rectal pain and bleeding

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Dear All,I have this rather tricky case of a lady in her fifties with severe pain in the rectum after passing stools and some bleeding - and I would really appreciate your collective wisdom on the matter. I have been treating her for a month with some progress but nowhere near a resolution. She presented to me with continuous rectal pain (agonising, cramp like) and bleeding after going to toilet. She has been to her GP and was given pain killers, ended up twice at A & E (given tranquilizeres and told it was psychosomatic), saw a consultant who could not examine her as the area is so tense it is not possible for her to have a rectal examination (and she will not agree to have it under a general anaesthetic). In the absence of a firm diagnosis (it is one of this situations where you really want

to exclude any nasties but not possible at the moment), I assumed that it is either a rectal fissure or a bleeding haemorrhoid and the wound will not heal because of a daily disturbance when she goes to the toilet. She has improved in the sense that there is very little bleeding and the very intense pain after moving the bowel last only about 5-10 min (used to be hours) but she still has residual pain for most of the time, bad enough to stop her from going out. Ideally I would like her to use a cream internally but it is not possible for her to insert anything at the moment, so she uses a muscle relaxing and healing cream outside the area.I would really appreciate your suggestions, especially on relaxing the muscle spasm in the area.Thanks in advance