Causes and Management of Pruritus Ani.

CASE SUMMARY: A 48-year-old healthy man presented to the office reporting a long-standing history of anal pruritus. He had tried various over-the-counter creams without much success. Besides an anal fissure in the past, which responded to nitroglycerin ointment, his medical history was unremarkable. On physical examination, he was found to have grade I hemorrhoids and mild fecal smearing on perianal skin. Recent colonoscopy and laboratory work ordered by the primary care provider were normal. He was counseled on common inciting agents and local irritants and was advised on hygiene, diet modification, and stool-bulking agents. The colorectal surgeon recommended that the patient keep a journal about his symptoms, foods, and household chemicals used. He was seen twice more over the course of 6 months to pinpoint the cause of his pruritus. A short-course trial of topical steroid, barrier cream, and topical tacrolimus was not helpful. A biopsy of perianal skin was performed and was unrevealing. Eventually, given the persistence of symptoms, it was decided that he would undergo methylene blue injection to address his pruritus (Fig. 1). The procedure consisted of several intradermal and subcutaneous injections of 10 mL of 1% methylene blue combined with 7.5 mL of 0.25% bupivacaine with adrenaline (1/100,000) and 7.5 mL 0.5% lidocaine. After the methylene blue injection, the severity of his symptoms improved, but pruritus still persisted. A methylene blue injection of the same concentration was repeated in 3 months with complete resolution of symptoms.

Efficacy and safety of methylene blue injection for intractable idiopathic pruritus ani: a single-arm metaanalysis and systematic review.

PURPOSE: To evaluate how effective methylene blue injection was at treating intractable idiopathic pruritus ani. METHODS: A comprehensive literature search of the PubMed, Embase, Cochrane library, and Web of Science databases was conducted. All clinical studies (prospective and retrospective) that evaluated the efficacy of methylene blue in treating intractable idiopathic pruritus ani were included. Studies that reported the resolution rate, after a single injection and after a second injection, the recurrence rate, symptom scores, and transient complications of methylene blue injections in treating intractable idiopathic pruritus ani were included. RESULTS: The seven selected studies included 225 patients with idiopathic pruritus ani. The resolution rates after a single injection and after a second injection was 0.761 (0.649-0.873, P < 0.01, I2 = 69.06%) and 0.854 (0.752-0.955, P < 0.01, I2 = 77.391%), respectively, the remission rates at 1, 3, and 5 years were 0.753 (0.612-0.893, P < 0.001), 0.773 (0.675-0.871, P < 0.001) and 0.240 (0.033-0.447, P < 0.001), respectively, the effect value of the merger was 0.569 (0.367-0.772, P < 0.001, I2 = 79.199%), and the recurrence rates at 1, 2, 3, and < 1 year were 0.202 (0.083-0.322, P < 0.001), 0.533 (0.285-0.781, P < 0.001), 0.437 (-0.044, 0.917, P < 0.001) and 0.067 (0.023-0.111, P < 0.001), respectively. The effect value of the merger was 0.223 (0.126-0.319, P < 0.001, I2 = 75.840). CONCLUSION: Using methylene blue injections to treat intractable idiopathic pruritus ani is relatively efficacious, resulting in a relatively low recurrence rate and no severe complications. However, the available literature was of poor quality. Therefore, higher quality studies are necessary to confirm that methylene blue injection is efficacious for pruritus ani, such as a randomized prospective multicenter studies.

[Web search data as health data? : Geographic differences, temporal trends, and topics of interest from internet search engine analyses in Germany]. / Websearch-Daten als Gesundheitsdaten? : Geografische Unterschiede, zeitliche Trends und Interessenschwerpunkte von Internetsuchmaschinenanfragen in Deutschland.

BACKGROUND: Limited timely, cost-effective, and regional availability of healthcare data is considered one of the limiting factors for timely analyses in the field of health services research and thus for healthcare delivery to the general population. Thus, Internet search engine analyses are coming into focus in this context. OBJECTIVES: What contribution can data on the volume of Internet searches for various diseases make to the health care of the German population? Where is the potential and where are the limitations? METHODS: A review of the current literature and a selective overview of Internet search engine analyses of dermatological, allergological, and infectious diseases published in the last 4 years in Germany were performed. RESULTS: By analyzing web search data, temporal developments such as seasonality, months with the highest interest, and geographical differences can be mapped at the national, state (Bundesländer), and city level and major points of interest (e.g., skin cancer of the eye or anal itching) regarding a certain health topic can be identified. In addition, some studies were able to show correlations between search volume and external factors (e.g., temperature, care structure) and to registered cases (e.g., skin cancer, Lyme disease). CONCLUSION: Web search data, given the limitations noted, are able to directly provide spatiotemporal mapping regarding the needs of the Internet-using population. They are particularly useful in situations where traditional health data are limited or unavailable.

Medical needs and major complaints related to pruritus in Germany: a 4-year retrospective analysis using Google AdWords Keyword Planner.

BACKGROUND: It is difficult to estimate the prevalence of acute and chronic pruritus in the population at large due to a lack of affected persons seeking medical assistance. OBJECTIVE: To discover the incidence of pruritus in Germany and determine what the most common related complaints are via an analysis of Google's search volume. METHODS: From June 2013 to April 2017, the Google AdWords Keyword Planner was utilized to select and critically assess relevant keywords for 'pruritus'. RESULTS: Among a total of 13 691 470 German language Google searches on the topic of pruritus, it was found that the most searched for terms included atopic eczema (24.3%) and the layman's term for psoriasis ('Schuppenflechte'; 17.8%), as well as just psoriasis (13.4%). 'Juckreiz', the German word for pruritus, was determined to be only the sixth most searched for term (2.9%). Anal pruritus and pruritus of the entire body comprised the most searched for localizations. The various factors that impact pruritus, particularly skin conditions and disorders, were established to be among the most searched for terms (72.6%). A decreased monthly search volume was associated with the changing seasons; the summertime had the lowest number of searches for pruritus. CONCLUSION: The Google search engine analysis provided insight for this study into the unexpectedly large number of unmet medical needs of those suffering from pruritus within Germany, especially that of specific localizations on the body.

Long-term follow-up of intradermal injection of methylene blue for intractable, idiopathic pruritus ani.

BACKGROUND: While various medical treatments such as topical steroid ointment, antihistamine agent, and sedatives have been used for treating idiopathic intractable pruritus ani, they are not long-term solutions, due to the high recurrence rate. The aim of this study was to determine the effect of methylene-blue intradermal-injection therapy for treating patients with idiopathic intractable pruritus ani. Symptom improvement and recurrence rates were determined with a long-term follow-up. METHODS: A retrospective study was conducted from January 2011 to October 2013 on consecutive patients with intractable pruritus ani treated with methylene-blue intradermal injection. The therapy included 5 ml of 1% methylene blue and 15 ml of 1% lidocaine. Follow-up included a physical exam and satisfaction-score survey (1 = much worse, 2 = worse, 3 = no improvement, 4 = much better, 5 = gone completely) before treatment, 6 weeks after treatment, and 3 years after treatment to check patient status and recurrence rate. RESULTS: Of 103 treated patients, 96 were able to attend the 6-week follow-up visit. There were 58 (60.4%) males and 38 (39.6%) females with a mean age of 48.34 ± 10.21 years. Their mean satisfaction score at 6 weeks was 4.23 ± 0.86. Of the total of 96 patients, 9 (9.4%) patients scored 3 or less in their satisfactions score at 6 weeks. 62 (64.6%) patients were evaluated 3-year post-treatment. The satisfaction score at 3 years after treatment was 4.74 ± 0.57. Besides the 9 patients who initially failed treatment, 4 of the remaining 53 patients scored 3 or less in their satisfaction score surveys. Thus, the recurrence rate at 3 years was 7.5% (4/53). CONCLUSIONS: Methylene-blue intradermal injection can result in a high symptom improvement rate with low recurrence rate for patients with idiopathic pruritus ani.

[Pruritus in Germany-a Google search engine analysis]. / Pruritus in Deutschland ­ eine Google-Suchmaschinenanalyse.

BACKGROUND: Because affected persons often do not visit a doctor, the prevalence of chronic and acute pruritus in the general population is difficult to determine. OBJECTIVES: The aim of this study is to estimate the frequency and the most common locations of pruritus in German internet users, who-with 62.4 million persons-represent a large majority of the German population, by analysing the Google search volume. MATERIALS AND METHODS: Relevant keywords for the subject "pruritus" were identified and analysed using the Google AdWords Keyword Planner. The assessment period was January 2015 to December 2016. RESULTS: In total the Google AdWords Keyword Planner identified 701 keywords for the topic "Juckreiz" (German lay word for pruritus), resulting in 7,531,890 pruritus-related Google searches during the assessment period. Most common search terms were the German lay term for atopic eczema ("Neurodermitis", 23.7%), the German lay term for psoriasis ("Schuppenflechte", 17.8%) and "psoriasis" (13%). The German lay term for pruritus ("Juckreiz") was only the sixth most searched term (3%). Most searches (72%) focused on influencing factors for pruritus, especially on skin diseases and skin conditions. The most commonly searched location was pruritus on the whole body, followed by anal pruritus. Analysis of the temporal course showed a higher monthly search volume during winter. CONCLUSION: With its unconventional methodology, a Google search engine analysis, this study allows a rough estimation of the medical need of pruritus in the German general population, which seems to be higher than expected. Especially pruritus in the anal area was identified as an unmet medical need.

Comparison of captopril (0.5%) cream with diltiazem (2%) cream for chronic anal fissure: a prospective randomized double-blind two-centre clinical trial.

AIM: This study compared the efficacy of topical captopril with topical diltiazem in the treatment of chronic anal fissure (CAF). METHOD: Fifty patients aged between 15 and 75 years with CAF were included in a prospective randomized, double-blind clinical trial. They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks. The intensity of pain upon defaecation was evaluated every 10 days using a visual analogue scale. Bleeding on defaecation, pruritus and the presence of perianal irritation were also recorded before and during the trial. RESULTS: The average pain scores were lower in the diltiazem group on the 20th and 30th days. From day 40 to the end of the trial the average pain scores of the two groups did not differ significantly. There were no significant differences in bleeding or perianal irritation between the groups, but the incidence of pruritus was considerably higher in the captopril group, and at the end of the trial 45.8% of the patients in this group still suffered from pruritus. CONCLUSION: Topical captopril and diltiazem were found to be equally effective in the management of pain, bleeding and perianal irritation due to CAF, but due to the high incidence of pruritus observed with topical captopril this medication is not recommended for the treatment of CAF.

Survey of electric bidet toilet use among community dwelling Japanese people and correlates for an itch on the anus.

OBJECTIVES: We conducted a survey to investigate the use of bidet toilets among community dwelling Japanese people and explored the correlates for an itch on the anus. METHODS: A questionnaire-based survey was conducted among a convenience sample of individuals, who were derived from outpatients and employees of Kameda Medical Center, and students and employees of two technical colleges. RESULTS: A total of 4,963 respondents were evaluated in this study, 55 % of whom used bidet toilets either before or after defecation, and at least 30 % of bidet users washed the anus before defecation, partly to aid defecation. Men rather than women, and older people (aged ≥50 years) rather than younger people used bidets more actively. Logistic regression analysis showed that the correlates for an itch on the anus included male sex, younger age, washing the anus before defecation, warmer water for washing the anus after defecation, and the frequency of fecal leakage. CONCLUSIONS: Nearly, one-third of bidet toilet users washed the anus before defecation. An itch on the anus may be associated with the active use of bidets.

Benign anal disease.

Benign anal disease encompasses common problems including hemorrhoids, anal fissures, pruritus ani, perianal abscesses, and fistulae. Although many people will suffer from at least one of these conditions in their lives, healthcare practitioners diagnose and treat them accurately about 50% to 83% of the time. This article reviews common anal problems and the importance of a thorough history and physical examination to proper patient management.

[Differential diagnosis of anal eczema]. / Differenzialdiagnose des Analekzems.

Dermatologic disorders often show involvement of the (peri)anal skin. However, diagnosis of (peri)anal dermatoses is often difficult even for experienced dermatologists due to delayed clinical presentation or prior treatment with over-the-counter medications. The distinct anatomical conditions of the (peri)anal region results in atypical clinical presentation of common dermatoses. Typical symptoms include pruritus, burning, bleeding and pain. Careful history of symptoms, stool, hygiene, sexual practice as well as thorough inspection of the entire body and proctological examination are crucial to make the correct diagnosis. In case of atypical presentation or uncertainty a biopsy needs to be obtained to ensure correct diagnosis and treatment.

[Pruritus ani]. / 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.

Management and outcome of perianal Paget's disease: a 6-decade institutional experience.

BACKGROUND: Perianal Paget's disease (intraepithelial adenocarcinoma) is rare and sometimes difficult to diagnose because symptoms are nonspecific. It is often noninvasive but frequently recurs locally. Invasive disease can metastasize to distant sites. OBJECTIVE: The purpose of this work was to review the diagnosis, management, and outcomes of patients with perianal Paget's disease. DESIGN: Institutional databases were queried for all of the cases of perianal Paget's disease at Memorial Sloan-Kettering Cancer Center between 1950 and 2011. Clinicopathologic factors were investigated for association with recurrence and survival. SETTINGS: The study was conducted at a tertiary care center. PATIENTS: Sixty-five patients with perianal Paget's disease were included in the study (35 women [54%]; median age at diagnosis, 66 years [range, 60-72 years]; and 41 with invasive disease/24 with noninvasive disease). A total of 56% with invasive disease were men. MAIN OUTCOME MEASURES: Measures included median follow-up, disease status, local and distant recurrence, sites of recurrence, disease-specific survival, overall survival, and treatment modality. RESULTS: A total of 95% with invasive disease and 87% with noninvasive disease were symptomatic at presentation. The most common symptoms were pruritus and perianal bleeding. The duration of symptoms was longer in patients with invasive (12.0 months; range, 4.0-18.0 months) versus noninvasive (3.5 months; range, 1.0-10.0 months) disease. Synchronous malignancies unrelated to the primary disease were noted in 5 patients with invasive disease and 3 with noninvasive disease. Noninvasive disease was treated with a wide local excision and invasive disease with a wide local excision (n = 32, 78%) or abdominoperineal resection (n = 9, 22%). Forty-one patients (27 invasive and 14 noninvasive) required multiple operations for tumor clearance. In those with invasive disease, the median time to recurrence was 5 years, and the median tumor-specific survival rate was 10 years. LIMITATIONS: This was a retrospective study, limited by selection bias. CONCLUSIONS: Perianal Paget's disease is associated with nonspecific symptoms, frequently delaying diagnosis. Wide local excision is the treatment of choice if negative margins can be obtained. Abdominoperineal resection should be considered for invasive disease. Local recurrence is common; follow-up includes periodic proctoscopy and digital examination. Invasive disease can metastasize to distant sites; follow-up should include the examination of inguinal lymph nodes and the imaging of liver and lungs.

Common anorectal conditions: evaluation and treatment.

Anorectal conditions are frequently encountered clinical entities but are often misunderstood and misdiagnosed. Although the most common anorectal disorders are not considered life threatening, they can negatively impact patients' activities of daily living and quality of life. Comprehensive anorectal examination, including the use of anoscopy, has become a "lost art," and graduate medical education programs should utilize more formal training in this area. This review discusses the comprehensive anorectal exam and the diagnosis and management of three common anorectal disorders: hemorrhoids, anal fissure, and pruritus ani.

Perianal pruritus in dogs with skin disease.

BACKGROUND: Perianal pruritus has been reported in dogs with anal sac disease but not in healthy dogs. Some authors describe it as typical of allergy, but there is little evidence in support of this. HYPOTHESIS/OBJECTIVES: The aim was to investigate the association between perianal pruritus and canine atopic dermatitis (CAD), adverse food reaction (ARF) and other skin diseases in dogs. ANIMALS: Two hundred and fifty privately owned dogs with skin disease and without anal sac disease. METHODS: The presence or absence of perianal pruritus, macroscopic and cytological evaluation of the perianal skin surface and the macroscopic appearance of anal sac contents were assessed. Chi-square and Fisher's exact tests were performed to compare the frequency of perianal pruritus with the clinical diagnoses and with clinical and cytological parameters. RESULTS: Perianal pruritus was seen in 39 of 75 dogs with CAD, in 29 of 57 dogs with ARF and in only 24 of 118 dogs with other conditions. The frequency of perianal pruritus in dogs with CAD and/or ARF was significantly higher than that in dogs with other diagnoses (P < 0.0001). No other disease was significantly associated with perianal pruritus. Perianal pruritus was significantly associated with signs of perianal alopecia, erythema, excoriations, lichenification and hyperpigmentation; it was not associated with the presence of bacteria or yeasts or with anal sac impaction. CONCLUSIONS AND CLINICAL IMPORTANCE: Perianal pruritus was seen more frequently in dogs with AFR/CAD than with other dermatological diseases. This is the first study to evaluate perianal pruritus in dogs with skin disease and without anal sac disease.

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]. / Douleur anale aiguë.

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.

Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement.

Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract that includes both Crohn disease (CD) and ulcerative colitis. Abdominal pain, rectal bleeding, diarrhea, and weight loss characterize both CD and ulcerative colitis. The incidence of IBD in the United States is 70 to 150 cases per 100,000 individuals and, as with other autoimmune diseases, is on the rise. CD can affect any part of the gastrointestinal tract from the mouth to the anus and frequently will include perianal disease. The first description connecting regional enteritis with perianal disease was by Bissell et al in 1934, and since that time perianal disease has become a recognized entity and an important consideration in the diagnosis and treatment of CD. Perianal Crohn disease (PCD) is defined as inflammation at or near the anus, including tags, fissures, fistulae, abscesses, or stenosis. The symptoms of PCD include pain, itching, bleeding, purulent discharge, and incontinence of stool. In this report, we review and discuss the etiology, diagnosis, evaluation, and treatment of PCD.