Anorectal Disease by Massarat Zutshi

Author:Massarat Zutshi
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

7.1 Case 1

The patient is a 45-year-old female who presents to your office with the complaint of perianal itching. The assessment of the complaint of pruritus ani begins with a thorough history. The eventual successful treatment of the condition will be facilitated by carefully listening to the patient at the initial visit to investigate his or her symptomology. When did the condition arise? Patients with pruritus ani due to a dermatosis or neoplasia often experience symptoms for longer than those with idiopathic pruritus ani [8]. How often does the patient feel the perianal itching? Is it constantly present or does it ultimately subside? The precipitating and/or exacerbating factors—especially the initial inciting event—for pruritus should be explored. In general, perianal itching usually develops following a bowel movement, particularly if it has a liquid consistency, or at bedtime [12]. Does the itching wake the patient from sleep? Is the area being traumatized: Does the patient scratch or vigorously rub the perianal skin? Alternatively, does the patient engage in perianal grooming—by waxing, shaving, or depilatory—that may damage the skin? Does the perianal skin seem moist or sweaty or is there drainage noted? Do any members of the same household have a similar complaint of perianal itching, suggestive of an infectious etiology such as pinworms? Prior and current prescription and over-the-counter medications, especially used by the patient for the treatment of the condition, should be reviewed. The bowel habits—the stool frequency and consistency—and the perianal cleansing methods of the patient should be elucidated. Has the patient added or changed any cleansing products such as soap, detergent, toilet paper, or wet wipes recently? The patient should be questioned about the presence of rectal bleeding. Such bleeding, however, may emanate from fissuring or excoriation of the perianal skin. Other alarm symptoms—such as unintentional weight loss, melanotic stools, unusual fatigue, and changes in bowel habits or stool caliber—should be sought. Is there itching or a rash elsewhere on the patient’s skin surface that might point to a dermatologic condition? Any recent illnesses and their treatment, particularly with antibiotics and steroids, should be explored. As part of the inquiries regarding the medical history, the patient should be asked about skin diseases, allergies, atopy, urticaria, and previous skin patch testing that might signal a contact dermatitis [2]. Systemic diseases such as diabetes mellitus, liver disease, renal failure, hyperthyroidism, iron-deficiency anemia, leukemia, and lymphoma may be associated with pruritus ani, although the itching usually is more generalized; diabetic patients have a greater propensity to infection and to low resting sphincter pressures [13]. In females, details of previous child bearing should be elicited. The patient should be surveyed about previous sexually transmitted diseases and anoreceptive intercourse; MacLean and Russell comment that latex condoms or lubricant may produce a contact dermatitis [13]. Has the patient underwent previous anorectal procedures that may have altered the anal morphology or weakened the anal sphincters? Mazier emphasizes the importance of a dietary history, particularly focusing on caffeine, chocolate, citrus products, and tomatoes and tomato products [12].

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