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Sorting out the symptoms - anal itching

GPs Dr Keith Hopcroft and Vincent Forte continue their series on how to make sense of common presentations by looking at an embarrassing but very treatable condition

GPs Dr Keith Hopcroft and Vincent Forte continue their series on how to make sense of common presentations by looking at an embarrassing but very treatable condition

The GP overview

Straight out of the list of ‘embarrassing things to see your GP about', this is a presentation that patients love to hate. From a GP perspective, it's one that is generally straightforward to deal with, and effective treatment can usually be offered immediately, much to the patient's relief.

Differential diagnosis


• fungal infection, such as tinea or thrush

• threadworms

• haemorrhoids

• perianal skin tags

• anal fissure


• poor hygiene

• recurrent or chronic diarrhoea

• perianal warts

• trauma from sexual practices – anal intercourse and foreign body insertion

• faecal incontinence, including liquid faecal seepage around impacted scybala

• psoriasis

• secondary to underlying diabetes

• anorectal carcinoma

• chemical irritation: defaecation after a very spicy meal (commonly experienced, rarely presented in practice), bubblebaths, soaps, sexual lubricants


• irritation from perineal decorative body piercing (the ‘guiche')

• lichen sclerosus et atrophicus – affects one in 100 women, three in 10 of these have anal symptoms

• Crohn's disease (anal or perianal fistula)

• rectovaginal fistula

• rectal prolapse

• any other cause of rectal discharge or anal swellings

• any serious cause of generalised pruritus – rare here because pruritus ani is unlikely to be a presenting complaint

• STDs, for example, syphilis, gonorrhoea

Typical investigations

Likely none

Possible skin swab, FBC, ESR, fasting glucose, proctoscopy

Small print none

In general, unless there are obvious pointers to other more serious disease, investigations would usually only follow after failure of empirical treatment.

• Skin swab for bacteriology May help identify local infection

• FBC and ESR May be helpful if Crohn's disease is suspected, but only as an adjunct to referral as the appropriate management

• Fasting glucose Essential in recurrent or prolonged cases

• Proctoscopy Quick to do in general practice and can yield valuable information if there is an underlying rectal cause

Top tips

• Most patients will have attempted self-treatment before presenting in the surgery. This may not always have been appropriate, and could have made the problem worse.

• Unless you are absolutely sure of an obvious cause, it is wise to perform a digital rectal examination to look for rectal causes.

• Perianal warts imply an STD contact. Refer to GUM clinic.

• Anal itching is often associated with soreness. If it precludes a rectal examination but there is no obvious primary anal cause for itching, treat symptomatically and ask the patient to come back for complete assessment when it is more comfortable. The patient is unlikely to want to return for this unless you give a clear explanation of why it is necessary.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

This is an extract from , third edition, published by Radcliffe Publishing,

priced £24.95 ISBN-10 1 84619 1955

Threadworm: one of the common causes of anal itching Threadworm

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