[Pruritus ani]

INTRODUCTION

Pruritus ani is defined as a dermatologic disease characterized by itching and/or burning in the perianal area. It occurs in 15% of the population. Men are affected more frequently than women, in the ratio 4:1. It is accompanied by an irresistible desire to scratch in the perianal area. Pruritus ani is divided into two subtypes: primary (idiopathic) and secondary. In idiopathic (primary) pruritus it is not possible to detect any other cause of itching. Secondary pruritus has an obvious causal origin.The aim of this paper is to offer a complex overview of possible causes, diagnostic procedures and treatment possibilities of this unpleasant and annoying disease.

METHODS

We have researched available publications using PubMed and MEDLINE databases, focusing on articles on anal pruritus. At first the key word "Pruritus ani" was put in without any restrictions. Subsequently, we limited the selection by the time period of 5 years and 10 years; then we looked up articles in English, German and Czech languages, and finally review articles, clinical trials and others.

RESULTS

574 articles were found without entering any restrictions; 45 of them were review articles and 25 clinical trials. 437 articles were in the English language and 40 of them were review articles. 44 were in the German language and 1 of them was a review article. A total of 33 articles were found with a 5-year time limit. 6 of them were review articles and 4 were clinical trials. 66 articles from the last 10 years were found. 14 of them were review articles and 10 were clinical trials. In most of the other articles among the total number of articles found, pruritus ani was mentioned only marginally in articles focused on different topics. We have not found any summary articles on this topic in Czech publications.

CONCLUSION

Pruritus ani is a common disease with a number of causes; therefore, effective treatment may be insufficient in the initial stages. The therapy is focused on the primary cause, if found. Broad differential diagnosis options need to be taken into consideration, and reevaluation of the therapy is a priority. When no obvious secondary cause is found, the empiric treatment is focused on an improvement of hygiene and change in the life style, removal of common irritators, and protection of perianal skin.

Pruritus ani: more than a decade of personal experience in Lebanon

INTRODUCTION

Pruritus ani is a common medical condition that is difficult to treat in the absence of obvious predisposing factors. Hereby, we report more than a ten-year experience in the management of pruritus ani stressing the importance of early detection, identification of the etiology, and management.

METHODOLOGY

A total of 124 patients were managed in the surgical clinic. The follow-up was between 11 to 17 months. All patients had the symptoms for a period of time ranging between 6 and 40 months. Patients were treated according to their respective etiology. Medical cases like contact dermatitis and psoriasis were treated by applying proper topical ointments, while other cases like anal fissure and fistula were treated surgically. Idiopathic patients were treated by tattooing (injection to perianal skin with methylene blue).

RESULTS & DISCUSSION

The majority of patients with known medical etiology responded favorably to conservative treatment (≈ 92%). In addition, surgical management for anorectal disorders like hemorrhoids and fistula showed a consistent improvement (94%). However, patients who had their symptoms neglected for longtime or had used over the counter medication without a proper medical follow-up, experienced a lower success rate of cure (76%).

CONCLUSION

Patients who were diagnosed and treated at first hand, showed better results than those who sought late medical advice and management (i.e. > 18 months). In light of the above, a multidisciplinary team approach consisting of a proctologist, a gastroenterologist and a dermatologist is recommended.

[Acute anal pain]

Anal pain is a common reason for consultation, whose etiology is varied and should not be limited to the hemorrhoidal disease. The purpose of this article is to conduct a review of the literature on anorectal pathologies most frequently encountered and make recommendations regarding their management.

Management of anaemia and other treatment complications

Antiviral treatment for hepatitis C virus infection has dramatically changed with the advent of triple therapy including telaprevir or boceprevir, which is associated with a new spectrum of adverse events. These may lead to dosage reduction and early discontinuation of therapy. An increase in the frequency and severity of anaemia was reported in clinical trials for both drugs, and skin disorders including rash and pruritus occurred more frequently with the telaprevir-based regimen. The first-line management of anaemia is ribavirin dose reductions. In cirrhotic patients, aggressive ribavirin dosage reductions, erythropoietin alpha and blood transfusions are effective in managing anaemia. Several deaths and cases of severe infections and hepatic decompensation were reported in cirrhotics treated in real-life setting. Patients with platelet count ≤ 100,000/mm(3) and serum albumin < 35 g/L should not be treated with triple therapy as it is related to a high risk of developing severe complications. The management of rashes, if well planned, does not require telaprevir discontinuation. However, approximately 5% of rashes were severe and a few cases were classified as severe cutaneous adverse reactions leading to treatment discontinuation. Successful treatment can be enhanced by a strong patient support network including a multidisciplinary team.

[Observation of therapeutic effect on perineal, crissal and progenital pruritus treated with acupuncture according to differentiation]

OBJECTIVE

To observe the therapeutic effect and safety of perineal, crissal and progenital pruritus treated with acupuncture according to differentiation.

METHODS

Self-control method was applied in these 32 cases. Changqiang (GV 1), Huiyin (CV 1), Qugu (CV 2), Sanyinjiao (SP 6) and Ashi points etc. were punctured as main points, and adjunct points were added according to differentiation: Taichong (LR 3) and Ququan (LR 8) etc. were added for wind and heat excess of liver meridian, Xuehai (SP 10) and Quchi (LI 11) etc. were added for blood deficiency and wind dryness. Itchiness, skin lesions sign scores and therapeutic effects were observed before and after treatment.

RESULTS

The total scores of itchiness before and after treatment were 6.06 +/- 1.46 and 2.19 +/- 1.71 respectively, and the total scores of skin lesions sign were 4.38 +/- 2.21 and 1.50 +/- 1.44, indicating that the scores and the total scores of itchiness and skin lesions sign reduced obviously after treatment (P < 0.05, P < 0.01); the cured and markedly effective rate was 73.4% (11/15) for wind and heat excess of liver meridian, and 70.6% (12/17) for blood deficiency and wind dryness, presenting similar therapeutic effect (P > 0.05). Hematoma or ecchymosis appeared in 2 cases, and disappeared spontaneously after 2-3 days, without obvious adverse reaction.

CONCLUSION

Simple perineal, crissal and progenital pruritus treated with acupuncture according to differentiation is effective, safe and applicable.

[Diagnostics and treatment of pruritus ani]

Pruritus ani is defined as an intense itching sensation affecting the perianal skin. The condition affects up to 5% of the population, and occurs four times more commonly in men than in women. Pruritus ani occurs in a primary form caused by overt but insufficient cleansing of the perianal skin, and in a secondary form caused by underlying pathology, often of proctological or dermatological/infectious origin. Causes and treatment are reviewed, and it is concluded that the condition, even in its chronic refractory form, has a favourable prognosis.

Common anorectal disorders: diagnosis and treatment

Anorectal disorders affect men and women of all ages. Their management is not limited to the evaluation and treatment of hemorrhoids. Rather, a spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer). Symptoms are nonspecific, which can make the evaluation of patients difficult. In addition, treatment can be frustrating because clinicians are hamstrung by a lack of well-designed, prospective, clinical trials. Some of the most common anorectal disorders include fecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome. This article provides an update on the evaluation and treatment of common anorectal disorders.

Idiopathic perianal pruritus: washing compared with topical corticosteroids

BACKGROUND

Idiopathic perianal pruritus is a poorly managed condition. Topical corticosteroids are effective in idiopathic perianal pruritus, but they may cause some side effects. In this study, the effectiveness of topical steroids were compared with perianal cleansers in the treatment of idiopathic perianal pruritus.

PATIENTS AND METHODS

Seventy two patients with the complaint of perianal pruritus were evaluated; 60 of the 72 patients were found to be idiopathic. Twenty eight patients were treated with topical steroids and 32 patients were treated only with a liquid cleanser.

RESULTS

At the end of this two week period, cleansers were found to be as effective as topical corticosteroids.

CONCLUSION

This study shows that perianal cleansers can be used as a safe first step treatment in idiopathic perianal pruritus.

Pruritus ani

BACKGROUND

Pruritus ani is a common presenting problem in general practice, one that is particularly distressing to patients. However, there is little available research on which to base management

OBJECTIVE

This article discusses the causes and management of this distressing symptom based on thecurrent available evidence.

DISCUSSION

Perianal itch probably arises from localised inflammation. This may be the result of anorectal disease, skin disorders, excessive cleaning, application of local irritants or other causes. In children, perianal itch may be caused by intestinal hermetic Infection such as pinworm. Whatever the initial cause, the problem may at times become chronic, with scratching inflaming the area and more itching resulting. Avoiding trauma from excess washing, toilet paper and topical agents is important. Treatments likely to be effective are emollients such as sorbolene, a short course of topical hydrocortisone cream and capsaicin cream.

An approach to the treatment of anogenital pruritus

The anogenital area is a common location for pruritic complaints. Specific terms for chronic itch in this location have included pruritus vulvae, pruritus ani, lichen simplex chronicus, and neurodermatitis. A male counterpart to pruritus vulvae, pruritus scroti, is less common. Acute anogenital pruritus is usually caused by infections or contact dermatitis. In chronic pruritus, inflammatory dermatoses and malignancies must be ruled out. In idiopathic anogenital pruritus or neurodermatitis, the skin findings should be limited to lichenification and excoriations. Skin findings may be entirely absent. When treating anogenital pruritus, topic irritants and potential sensitizers must be eliminated. Cleansing and toilet habits must be addressed. A short course of a high-potency topical steroid should bring moderate to complete relief. Sedating antihistamines may limit nighttime symptoms. In some patients, psychotropic agents are required to achieve adequate sedation. Antidepressants may be required in patients refractory to treatment or with underlying psychiatric disorders.

Diseases of the rectum and anus: a clinical approach to common disorders

Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.

Don't forget your toothbrush!

Patients with rectally inserted foreign bodies can present to accident and emergency departments or general medical practitioners. Rarely dentally related objects are inserted because of their ready availability in the domestic environment. There are many reasons given for their presence in the rectum, most commonly accidental insertion, assault, and psychosexual motives. This case is the first reported incident of a patient using a toothbrush to relieve his pruritus ani and subsequently losing it up into the rectum.

Palliative care in inflammatory bowel disease: an evidence-based approach

The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients' lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid-related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence-based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case-controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.

Pruritus ani

The possible dermatological and proctologic causes, of Pruritus Ani that often, due to its persistence and for its consequent lesions of scratching, becomes a real disease, are analysed. Particular attention is given to therapeutical treatment, describing which hygienic-dietetic rules must be followed and which treatments can be utilised, if the cause of the symptom is known and if it is possible to remove it or not. Moreover, personal experience on 312 patients examined in twelve years is reported.

Hypnosis in a case of long-standing idiopathic itch

OBJECTIVE

This article presents the results of a brief hypnosis treatment of a woman with chronic, idiopathic vaginal and anal itch.

METHODS

The patient was referred after 3 years of unsuccessful outcomes with standard topical and oral treatments prescribed by her family physician and three dermatologists. Treatment consisted of five sessions of self-hypnosis training in techniques of relaxation, deepening, and imagery, and home practice with an individualized instructional tape.

RESULTS

After treatment, the patient reported substantial tissue healing, confirmed by her treating physician, that coincided with significant reductions in her scores of itch intensity, itch-related sleep disruption, and distress from pre- to posttreatment. These improvements continued at 4 months of follow-up, and the patient reported complete resolution of physical symptoms.

CONCLUSIONS

The fact that these changes coincided with only minor improvements in general anxiety scores suggests that the resolution of the patient's itch condition was treatment-specific rather than the result of methodological artifact, participant reporting bias, or a general sense of feeling better. These findings suggest that hypnosis is a cost-effective treatment for idiopathic itch conditions, especially those that are unresponsive to standard medical treatments.

Primary care office management of perianal and anal disease

Benign anorectal processes, hemorrhoids, fissures, abscesses, fistulas, and infections, as well as some functional disorders, are common. They generate significant patient discomfort and disability. Appropriate recognition of these processes allows for outpatient, office-based intervention. With the techniques and management described in this article, many patients' symptoms can be ameliorated expeditiously.

Hemorrhoids, fissures, and pruritus ani

The diagnosis and management of hemorrhoids, fissures, and pruritus ani probably accounts for more than 81% of the complaints centered on this part of the human anatomy. This brief treatise offers a safe and practical approach to the management of these three diseases.

ABC of colorectal diseases. Pruritus ani

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Treatment of common anorectal disorders

Family physicians can manage most common anorectal disorders seen in office practice. Proctitis is usually caused by sexually transmitted infections that can be treated with antibiotics. Pruritus ani, anal fissures, fungal infections and hygiene problems are all amenable to simple treatments. Thrombosed external hemorrhoids can be opened and drained. Bleeding or symptomatic internal hemorrhoids can be treated with rubber-band ligation. Perirectal or ischiorectal abscesses require incision and drainage, sometimes under general anesthesia. Serious disorders such as inflammatory bowel disease and cutaneous malignancies should always be considered in the differential diagnosis of common anorectal disorders.

Can proctological procedures resolve perianal pruritus and mycosis? A prospective study of 23 cases

Twenty-three patients with pruritus ani associated with anal mycosis underwent primary treatment of a concurrent anal disorder. The anal disorders included haemorrhoids (n = 9), fissure (n = 8), anal spasm without fissure (n = 5), and occult mucosal prolapse (n = 1). Pretreatment investigation of faeces for parasites was negative. The glucosal tolerance test and white blood cell count were normal in all cases. Culture of skin smears from the perianal region was positive for Candida only in 16 patients, Dermatophytes only in 6 and a combination of both in 1 patient. Following the appropriate proctological procedure, pruritus resolved or markedly improved in 20 patients. The remaining three patients required antifungal treatment with econazole. Two of these, however, continued to complain of pruritus. It is suggested that in patients with pruritus ani associated with perianal mycosis, antimycotic therapy should be used only if fungal infection persists after treatment of the underlying proctological disease.

Treatment of intractable pruritus ani

The majority of patients with idiopathic pruritus ani respond favorably to conservative treatment. Moreover, response to specific medical therapy is almost always favorable in certain dermatologic diseases such as psoriasis, mycotic dermatitis, and contact dermatitis. When surgery is performed for anorectal disorders such as hemorrhoids and fistulas, or potentially malignant entities such as extramammary Paget's disease, the accompanying pruritus ani invariably improves as well. Only patients with chronic intractable pruritus ani are included in the current study. Methylene blue (methylthionine chloride) 0.5 percent is injected intracutaneously on the anodermal and perianal skin. With one treatment, long-term cure has been observed.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. XXIII. An injection technique for the treatment of idiopathic pruritus ani

An injection technique for the treatment of idiopathic pruritus ani is presented. The technique was performed on 67 patients after failure of other methods to achieve permanent cure. The technique comprises injection of 5% solution of phenol in almond oil in the subcutaneous tissue of the rectal neck aiming at destruction of the "epithelial debris" which exists in this area and is considered the primary cause in idiopathic pruritus. Cure was obtained in 62 patients (92.5%). The remaining five patients underwent recurrence after a period of remission, and were cured after a second injection. The advantages of the present technique over others in common use are discussed.

A randomised trial of simple excision of non-specific hypertrophied anal papillae versus expectant management in patients with chronic pruritus ani

Forty-one patients with non-specific hypertrophied anal papillae and chronic idiopathic pruritus ani were randomly assigned to simple excision of the anal papillae (n = 21) or expectant management (n = 20). The patients were examined blindly 1 and 4 weeks after treatment and 1 year later. None of the patients were lost to follow-up. Of 21 patients treated with simple excision, 14 (67%) were symptom-free at 1 year after treatment compared to 11 out of 20 patients (55%) maintained on expectant management (P greater than 0.05). It is concluded that simple excision of non-specific hypertrophied anal papillae is without effect on chronic idiopathic pruritus ani.

Pruritus ani

Management of pruritus ani rests on a few basic principles. The first and foremost is to listen to the patient and accept how uncomfortable and even disabling this common disorder can be. Such causes as parasites, diarrhea, trauma, hemorrhoids, and fistulas must be accurately diagnosed and treated. Contributing factors, such as poor hygiene or, paradoxically, too vigorous cleansing, must be corrected. Certain foods, such as spices and citrus fruits, need to be eliminated from the diet. Use of all over-the-counter preparations, cleaning pads, and solutions except water must be stopped. Finally, a mild steroid cream should be prescribed on a temporary basis, and the patient should be reexamined in two to three weeks. In the vast majority of cases, the physician will have a very happy and appreciative patient.

Pruritus ani. Classification and management

Pruritus ani is a common dermatologic complaint that can be frustrating to treat. Effective therapy depends upon recognition of a variety of etiologic factors that may contribute to the symptom.

[Current trends in the diagnosis and therapy of anal pruritus. Review of 238 cases]

Perianal pruritus may be caused by a variety of factors. Of these, the most frequently occurring are proctological, infections, dermatological, dietary, and systemic. The results of a study carried out on 238 patients from 1980 to 1984 are reported. The survey was carried out with the aim of defining the frequency of pruritus in relation to the triggering cause, to sex and to age. It is emphasised that diagnosis is often difficult and requires the measurement of the following parameters: blood glucose levels, blood, nitrogen levels, ESR, haemochrome, hepatic functions, in addition to a gynaecological examination, analysis of faeces, proctocolonoscopy, skin biopsy and other tests. These are carried out to determine whether anal pruritus is a symptom of a systemic disease, or whether it is brought about by local causes. Treatment measures adopted are reported. Treatment is mainly symptomatic and aetiological for cases caused by local disturbances.

Pruritus ani. What to do, what not to do to control this infernal itch

The essentials of the treatment of pruritus ani consist of keeping the perianal skin scrupulously clean and dry. The most important damaging factors are fecal residue, moisture, scratching, steroids, and local anesthetics.

Common anorectal disorders

Anorectal disorders include a diverse group of pathologic processes that are frequently encountered in general medical practice but are poorly understood. The optimal management of anal pain, itching, bleeding, and incontinence is based on sound anatomic and pathophysiologic principles. Advances have been made in understanding the pathogenesis and management of four anorectal disorders frequently encountered by internists: hemorrhoids, fissures, pruritus, and incontinence.