Anal Pain and Itch

Essentials

• Carefully taken patient history and clinical examination are usually sufficient for the diagnosis.
• Further investigations mainly aim at the exclusion of precancerous and cancerous conditions and inflammatory bowel diseases.

Epidemiology

• Anal pain and itching are common symptoms. They are usually caused by a benign condition, most commonly anal fissure.
• There is no specific explanation for anal itching in about 60% of cases.
• A tumour is a rare cause of anal pain.
• Patients often try self-medication with topical over-the-counter ointments. Patients often delay seeking medical care for anal problems.

Causes of anal pain

• Common causes of anal pain and itching are listed in table T1.
• Most commonly, the cause of anal pain can be treated in primary health care.

• Rare causes
  • Crohn's disease Crohn's Disease
  • Rectal cancer Colorectal Cancer
  • Other anorectal malignancies
  • Rectal prolapse Haemorrhoids
  • Mucosal prolapse
  • Anal fistula
  • Leukaemia
  • Suppurative hidradenitis
  • Rectal intussusception
    • Symptoms include pain/feeling of pressure deep in the lesser pelvis after defecation.

History and clinical examination

• Table T1 shows the type of pain, along with the causes.
• It is important to ask about other symptoms that can give a clue to the diagnosis. The patient usually complains of haemorrhoids irrespective of the actual cause of the symptoms. Other common proctological symptoms include bleeding, itch, discharge, incontinence, and mucosal prolapse.
• The proctological examination consists of local examination and palpation of the abdomen and inguinal lymph nodes.
• The anus can most easily be examined when the patient is lying on their left side with the hips and knees flexed.
• Good focal and general light is necessary.
• Proceed slowly with the examination so that the patient can overcome their anxiety and relax; the doctor thus obtains more information.
• Continuously explain to the patient the course of the examination, as they cannot see what happens behind their back.

Inspection

• During the inspection, ask the patient to strain down, as if defecating.
• Palpate the perineum for the presence of a hidden abscess in patients who complain of pain.
• If the inspection is difficult because of large buttocks elevate the right buttock to make the anus visible.
• Inspection is an essential part of diagnosis e.g. in the case of the diseases listed below.
  • Incarcerated haemorrhoids
  • Perianal haematoma
  • Anal itching
  • Anal fistula
  • Anal fissure
  • Prolapsed haemorrhoids
  • Rectal prolapse
  • Anal malignancies
  • Anal condylomata

Digital rectal examination (DRE)

• DRE can usually be performed, with the exception of very painful conditions such as incarcerated haemorrhoids, anal fissure or perianal abscess.
• An impression of the condition of the structures mentioned below should be obtained by DRE.
  • Rectal mucosa
  • Anal canal
  • Levator muscle (the so-called anorectal ring)
  • Sites of pain
  • Palpable masses (tumours of the rectum and anal canal)
  • Finally, the material visible on the glove should be examined, particularly for the presence of blood.
• In levator ani syndrome, the levator muscle may be tender on stretching, and moving the coccygeal bone can be painful.

Proctoscopy

• Proctoscopy (anoscopy) is a simple investigation and a part of adequate proctological practice. No emptying of the rectum is necessary.
• Proctoscopy is an important part of the diagnosis of diseases of the anal canal and the distal part of the rectum.
  • Haemorrhoids
  • Anal fissure
  • Anal stenosis
  • Tumours of the anal canal
  • Hypertrophic anal papillae

Further investigations

• The above-mentioned investigations do not require any preparation.
• Colonoscopy is recommended as a further investigation to exclude malignancy and inflammatory diseases, if the cause of the pain is not obvious Colonoscopy and Sigmoidoscopy.

Treatment

• Disease-specific guidelines: see table T1.
• Anal itching without specific cause
  • Skin needs air and anal hygiene must be maintained (showering or washing with water after defecation, gentle drying)
  • E.g. zinc ointment can be used topically and for severe itching temporarily 1% hydrocortisone and a fungicidal preparation. Avoid allergizing combination products.
  • Cotton underwear is recommended.
  • If the symptom continues to be severe despite treatment, a biopsy of the itchy skin area is warranted.
• Muscle relaxants and analgesic drugs may be tried in the treatment of idiopathic proctalgia.
• Biofeedback therapy provided by a physiotherapist can be used in the treatment of pain caused by excessive nervous tension.
• Injecting a mixture of a local anaesthetic and a glucocorticoid into an insertional-tendinitis type painful spot at the margin of the pubic bone may be tried, if the spot is clearly palpable through the anus. The injection is performed through perineal skin and guided by rectal touch.
• Consultation at a specialized pain management clinic may sometimes be useful.