Care for Pruritis Ani
Pruritis Ani, or “itchy butt”, is a frustrating and uncomfortable disorder in which the affected person develops severe itching around the anus. Some patients don’t describe itching but will experience severe burning or pain in the area. This condition occurs as a result of more than 100 different causes, so it is often difficult or impossible to find the source or cause in any given patient. Your doctor will examine you to try to get clues as to the cause. Additional testing may be recommended, including blood work, biopsies of the area, colonoscopy, and stool testing. Frequently we don’t find a source or cause — most doctors feel in this case that an environmental agent is causing the problem, either a food sensitivity or a chemical you use at home like shampoo, soap or body lotions. The following are tips for caring for the skin of the anal area and may help mitigate or eliminate the itching.
- Your goal is to keep the skin of the anal area clean, dry.
- Most people will experience some relief from itching within a week. A cure may take four to six weeks, or longer.
- Recurrences are common and to be expected; try to follow these recommendations as closely as possible.
1. Stop using any chemicals or agents in the area except what you and your doctor specifically discuss. If you forgot to mention something, call your doctor and let them know. The tiniest bit of information may help solve the mystery.
2. During bath or shower, it is important that you keep other cleansing products away from this area. For example, shampoo will naturally drain down into the anal area when you rinse, and could be the cause of irritation. After washing with other skin care products (shampoo, rinse, soap) wash the outside of the anal area thoroughly with water. Do not use soap in the anal area (it is alkaline and will increase discomfort). As the final step in your morning shower or bath, cleanse the anal area with hot water and Balneol Lotion (Solvay Pharmaceutical, Marietta, GA) applying it with fingertips or wet cotton balls, then rinse lightly afterwards. Balneol is available hit and miss at pharmacies around the area, and if available, is usually located in the hemorrhoid section.
3. Dry carefully after cleansing. Avoid abrasive trauma or vigorous rubbing while drying – instead pat the skin dry with a soft towel or blow-dry the area with a hair dryer.
4. Following each bowel movement, make sure the anal area is cleansed of any residual stool. This is best accomplished by washing with hot water and Balneol Lotion. Alternatively, a non-alcoholic towelette may be used. Avoid the use of toilet paper on irritated skin – never use colored or scented toilet paper. Dry thoroughly.
5. If persistent fecal afterdrainage occurs following your bowel movement, rectal irrigation may be helpful. Rectal irrigation is performed with warm water, like taking an enema. A Fleets Enema bottle is useful for this purpose. The bottle should be emptied of the Fleets enema and filled 2/3 full with warm water. After you have your morning bowel movement, instill the enema, hold it as long as you can and then expel. The fleets bottle can be rinsed after use and reused as necessary. This will prevent fecal drainage for several hours.
6. In the morning and at bedtime, apply a thin cotton pledget or 4 x 4 gauze directly in the anal crease. It should be small enough so that you are not conscious of its presence. You may dust the cotton with corn starch if needed to keep dry. It is important to change the cotton pledget frequently during the day if it becomes moist.
7. You will need to use a barrier cream several times daily, usually calmoseptine or desitin or A & D ointment.
8. Maintain a soft, large, and nonirritating stool so that it can pass through the anal canal without causing mechanical or chemical trauma. This may be accomplished by the following:
- Fiber bulking agent such as Konsyl, Metamucil, Citrucel, or Fibercon. Begin with 1 teaspoon twice a day with 6 – 8 glasses of water each day, for two weeks. After two weeks increase the fiber to 1 tablespoon or scoop twice a day with 6 – 8 glasses of water each day. Drinking plenty of water is very important.
- Eat a high–fiber diet that includes 8 – 10 glasses of water or juice a day, plenty of fruits and vegetables, and bran cereal every day. Refer to the High Fiber Diet handout in the Patient Information section of this web site.
9. Avoid foods known to cause anal irritation. These include dark colas, spicy foods, citrus fruits and juices, tomatoes, alcohol (yes, beer too), coffee (regular or decaffeinated), chocolate, nuts, popcorn, and milk. Eliminate all of these from your diet, then reintroduce them, one at a time. If the itching returns, permanently eliminate that item from your diet.
10. Wearing cotton gloves to bed can be of benefit to prevent unconscious scratching while you sleep.
11. After the blood work, colonoscopy, fecal testing and biopsies as recommended by your doctor, you may be started on a steroid cream. It is important you use this as directed. Misuse of steroids in this area can permanently damage the anal skin.
Major Causes of Pruritis Ani
Idiopathic – “No known cause”
Personal Hygiene – Poor cleansing habits result in chronic exposure to residual irritating feces; conversely, overmeticulous cleansing with excessive rubbing and soap use.
Diet – Consumption of large volumes of liquids: coffee (caffeinated and decaffeinated, coffee–containing products), chocolate, citrus, tomatoes, spicy foods, popcorn and nuts, tea, alcohol including beer, milk and milk products, Vitamin A and D deficiency
Anatomic Compromise – Obesity, deep anal cleft, excessive hair, tight–fitting clothes (tight clothing or clothing that impairs adequate ventilation), fistula, fissure, skin tags, prolapsing papilla, or mucosal prolapse
Systemic Disease – Jaundice, diabetes mellitus, chronic renal failure, iron deficiency, thyrotoxicosis, myxedema, Hodgkin’s lymphoma, polycythemia vera
Gynecologic Conditions – Jaundice, diabetes mellitus, chronic renal failure, iron deficiency, thyrotoxicosis, myxedema, Hodgkin’s lymphoma, polycythemia vera
Neoplasms – Bowen’s disease, extramammary Paget’s disease, squamous cell carcinoma, cloacogenic carcinoma, rectal or polypoid lesion
Diarrhea States – Irritable bowel syndrome, Crohn’s disease, chronic ulcerative colitis
Radiation – Postirradiation changes
Psychiatric Diagnoses – Anxiety, neuroses, psychoses
Drugs – Quinidine, colchicine, antibiotics (tetracycline), IV hydrocortisone phosphate, ointments or creams that contain “caine” drugs, nonprescription medications for personal hygiene such as perfumed soaps and ointments that may containe alcohol, witch hazel, or other astringents
Dermatologic conditions – Psoriasis, seborrheic dermatitis, atrophic dermatitis, lichen simplex, cytomegalovirus, papillomavirus, bacteria (staph aureus, erythasma), mixed infections, fungi (dermatophytosis, candidiasis), parasites (pinworms, scabies, pediculosis), spirochetes (syphilis)
This information is for guidance only and should not constitute medical advice. Adapted from Clinical Decision Making in Colorectal Surgery. Wexner. copyright 1995. pp51–53.