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88
N. Scott
10. Martínez F, Nos P, Benlloch S, Ponce J. Hidradenitis suppurativa and Crohn’s disease: response
to treatment with infl iximab. Infl amm Bowel Dis. 2001;7(4):323–6.
11. Gorovoy I, Berghoff A, Ferris L. Successful treatment of recalcitrant hidradenitis suppurativa
with adalimumab. Case Rep Dermatol. 2009;1:71–7.
12. Shah N. Hidradenitis suppurativa: a treatment challenge. Am Fam Physician.
2005;72:1547–52.
13. Parks RW, Parks TG. Pathogenesis, clinical features and management of hidradenitis suppura-
tiva. Ann R Coll Surg Engl. 1997;79(2):83–9.
14. Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradeni-
tis suppurativa. Dermatol Surg. 2000;26:638–43.
15. Ritz JP, Runkel N, Haier J, Buhr HJ. Extent of surgery and recurrence rate in hidradenitis sup-
purativa. Int J Colorectal Dis. 1998;13:164–8.
16. Harrison BJ, Mudge M, Hughes LE. Recurrence after surgical treatment of hidradenitis sup-
purativa. Br Med J (Clin Res Ed). 1987;294(6570):487–9.
17. Jan von der Werth, (2001) Hidradenitis suppurativa, Dermatology in Practice 2001;9(3):
22–5, ISN.
18. Kagan RJ, Yakuboff KP, Warner P, Warden GD. Surgical treatment of hidradenitis suppurativa:
a 10-year experience. Surgery. 2005;138(4):734–41.
19. Wiseman MC. Hidradenitis suppurativa: a review. Dermatol Ther. 2004;17:50–4.
20. Morgan WP, Harding KG, Hughes LE. A comparison of skin grafting and healing by granula-
tion, following axillary excision for hidradenitis suppurativa. Ann R Coll Surg Engl.
1983;65(4):235–6.
21. Ather S, Chan DSY, Leaper DJ, Harding KG. Surgical treatment of hidradenitis suppurativa:
case series and review of the literature. Int Wound J. 2006;3(3):159–69.
22. Maclean GM, Coleman DJ. Three fatal cases of squamous cell carcinoma arising in chronic
perineal hidradenitis suppurativa. Ann R Coll Surg Engl. 2007;89(7):709–12.
23. Endo Y, Tamura A, Ishikawa O, Miyachi Y. Perianal hidradenitis suppurativa: early surgical
treatment gives good results in chronic or recurrent cases. Br J Dermatol. 1998;139:906–10.
24. Bocchini SF, Habr-Gama A, Kiss DR, Imperiale AR, Araujo SE. Gluteal and perianal hidraden-
itis suppurativa: surgical treatment by wide excision. Dis Colon Rectum. 2003;46(7):944–9.
25. Balik E, Eren T, Bulut T, Büyükuncu Y, Bugra D, Yamaner S. Surgical approach to extensive
hidradenitis suppurativa in the perineal/perianal and gluteal regions. World J Surg.
2009;33(3):481–7.
26. Ramasastry SS, Conklin WT, Granick MS, Futrell JW. Surgical management of massive peria-
nal hidradenitis suppurativa. Ann Plast Surg. 1985;15(3):218–23.
27. Wiltz O, Schoetz Jr DJ, Murray JJ, Roberts PL, Coller JA, Veidenheimer MC. Perianal
hidradenitis suppurativa. The Lahey Clinic experience. Dis Colon Rectum. 1990;33:731–4.
89
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_7, © Springer-Verlag London Limited 2012
Itch is the sensation that provokes an urge to scratch, which distinguishes it from
pain (which induces a withdrawal response). The physiology of itch is imperfectly
understood. Itch receptors are apparently unspecialized nerve endings in the skin
and cornea that lead to unmyelinated C fi bers that travel in the spinothalamic tracts.
Both histamine and interleukin-1 are mediators of itch; prostaglandin E1 lowers the
itch sensory threshold; and substance P can cause itching by inducing the release of
histamine. Endogenous opioids and exogenous opiates can cause itching.
Itch in and around the anus is a common presenting symptom in a colorectal
clinic. Some patients may complain of soreness or burning rather than itching.
Pruritus ani has not been the subject of a wealth of good quality original research,
and much of current practice is based on observational studies.
7.1 Etiology
Pruritus ani may be primary (idiopathic) or secondary. There are a number of causes
of secondary pruritus ani: some can be treated by a coloproctologist, some can be
treated by other specialists, and some have no treatment (Box 7.1 ).
I. Badger , FRCS, M.D. (Hons)
Department of General Surgery, Royal Wolverhampton Hospital Trust ,
New Cross Hospital , Wolverhampton ,
WV10 OQP , UK
e-mail: ibadger@nhs.net
Chapter 7
Pruritus Ani
Ian Badger
90
I. Badger
7.1.1 Idiopathic Pruritus Ani
In many cases of perianal itching, there is no discernible clinical cause: idiopathic
pruritus ani. The itch is probably caused by irritation of the perianal skin due to
repeated contamination by leakage of tiny quantities of the rectal contents. The
perianal skin becomes moist, and the resulting maceration is irritating. The fecal
matter can cause chemical or atopic damage to the skin. The use of proprietary or
prescribed topical agents may exacerbate the wetness and may stimulate an allergic
response. Excessive sweating may be a contributory factor. The trauma caused by
scratching, which often occurs, adds to the list of injurious agents and may perpetu-
ate the symptoms even if the precipitant is eliminated. Finally, secondary fungal
infection may develop on the damaged skin.
Box 7.1: A Classifi cation of the Causes of Pruritus Ani
Itches colorectal surgeons
can scratch
Itches other specialists
can scratch
Itches that nobody
can scratch
Hemorrhoids Threadworm infestation
Psychogenic
pruritus
Fistula-in-ano Taenia infestation Geriatric pruritus
Fissure Amebiasis
Perianal warts Dermatoses: eczema, erythr-
asma ( Corynebacterium
minutissimum infection),
fungal infections, impetigo,
intertrigo, lichen planus et
sclerosus, pediculosis,
psoriasis, and scabies
Anal skin tags Venereal diseases: anal syphilis,
gonococcal proctitis,
chlamydia proctitis, and
perianal herpes
Anal cancer and intraepi-
thelial neoplasia
Systemic diseases
Rectal cancers and
adenomas
Gynecological causes
Rectal prolapse Medications: e.g., tetracy-
clines, cocaine, pepper-
mint oil, and morphine
Hidradenitis suppurativa
Impaired anal continence
with seepage
Diarrhea
91
7 Pruritus Ani
Many of the coloproctological causes of secondary pruritus probably act through
a similar mechanism: perianal contamination with rectal contents. In some cases,
local anorectal pathology may be coincident with idiopathic pruritus ani and not
causal. Hemorrhoids, for example, are common and may be innocent bystanders.
Anal skin tags are also common in people with and without itchy bottoms [
1 ] , and
their excision will only be helpful if they interfere with adequate anal hygiene [
2 ] .
7.1.2 Pruritus of Systemic Diseases
A number of systemic diseases produce itching – cholestasis and uremia are well-
known examples. The itch of primary biliary cirrhosis may precede the fl orid hepatic
features of the disease. Iron defi ciency, myxedema, and thyrotoxicosis can all cause
generalized pruritus; bronchial carcinoma, diabetic neuropathy, lymphoma, chronic
leukemia, and polycythemia rubra vera can cause localized perianal itching. The
itch in polycythemia may precede any hematological manifestations of the disease
and is typically provoked by contact with water (aquagenic itch).
Diabetes is often cited as a cause of pruritus ani, and there are two ways in which
it can do so – diabetic neuropathy can provoke itching, and fungal skin infections
can do so. Uncomplicated diabetes is not an adequate explanation for pruritus ani.
Postmenopausal itch may be generalized or perianal and may respond to hor-
mone replacement. Geriatric itch is a different problem that is said to occur only
over the age of 75 years. Psychogenic itch is often located around the anus and geni-
tals and is a fi nal diagnosis of exclusion of uncertain bona fi des and causation.
7.1.3 Dermatological Pruritus
Many skin conditions can cause pruritus, and some can affect the perineum. The
frequency with which pruritus ani is due to a primary skin disorder is diffi cult to
establish: Dasan et al. [ 3 ] reported that 85% of patients attending a combined der-
matology and coloproctology clinic had a dermatosis, but Smith et al. [ 4 ] found that
only 7 of 75 attenders to a colorectal clinic had a primary dermatological cause.
Bowyer and McColl [ 2 ] found that many patients have more than one possible
causes of pruritus, often a combination of a dermatosis and a local anorectal
pathology.
Regardless of the type of clinic to which a patient with pruritus ani is fi rst referred,
some patients will need help from both a dermatologist and a coloproctologist.
Secondary fungal infection, for example, is a common complication in idiopathic
pruritus ani. Fungi can be cultured from the perianal skin of over 40% of nondia-
betic patients with pruritus ani and benign anorectal disease and from over 60%
who have pruritus ani and no overt anorectal disease, but fungi can also be cultured
from the skin of roughly one-quarter of people who have no perianal itch [
5 ] .
92
I. Badger
7.1.4 Colorectal Pruritus
In essence, any disease that cause diarrhea and any problem that leads to anal seep-
age or more fl orid incontinence can provoke perianal irritation. It is important that
these pathologies are identifi ed and treated appropriately.
7.2 Pathophysiology
The underlying cause of leakage in idiopathic pruritus ani has not been determined.
There is evidence of an exaggerated rectoanal inhibitory refl ex, such that sufferers
of idiopathic pruritus ani, despite having normal resting and squeeze pressures, have
more frequent episodes of transient internal anal sphincter relaxation (sampling
refl ex) that are of longer duration and of greater magnitude than normal [ 6, 7 ] .
Smith et al. [ 4 ] documented a reduction in resting anal pressure in patients with
pruritus ani after drinking coffee and showed that symptoms improved in 50% of
their patients who adhered to exclusion diets. Caffeinated drinks, alcohol, peanuts,
dairy products, and citrus products were specifi cally identifi ed as causal in some
patients, but others found benefi t from avoiding all such items as well as chocolate,
tobacco, pork, tea, spices, and ketchup.
7.3 Clinical Assessment
There may be important clues to the cause of perianal itching from the history.
Simple questioning may reveal features of an underlying systemic disease, a derma-
tosis, diarrheal diseases, rectal prolapse, fecal incontinence, or gynecological disor-
ders. A recent change in brand of toiletries or toilet paper might suggest an allergic
reaction. It is important to ask about blood loss per anum, anal pain on defecation,
and purulent discharge. The features of threadworm infections (common in young
children and often affecting a number of family members at the same time) can usu-
ally be elicited with ease. Candor about sexually transmitted diseases is less likely.
A general physical examination should be done to look for systemic signs.
Examination of the scalp, fl exural creases, and extensor surfaces of the limbs may
reveal the features of eczema, psoriasis, or scabies. Erythrasma and fungal skin
infections may affect the skin of the groins and between the toes. The abdomen and
inguinal lymph nodes should be examined as for any other colorectal presentation.
There may be physical evidence of piles, warts, fi ssure, or fi stula. Digital examina-
tion of the rectum, rigid sigmoidoscopy, and proctoscopy may yield important diag-
nostic information and may allow access for biopsies or rectal swabs to be taken.
Asking the patient to strain during proctoscopy will demonstrate mucosal prolapse,
a treatable cause of fecal discharge. A vaginal examination may be indicated.
93
7 Pruritus Ani
The appearance of the perianal skin needs particular attention. Pruritus ani is
often accompanied by a macerated appearance of the perianal skin with fi ne linear
or punctate erosions, but the appearances do not distinguish between primary and
secondary pruritus. There may be longitudinal fi ssures radiating out from the anal
margin, and this may cause confusion with fi ssure-in-ano. Skin infl ammation may
be due to scratching or dermatosis. There may be recognizable features of skin dis-
ease, such as the bright erythema or white plaques of fungal infection, or the silvery,
wrinkled, atrophic changes of lichen planus. Psoriasis may not be scaly around the
anus and often extends to the natal cleft. Unfortunately, chronic infl ammation from
a variety of causes can cause lichenifi cation and thickening of the perianal skin,
sometimes confused for perianal warts. The infl ammatory skin changes often have
relatively indistinct borders, but the erythema that occurs in psoriasis, tinea infec-
tion, and neoplasia typically has a sharp border between normal and affected skin.
7.4 Management
The treatment principles for people who have pruritus ani have changed very little
in the past 70 years or more [ 8 ] . If there is a suspicion of a systemic disorder, a full
blood count, infl ammatory markers, serum ferritin, and biochemical tests of liver,
thyroid, and renal functions should be done. Rectal biopsies and swabs may be
indicated if there is infl ammation within the rectum, and skin scrapings can also be
taken in the clinic to pursue microbiological evidence of fungal infection. A
Sellotape slide is used to diagnose threadworms. If there is diarrhea, fl exible endos-
copy or radiological imaging may be indicated to defi ne its cause. It may be neces-
sary to do an examination under anesthetic, and biopsies of the perianal skin can be
taken to pursue any suspicion of neoplasia or to refi ne the diagnosis of an infl amma-
tory condition (although the infl ammatory changes are frequently nonspecifi c).
Any underlying cause should be treated appropriately by a coloproctologist,
a dermatologist, or another appropriate specialist. Treatment of hemorrhoids by rubber
band ligation or hemorrhoidectomy will relieve pruritus associated with hemorrhoids
in between one-half and two-thirds of patients with second- and third-degree piles [ 9 ] .
Most patients with idiopathic pruritus ani can be managed on the basis of the clini-
cal assessment and a few simple investigations. Antidiarrheal agents may help if the
stool is loose, and fi ber may soften hard stool. In most cases, there is no specifi c ther-
apy, and the aims of treatment are detailed in Box 7.2 . The mainstay of treatment of
idiopathic pruritus ani is to try to reduce the amount of seepage and to limit its conse-
quences by appropriate hygiene measures or the use of a barrier cream and by discour-
aging scratching. Surgical excision of anal skin tags is appropriate if they are inhibiting
good perianal hygiene [
2 ] . It is important to explain the underlying problem to the
patient. Most coloproctologists offer written advice about perianal hygiene, such as:
1. Clean the perianal skin after each defecation, at night and in the morning, and
whenever itching occurs. The perineum is stretched while squatting or sitting,
94
I. Badger
which helps to achieve thorough cleaning. A bidet is ideal but a shallow bath or a
well-directed shower spray can be used. Small amounts of a simple soap, or none,
should be used, but all of it must be rinsed away. Rubbing with rough fl annels or
tissues is forbidden – fi ngers are ideal. Proprietary moist toilet tissue or baby
wipes can be used, and although they may cause stinging they can be carried
easily for use outside the home. Soft moistened toilet paper is an alternative.
2. The area must be dried carefully by blotting with soft materials or even using a
hair dryer on a low heat setting. After drying, a thin piece of cotton wool, twice
the size of a 50p coin, can be laid against the anus to absorb moisture.
3. Tight sweaty clothing and nylon underwear should be avoided. Skirts and stock-
ings are better than trousers and tights.
4. Weight loss may help to reduce the trapping of sweat between the buttocks (note
that some individuals try to strap the buttocks apart).
5. Avoid soaps, scents, creams, and powders unless they are specifi cally recom-
mended (such as antifungal creams). Barrier creams such as zinc oxide and
Metanium ® can be useful in the presence of diarrhea.
6. Make dietary changes or use appropriate medication to keep a regular bowel
habit.
7. Avoid spices, alcoholic drinks (beer seems to be worse than wine or spirits), caf-
feinated drinks, milk, chocolate, tomatoes, peanuts, grapes, and citrus fruits.
8. In extreme cases, wear cotton gloves at night to stop nocturnal scratching.
These strictures can be relaxed as the condition remits but will have to be rein-
troduced when there is a relapse. Many of these changes seem simple enough to
make, but complete compliance is inconvenient for many people – it is, for example,
not always possible to fi nd adequate lavatory facilities in places of work or in public
conveniences.
Topical 1% hydrocortisone in short courses (2 weeks) can be helpful [
10 ] but may
not be superior to adequate cleaning of the perianal skin [
11 ] . Combined preparations
of hydrocortisone with an antifungal agent usually provide good symptom relief. It is
reasonable to treat empirically without obtaining proof of fungal infection in straight-
forward cases. Bismuth subgallate and zinc oxide ointments may be soothing if the
area is particularly sore. Sedating antihistamine drugs taken at bedtime may help sleep
and reduce nocturnal scratching. Topical capsaicin ointment diluted to 0.006% (higher
concentrations do not help) can relieve pruritus ani when used three times a day; it
may cause a burning sensation, but it is not yet available commercially [ 12 ] .
Box 7.2: Principles of the Management of Pruritus Ani
Eradicate secondary fungal infection with appropriate topical agents •
Eliminate dietary or other triggers (ointments, soaps, etc.) •
Promote meticulous cleaning and drying of the perianal skin (moisture •
increases risk of secondary infection)
Prevent scratching •
Try to control anal seepage •
95
7 Pruritus Ani
If simple measures fail, treatment to denervate the perianal skin can relieve the
perception of itching. Previous surgical techniques involving undermining the
perianal skin were troubled by skin necrosis. Intradermal injection of methylene
blue can achieve the same effect with fewer complications. One study reported
using 10 ml of methylene blue mixed with 7.5 ml of 0.25% adrenalized Marcaine
and 5 ml of saline: this mixture was injected along the perianal skin furrows and in
excoriated skin under general anesthetic and antibiotic cover with few side effects
and reasonable outcomes [
13 ] . More recently, Sutherland et al. [ 14 ] used a mixture
of 10 ml of 1% methylene blue, 20 ml of 0.5% Marcaine with 1:200,000 adrenaline,
and 40 mg methylprednisolone (in 1 ml). This solution was injected with a fi ne
needle (26 gauge) to raise a series of adjacent intradermal blebs 10–15 mm, which
were then massaged to spread out the drugs. The area where the itching was per-
ceived was marked out preoperatively. In a series of 49 patients, 57% became
asymptomatic after a single treatment, and no patient had residual symptoms after a
second injection; seven patients experienced transient impairment of continence,
but none suffered perianal skin necrosis.
7.5 Summary
Pruritus ani is a common and frustrating condition that causes signifi cant unpleas-
antness and embarrassment. It has a tendency to relapse and remit, which can make
it diffi cult to judge the true effect of treatment. Coloproctologists need to be aware
of the pruritus of systemic disease and dermatological pruritus. The current approach
to treatment involves lifestyle modifi cation, treatment of any cause of fecal leakage,
and the use of combined steroid and antifungal creams.
References
1. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and
anal fi ndings. Int J Med Sci. 2009;6:77–84.
2. Bowyer A, McColl I. A study of 200 patients with pruritus ani. Proc R Soc Med.
1970;63:96–8.
3. Dasan S, Neill SM, Donaldson DR, Scott NJ. Treatment of persistent pruritus ani in a com-
bined colorectal and dermatological clinic. Br J Surg. 1999;86:1337–40.
Key Points
Pruritus ani is common in colorectal practice. It may be primary or second-•
ary. A few cases have serious underlying pathology. Idiopathic pruritus ani
is a complex functional abnormality of the anorectum that is treated by
dietary manipulation, lifestyle changes and careful perianal hygiene.
96
I. Badger
4. Smith EL, Henrichs D, McCullam RD. Prospective studies on the etiology and treatment of
pruritus ani. Dis Colon Rectum. 1982;25:358–63.
5. Dodi G, Pirone E, Bettin A, Veller C, Infantino A, Pianon P, Mortellaro LM, Lise M. The
mycotic fl ora in proctological patients with and without pruritus ani. Br J Surg. 1985;72:
967–9.
6. Eyers AA, Thomson JPS. Pruritus ani: is anal sphincter dysfunction important in aetiology?
Br Med J. 1979;2(6204):1549–51.
7. Farouk R, Duthie GS, Pryde A, Bartolo DC. Abnormal transient internal sphincter relaxation
in idiopathic pruritus ani: physiological evidence from ambulatory monitoring. Br J Surg.
1994;81:603–6.
8. Abel AL. Pruritus ani. Br Med J. 1939;1(4081):627–30.
9. Murie JA, Sim AJW, Mackenzie I. The importance of pain, pruritus and soiling as symptoms
of hemorrhoids and their response to haemorrhoidectomy or rubber band ligation. Br J Surg.
1981;68:247.
10. Al Ghnaniem R, Short K, Pullen A, Fuiller LC, Rennie JA, Leather AJ. 1% hydrocortisone
ointment is an effective treatment of pruritus ani: a prospective randomized controlled double
blind cross over trial. Int J Colorectal Dis. 2007;22:1463–7.
11. Öztaş MO, Öztaş P, Önder M. Idiopathic perianal pruritus: washing compared with topical
corticosteroids. Postgrad Med J. 2004;80:295–7.
12. Lysy J, Sistiery-Ittah M, Israelit Y, Shmueli A, Strauss-Liviatan N, Mindrul V, Keret D, Goldin
E. Topical capsaicin – a novel and effective treatment for idiopathic pruritus ani: a randomised,
placebo controlled crossover study. Gut. 2003;52:1323–6.
13. Farouk R, Lee PW. Intradermal methylene blue injection for the treatment of idiopathic pruri-
tus ani. Br J Surg. 1997;84:670.
14. Sutherland AD, Faragher IG, Frizelle FA. Intradermal injection of methylene blue for the treat-
ment of refractory pruritus ani. Colorectal Dis. 2009;11:282–7.
97
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_8, © Springer-Verlag London Limited 2012
8.1 Introduction
Although anorectal sexually transmitted diseases (STIs) commonly present directly
to “sexual health clinics,” patients may not necessarily attribute their symptoms and
signs to such diseases and consequently may present to a colorectal surgeon for
further investigation and management.
It is important that if a colorectal surgeon has a clinical suspicion of an STI,
advice from a sexual health specialist is sought to avoid unnecessary invasive inves-
tigations and to ensure that the appropriate microbiological tests, treatment, and
contact tracing are carried out. Most sexual health clinics will see such cases
promptly within 48 h if referral is indicated.
B. P. Goorney , M.B.Ch.B., FRCP
Sexual Health , Salford Royal Foundation Hospital Trust ,
Goodman Centre, Lance Burn Health Centre, Churchill Way , Salford , M6 5QX, UK
e-mail: benjamin.goorney@srft.nhs.uk
Chapter 8
Anorectal Sexually Transmitted Infections
Benjamin P. Goorney
Case Scenario
A 35-year-old homosexual male presents to your clinic with a 2-week history
of rectal pain, mucopurulent rectal discharge, and bleeding, along with inter-
mittent tenesmus. His previous health is good, and last had a full negative
sexual health screen (including HIV test) 2 years ago. Although he has a cur-
rent regular male partner, he admits to having “risky sex” with several casual
partners, including anal “fi sting” and use of poppers (nitrates) while on a trip
to Barcelona 6 weeks previously.
On clinical exam, he is afebrile and has a few enlarged inguinal lymph nodes
bilaterally, with normal external anogenital examination. Sigmoidoscopy reveals
an acute nonulcerative proctitis, with edema and mucopurulent exudates.
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