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Pruritus Ani - Itchy Bottom

Causes and treatment for this common condition

What is pruritus ani?

Pruritus ani means a chronic (persistent) itchy feeling around the anus. It is commonly know as itchy bottom or itchy bum.  The main symptom is an irresistible urge to scratch the anus or bottom. The urge to scratch may occur at any time, but most often happens after a bowel movement or at night (particularly just before falling asleep). The itch may be made worse by heat, wool, moisture, leaking, soiling, stress and anxiety.

Persistent scratching of the anal skin can damage the skin and make it more likely to develop a skin infection, that will give rise to pain and increased irritation. Chronic itching of the anal area may lead to feelings of embarrassment and both your mood and sleep can be affected.

Why does pruritus ani develop?

 Several factors may be at fault although frequently, no specific cause can be found. Common factors that may lead to pruritus ani include the following

• Excessive cleaning of the anal area. This can wash away natural oils in the skin that protect it.
• Excessive moisture around the anus, from excessive sweating during exercise or in hot weather
• Moist, sticky, loose or and/or irritating stool.
• High intake of liquids leading to loose stool.
• Certain drinks including beer, milk, citrus fruit juices and caffeine containing drinks such as coffee, tea and cola.
• Some foods that may be a problem include chocolate, fruits, tomatoes, nuts and popcorn.
• Bowel problems such as perianal infection/fistula, haemorrhoids and anal fissure  may cause itch, either directly or because of moisture from discharge of mucus, stool or pus
• Anal infections with thrush, herpes, anal warts and other sexually transmitted diseases
• Skin conditions such as psoriasis, eczema, dermatitis, and lichen sclerosis
• Some soaps, perfumes, creams, ointments, or the dye in some toilet tissue may sensitise (irritate) the skin around the anus in some people.
• Thread worms are a rare cause of pruritus ani. Typically, this give rise to intense itch at night

Does pruritus ani - itchy bottom develop because of a lack of cleanliness?

Cleanliness is occasionally a factor. However, the natural tendency once a person develops the itching is to wash the area vigorously and frequently with soap and  a wash cloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils, leading to a vicious circle. For example, if a person develops a mild anal itch, they may tend to wash the area more frequently. They may also use medicated wipes in the mistaken belief that these will help. Excessive washing leads to an increase in moisture and many soaps and wipes contain perfumes and additives that sensitise the skin, causing the itch to become worse. This leads to even more washing and the cycle gets worse, rather than better.

Another example of a vicious circle is when a person buys an ointment for an anal condition such as piles. These haemorrhoid creams often contain a local anaesthetic agent that initially numbs & soothes the itch. However, the skin can become sensitised to these ingredients very quickly leading to further itch and irritation. The tendency is to put on even more cream to help the worsening itch, which only leads to a further deterioration in symptoms. Most creams and ointments do not sensitise the skin in most people. However, be aware that there are many preparations with various ingredients and you may become sensitive to one of them.

How is pruritus ani treated?

 A careful examination by your doctor may identify a definite cause for the itching. Your doctor may recommend treatment to eliminate the specific problem. Treatment of pruritus ani may include these four points.

1. Avoid further trauma to the affected area:

• When showering or bathing, do not use soap or antiseptics of any kind in the anal area.
• Do not scrub the anal area with anything - even toilet paper.
• For hygiene, use wet toilet paper, a moist cotton ball, baby wipes or a wet washcloth to blot the area clean. Avoid alcohol-containing towelette. Never rub.
• Try not to scratch the itchy area. Scratching produces more damage, which in turn makes the itch worse. Pinching the skin from outside the underwear will relieve the desire to scratch. The wearing of cotton gloves at night is sometimes needed. Soaking in a hot bath for 20 minutes can also provide relief.

 2. Avoid moisture in the anal area:

• In the morning, at bedtime and after going to the toilet, place half a cotton ball into the anus to prevent mucous leakage.
• Avoid all medicated, perfumed and deodorant powders including talcum powder which can irritate the skin.
• Dry well after washing but do not rub – pat dry only with soft but strong toilet paper. Avoid leaving particles of tissue paper behind. A hair dryer also works well.
• Avoid synthetic underwear, especially in hot weather. Loose cotton is best. Change underwear frequently.

3. Use only medications prescribed by your doctor and use only as directed

• Avoid creams and ointments. Many creams also contain local anaesthetics. These frequently cause allergy and are best avoided altogether.
• You might be prescribed a steroid cream. This can be helpful in the short term but use for more than 10 days can damage the skin, leading to worsening problems in the long term, and can also encourage fungal infection.
• Very mild steroid creams which also contain an anti-fungal antibiotics can be bought over the counter without the need for a prescription e.g. Canestan HC 1% cream. This contains both a drug (clotrimazole 1%)  to treat thrush and also a very mild steroid (1% hydrocortisone). It is a good start before seeing your doctor/specialist.
• Apply prescription medications sparingly to the skin around the anal area and avoid rubbing.
• Medications that contain local anaesthetics should be avoided as they can give rise to allergies, thereby making the problem worse.
• If the anal area is very raw, then it is possible to apply a cream such as the Canestan HC cream first and then on top of this, apply a skin barrier cream such as Sudocrem. This is a common baby nappy rash cream and will protect the skin, giving it a chance to heal without being irritated by coming coming in contact with loose bowel motions etc.,

4. Adjust fluid & diet

• In most cases, a maximum of six glasses of fluid daily is reasonable.
• You may be given medications to firm the bowel motions, especially if the motions are loose and frequent. However, excessive constipation should also be avoided, a regular once daily bowel motion being the aim. This can be achieved by the following
• A bulking agent such as Fybogel (1 sachet twice daily).
• Additional fruit (not oranges or citrus fruits), vegetables and bran every day
• Avoid foods that cause bowel irritation or are mucus producing. These include

•  Dark colas,
• Spicy foods
• Citrus fruits & juices
• Coffee (regular or decaffeinated)
• Beer
• Nuts, popcorn,
• Milk and foods known to cause wind & indigestion.
• Ginger ale, 7-UP and other light coloured soft drinks are okay.

How long does this treatment usually take?

If a cause for pruritus ani can be identified, it is easier to treat and relieve your symptoms. Most people start to experience relief from itching within a week, but it may take several weeks to obtain complete relief. Remember, recurrences are common and to be expected. Don’t become despondent over this; just be sure to reconsult your doctor so that appropriate corrections in treatment can be made. 

The above measures will usually stop the itch. If symptoms persist for three or four weeks after doing the above, then your doctor may refer you to a specialist. This may be a skin specialist (a dermatologist) or a colorectal surgeon (who specialises in problems affecting the colon and anus). Tests may be needed to make sure a known cause has not been missed.

Can I be treated for pruritus ani at the Glasgow Colorectal Centre?

Yes. Glasgow Colorectal Centre surgeons Richard Molloy and Ahmed Alani are both experienced in the assessment and management of patients with pruritus ani. They will be able to perform an assessment and will also be able to exclude bowel problems such as an anal fissure or haemorrhoids. If problems such as haemorrhoids are felt to be causing the problem, they will be able to recommend an appropriate  management plan.

If you have any questions about pruritus ani or other colorectal issues, your own GP is often the best first port of call.

If appropriate, they will be able to arrange a referral to a colorectal specialist centre such as the Glasgow Colorectal Centre.

 Pruritus ani is a very common condition that gives rise to strong desire to itch around the anal area. An irresistible urge to scratch may result. In most cases, there is not specific reason why this condition develops, although it can occur in association with certain bowel problems and with some skin conditions. Proper assessment and treatment usually gives good relief of symptoms.