Pruritus Ani: Understanding the Vicious Itch-Cycle

What is pruritus ani?

Pruritus ani, also known as anal itching, is a medical condition where a person experiences itchiness around the anal region. You may notice that the itchiness worsens at night or when you are having a bowel movement [1]. 

There are two types of pruritus ani, these are:

• Primary pruritus ani: also known as idiopathic pruritus ani, it has no known or apparent cause and is the most common type of pruritus ani.
• Secondary pruritus ani: can be caused by various things such as infections, food, or medical conditions. 

While this condition does not threaten your internal health and body, it can affect you psychologically. This includes disrupting your sleep quality, affecting your mood, and even leading to embarrassment when symptoms occur in public.

What are the causes of pruritus ani?

As previously mentioned, most cases of pruritus ani have no apparent cause. However, sometimes, it can be seen as an early warning sign of an underlying medical condition. Some possible causes of pruritus ani include:

Skin conditions	Infections	Structural causes	Systemic medical conditions	Miscellaneous (food and medication)
-Eczema-Contact dermatitis-Psoriasis-Seborrhoeic dermatitis	-Fungal infection-Threadworms-STDS (herpes, scabies, warts, chlamydia)	-Piles/haemorrhoids-Cyst-Fissure-Abscess-Tumour/growth	-Thyroid disease-Diabetes-Iron deficiency anaemia-Liver disease	-Colchicine-Peppermint oil-Antibiotics-Food such as milk, spices, chilli peppers

What can exacerbate pruritus ani?

The symptoms of an itchy bottom can be exacerbated by: 

• Hot/humid weather
• Increased moist over the perianal region
• Excessive sweating
• Concurrent presence of residual urine/faeces around the anus
• Stress
• Anxiety

Is pruritus ani suggestive of having STDs?

While there can be various reasons for experiencing anal itching, it is essential to be aware that an untreated STD may potentially be a cause [2]. If the itch persists or becomes more severe and frequent, it is advisable to consult your doctor, especially if you have had a concerning exposure in the past.

It is important to know that STD-related pruritus ani is typically treatable, but diagnosis and prompt treatment by a healthcare professional is necessary.

What STDs are associated with pruritus ani?

If you are worried about contracting an STD and experiencing anal itching, you can discuss it with your doctor. Common STDs linked to anal itching are outlined below:

Bacterial STDs	Chlamydia, Gonorrhoea
Viral STDs	Warts (HPV), Herpes Simplex Virus (HSV)
Mites STDs	Scabies, Pubic lice/crab

You should speak to your doctor if you notice persistent or worsening peri-anal itch. Consider undergoing STD screening and seek early medical treatment if you test positive.

What should I do if I experience anal itching or symptoms to suggest pruritus ani?

If you find that the itching in your anal area persists or worsens in terms of frequency and intensity, it is recommended that you seek medical advice. Since there can be multiple underlying causes for pruritus ani, it is crucial to have a thorough examination by a healthcare professional. This will help identify potential causes and ensure you receive appropriate treatment for your symptoms.

What should I expect when seeing my doctor for anal itching?

When you consult your doctor regarding anal itching, they will begin by taking your medical history and conducting a physical examination. During this examination, your doctor will carefully inspect the external skin around the anal area, checking for any lumps, bumps, or rashes. In some cases, your doctor may suggest an anoscopy procedure, which involves using a proctoscope to examine the anal canal for any abnormalities visually.

Depending on your specific concerns and medical history, you may be recommended additional tests, such as swabs or blood tests. These tests help further assess the situation and determine any underlying causes for your symptoms.

Is anal itching or pruritus ani a sign of me being unhygienic?

Interestingly, while poor hygiene practices can contribute to skin problems and make you more susceptible to skin inflammation and itching, it is essential to note that perianal itching is typically not a result of inadequate cleanliness. In fact, individuals with pruritus ani often tend to be very concerned about hygiene and, as a result, may excessively and vigorously clean the affected area with soap and water. Paradoxically, this excessive cleaning can damage the skin’s protective barrier and lead to irritation, worsening the itching symptoms.

How can I treat anal itching?

If there is a specific underlying medical condition, your doctor may prescribe targeted treatments such as topical steroids, antifungal creams, deworming medications, or antibiotics to address the root problem. In cases involving structural issues such as haemorrhoids or anal fissures, your doctor will offer guidance on further treatments, which may include surgery.

However, pruritus ani may not have a clear cause in many instances. In such situations, you are advised to:

• Avoid possible irritants in the form of topical wash, perfume, deodorant, and scented tissue.
• Avoid possible food that may trigger anal itch (such as spicy foods, citrus fruits, dairy products. and more).
• Avoid overly washing your anus; use bland unscented soap.
• Avoid tight clothing/underpants.
• Wear cotton underpants and change your underpants daily.
• Avoid excessive sweating.
• Bathe or change your clothes after exercise.
• Avoid excessive moisturiser around your anus.
• Keep fingernails short and clean to avoid further anal skin damage from scratching.
• Consider antihistamines to manage the itch symptoms.

Will pruritus ani symptoms recur?

If the root medical problem is treated successfully, the itching symptoms can resolve independently. However, in cases where the cause of pruritus ani remains unknown, the itching can persist and become a chronic issue, which can be quite frustrating for you. In more chronic cases, your doctor may recommend consulting a dermatologist or a colorectal surgeon for further evaluation and management [3].

What symptoms are associated with pruritus ani that I should be worried about?

Symptoms or red flags that warrant you to seek medical attention immediately include:

• Persistent, worsening or increase in intensity and frequency of itch
• Surrounding skin rashes or blisters
• Blood in the stool
• Abnormal anal discharge
• Visible or palpable unusual lumps over the anal region
• Loss of control of bowel movement (soiling)

Conclusion

Pruritus ani can be frustrating for you and your physician because identifying the root cause can be challenging. Discussing this with your physician may feel embarrassing and daunting, but it is crucial to do so, especially if there is a chance of treatable or reversible causes such as STDs. You can receive the most appropriate and effective treatment through a thorough examination and screening for potential infections and other factors. It is essential not to let embarrassment deter you from seeking the help you need.

Reference

1. Seok-Gyu Song, S.-H. K. (2011). Pruritus Ani. Journal of the Korean Society of Coloproctology, 54-57.
2. K Manavi, A. M. (2004). The prevalence of rectal chlamydial infection amongst men who have sex with men attending the genitourinary medicine clinic in Edinburgh. International Journal of STD and AIDS, 162-164.
3. Matas Jakubauskas, A. D. (2023). Evaluation, management and future perspectives of anal pruritus: a narrative review. European Journal of Medical Research, doi: 10.1186/s40001-023-01018-5.