Anal itching (pruritus ani)

Anal itching (pruritus ani): Causes, work-up and treatment

Itching around the anus - pruritus ani - is a common but often under-reported reason for consultation, because the symptom is felt to be embarrassing [1]. How many people actually have it is poorly documented, precisely because many never seek help. In many cases there is a cause that can be treated, and a targeted work-up can clarify what lies behind the symptoms.

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What is pruritus ani?

Pruritus ani is intense itching or burning in and around the anus. It is divided into two groups:

• Secondary (the more common form) - caused by a specific condition such as hemorrhoids, anal fissure, anal fistula, eczema, fungal infection or faecal leakage.
• Primary / idiopathic - no clear cause is found, but a vicious circle of itching → scratching → skin irritation → more itching maintains the symptom [2].

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The most common causes

Category	Examples
Anorectal disease	Hemorrhoids, anal fissure, anal fistula, rectal prolapse
Skin	Contact eczema, lichen sclerosus, psoriasis, lichen sclerosus
Infection	Candida, Streptococcus, pinworm (Enterobius), HPV
Leakage	Incontinence for gas/stool, mucus from hemorrhoids
Diet	Coffee, tea, cola, beer, citrus, spicy food, milk, chocolate [3]
Hygiene	Excessive washing, perfumed wet wipes, soap residue

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When should you see a doctor?

Contact your GP or a specialist surgeon if you have:

• Itching for more than 4-6 weeks despite normal hygiene
• Concurrent rectal bleeding (read more)
• Visible lumps, sores or skin changes
• Mucus or unintentional stool in your underwear
• Night-time itching that wakes you (classic for pinworm and lichen sclerosus)

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How pruritus ani is worked up

At the clinic we perform:

1. History and dietary review - identifies triggering foods and hygiene habits.
2. Inspection and digital rectal examination - reveals hemorrhoids, fissure, eczema.
3. Anoscopy - an examination with a short instrument that gives a view of roughly the last 5 to 6 cm from the anal verge.
4. Colonoscopy if symptoms, alarm features, age, test results and the overall medical assessment support it.
5. Skin biopsy if lichen sclerosus or malignancy is suspected.

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Treatment

General advice (resolves the problem for many) [4]:

• Change hygiene: Rinse with lukewarm water without soap; dab dry with a soft towel - no wet wipes.
• Cotton underwear, avoid tight clothing and synthetic fabrics.
• Elimination diet for 2 weeks: leave out coffee, tea, cola, citrus, spicy food - reintroduce one at a time.
• Stop scratching - keep nails short, use cotton gloves at night if needed.

Medical treatment:

• Short-term hydrocortisone 1% cream for acute eczema, with duration assessed individually by a doctor [2].
• Antifungal cream should only be used for a verified fungal infection (e.g. candida) and after medical assessment.
• For verified pinworm, the whole household is normally treated at the same time, following current guidance from a doctor or pharmacist. Treatment is repeated in many cases because reinfection is common, but whether and when to repeat it is decided by a doctor or pharmacist. Choice of agent and dosing depend on factors such as age and pregnancy - never stop or start prescribed treatment on your own without agreeing it with your doctor.

Treatment of the underlying surgical cause:

• Hemorrhoids grade I-II: McGivney band ligation in the out-patient clinic.
• Hemorrhoids grade III-IV: surgical treatment.
• Anal fissure: conservative → diltiazem ointment → possibly surgery.
• Anal fistula: surgical fistula treatment.

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Treatment at Kirurgen.dk

We assess and treat common anorectal causes of itching - from hemorrhoids and fissures to fistulas - after referral from your GP. Whether a service is covered by the Danish public health insurance depends on the referral, the service and agreement in force and an individual assessment; contact the clinic or your GP if you are unsure. See also our articles on hemorrhoids and anal fissure.

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References

1. Nasseri YY, Osborne MC. Pruritus ani: diagnosis and treatment. Gastroenterol Clin North Am 2013;42(4):801-13.
2. Markell KW, Billingham RP. Pruritus ani: etiology and management. Surg Clin North Am 2010;90(1):125-35.
3. Daniel GL, et al. Pruritus ani: causes and concerns. Dis Colon Rectum 1994;37(7):670-4.
4. Siddiqi S, Vijay V, Ward M, Mahendran R, Warren S. Pruritus ani. Ann R Coll Surg Engl 2008;90(6):457-63.