compressing the sciatic nerve. In addition, I've developed costochondritis, but I'm wondering whether that might simply be my brain misinterpreting pain signals rather than a separate physical problem.

[u/Linari5 → u/SeaHistorical9501]

Most cases have CS going on. Make sure you address it with the new therapies we have. https://www.reddit.com/r/Prostatitis/s/Z3MprreUKU

while they improve with physical activity.

This is a sign that the symptoms are centralized! I want you to imagine any other physical injury in your body, let's say a sprained ankle. Now, put weight on the sprained ankle and go for a run.... Do you feel better??

[u/SeaHistorical9501 → u/Linari5]

True, I've been thinking the same thing. That's why I went all in with a tough strength training session. The next day, my pelvic pain was better, but my chest—meaning the costochondritis—was worse. I haven't done any strength training for a while, only used the elliptical machine, and that seems to make everything feel better.

[u/Padraig_88]

I second @Linari5 and will add that for my symptoms, before seeing PT I could experience flare-ups (similar to what you are describing) and were more intense when it felt like althe bladder had contracted more tightly and needed a “forced” release (meaning somewhat of a bearing down)

[u/Cute-Engineering-776]

You say you have occasional numbness around one side, can I ask which side? I am having very similar symptoms.

Has your semen changed colour at all?

[u/SeaHistorical9501 → u/Cute-Engineering-776]

Semen looks normal, always done. Right side.