Intramural abscess of the rectum is an uncommon (7%) form of perianal abscess in which the suppuration moves upwards within the rectal wall. Diagnosis is usually readily established on the presence of prominent anorectal symptoms and on rectal examination findings. However, atypical cases occur occasionally. Two cases of intramural abscess with misleading presenting symptoms suggestive of rheumatologic disease are reported herein. Both patients had subacute lumbosacral pain suggestive of an inflammatory condition. In one patient, the correct diagnosis was established two years after onset of symptoms when the patient passed pus per rectum. In the other, endoscopic ultrasonography readily evidenced the abscess. Modern imaging techniques including endorectal ultrasonography, CT scan with enhancement and MRI are very helpful for the diagnosis of such difficult cases. Intramural rectal abscess should be added to the list of possible nonspinal visceral etiologies routinely looked for during the evaluation of patients with atypical lumbosacral pain.