Review of systems should seek symptoms of causative disorders, including urinary or fecal incontinence local irritation , anal pain or lump, blood on toilet paper hemorrhoids , bloody diarrhea and abdominal cramps inflammatory bowel disease , and skin plaques psoriasis. Past medical history should identify known conditions associated with pruritus ani, particularly prior anorectal surgery, hemorrhoids, and diabetes.
General examination should obtain a sense of overall hygiene and note any signs of anxiety or obsessive-compulsive behavior. Physical examination focuses on the anal region, particularly looking for perianal skin changes, signs of fecal staining or soilage suggesting inadequate hygiene , and hemorrhoids. External inspection should also note the integrity of the perianal skin, whether it appears dull or thickened suggesting chronicity , and the presence of any cutaneous lesions, fistulas, excoriations, or signs of local infection.
Sphincter tone is assessed by having the patient contract the sphincter during digital rectal examination.
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The patient should then be asked to bear down as if for a bowel movement, which may show prolapsing internal hemorrhoids. Anoscopy may be necessary to further evaluate the anorectum for hemorrhoids. Dermatologic examination may reveal scabies burrows in the inter-digital webbing or scalp or signs of any other contributing systemic skin disease. Hygiene issues, use of topical agents, and local disorders eg, candidal infection , hemorrhoids are usually apparent by history and examination. In adults with acute itching without obvious cause, ingested substances should be considered; a trial of eliminating these substances from the diet may be useful.
In children, pinworms should be suspected. In adults with chronic itching and no apparent cause, overly aggressive anal hygiene may be involved. For many patients, a trial of empiric, nonspecific therapy is appropriate unless particular findings are noted. For example, biopsy, culture, or both of visible lesions of uncertain etiology should be considered.
If pinworms, which occur most often in school-aged children, are suspected, eggs can be detected by patting the perianal skinfolds with a strip of cellophane tape in the early morning; the tape is placed side down on a glass slide and viewed microscopically. Clothing should be kept loose, and bed clothing should be light.
After bowel movements, the patient should clean the anal area with absorbent cotton or plain soft tissue moistened with water or a commercial perianal cleansing preparation for hemorrhoids; soaps and premoistened wipes should be avoided. Liberal, frequent dusting with nonmedicated talcum powder or cornstarch helps combat moisture.
Sometimes, higher potency topical corticosteroids may be needed. Practicing appropriate, nonirritating hygiene ie, not too little but not too vigorous, avoiding strong soaps and chemicals and decreasing local moisture can help alleviate symptoms. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.
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Pruritis Ani Expanded Version
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Red flags. Interpretation of findings. General measures. Key Points. Test your knowledge. Which of the following is the most common cause of acute pancreatitis? Add to Any Platform. Click here for Patient Education. Most anal itching is. Idiopathic the majority. Some Causes of Pruritus Ani Cause. Possibly pink, thin, slightly raised lines or bumps burrows on the affected areas. Use of a possibly irritating or sensitizing substance described by the patient. The following findings are of particular concern:. Draining fistula. Systemic causes and parasitic or fungal infections must be treated specifically.
Foods and topical agents suspected of causing pruritus ani should be eliminated. Pinworms in children and hygiene-related issues in adults are common causes. Was This Page Helpful? Yes No. Rectal Prolapse and Procidentia. Anoscopy, sigmoidoscopy, or colonoscopy. With internal hemorrhoids, bleeding a small amount of blood on toilet paper or in the toilet bowl With external hemorrhoids, a painful, swollen lump on the anus.
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Primary pruritus ani is thought to be functional or psychological in nature: Functional pruritus ani — a small amount of faecal loss anorectal dysfunction causes itching and perianal erythema. Psychological pruritus ani — itching is associated with psychosomatic or psychiatric disorders such as depression. Secondary pruritus ani has many possible causes, including: Skin conditions, such as dermatitis and psoriasis. Colorectal and anal pathology, such as anal fissure and haemorrhoids which may also present with perianal pain and bleeding and colorectal cancer which may also present with altered bowel habits and rectal bleeding.
Systemic disease, such as diabetes mellitus and anaemia. Drugs, such as corticosteroids and colchicine. Food and drinks, such as spicy foods, nuts, beer, and wine.
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Unless a specific cause is diagnosed and treated, pruritus ani may be a chronic condition. However, most people respond well to management. Persistent scratching can tear the perianal skin, leading to eczema, lichenification, ulceration, excoriation, and secondary bacterial infection. Chronic itch can result in psychological problems such as feelings of embarrassment and stigma, depression, and anxiety and insomnia. Assessment of a person with pruritus ani should include taking a careful history and performing an examination of the perianal area, including a digital rectal examination in adults, to identify a cause for the itch.
If no cause for the itch is identified, primary pruritus ani is likely. Management of pruritus ani includes: Managing any underlying cause, where possible. Giving lifestyle advice, such as avoiding scratching, keeping nails short to reduce skin trauma, maintaining good anal hygiene, and avoiding foods or drinks known to aggravate the symptom.
Ensuring stools are regular and formed, to reduce perianal leakage.
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Referral to a specialist should be arranged if: A serious underlying cause such as anorectal cancer is suspected. An underlying cause requires treatment not available in primary care. From age 1 month onwards. This CKS topic covers the management of pruritus ani itching in the perianal area. Issued in November Evidence-based guidelines No new evidence-based guidelines since 1 September Economic appraisals No new economic appraisals relevant to England since 1 September Systematic reviews and meta-analyses No new systematic reviews or meta-analyses published in the major journals since 1 September Primary evidence No new randomized controlled trials published in the major journals since 1 September No new national policies or guidelines since 1 September No new safety alerts since 1 September No changes in product availability since 1 September To support primary healthcare professionals to: Assess a person with pruritus ani.
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Identify and manage secondary causes of pruritus ani, if possible. Relieve the symptoms of pruritus ani. Refer a person with pruritus ani to secondary care, where appropriate. No outcome measures were found during the review of this topic. No audit criteria were found during the review of this topic. No QOF indicators were found during the review of this topic. The presence of 'red flags' for anorectal cancer, such as symptoms for example altered bowel habits or a family history.
The appearance of the perianal skin will vary depending on the intensity and duration of pruritus ani:. The manufacturer of chlorphenamine advises avoiding its use during pregnancy.