Anal Itching

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.

Published: 1st August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Fungal Infection: Tinea, Thrush
  • Threadworms
  • Haemorrhoids
  • Perianal Skin Tags
  • Anal Fissure

Occasional Diagnoses

  • Poor Hygiene
  • Recurrent or Chronic Diarrhoea
  • Perianal Warts
  • Streptococcal Perianal Infection in Children
  • Trauma from Sexual Practices: Anal Intercourse and Foreign Body Insertion
  • Faecal Incontinence, Including Liquid Faecal Seepage Round Impacted Stool
  • Psoriasis
  • Secondary to Underlying Diabetes
  • Anorectal Carcinoma
  • Chemical Irritation: Defaecation after a Very Spicy Meal (Commonly Experienced, Rarely Presented in Practice), Bubble Baths, Soaps, Sexual Lubricants

Rare Diagnoses

  • Irritation from Perineal Decorative Body Piercing (the ‘Guiche’)
  • Lichen Sclerosus et Atrophicus (Affects 1 in 100 Women, 3 in 10 of these Have Anal Symptoms)
  • Crohn’s Disease (Anal/Perianal Fistula)
  • Rectovaginal Fistula
  • Rectal Prolapse
  • Any Other Cause of Rectal Discharge or Anal Swellings
  • Any Serious Cause of Generalised Pruritus – See Chapter on Anal Itching. Rare Here because Pruritus Ani is Unlikely to be a Presenting Complaint
  • STDs, e.g. Syphilis, Gonorrhoea, Chlamydia

Ready reckoner

Key distinguishing features of the most common diagnoses

Fungal infectionThreadwormsHaemorrhoidsSkin TagsFissure
Rectal BleedingNo Possible PossibleNoYes
Markedly Worse at Night PossibleYes Possible PossibleNo
Complains of LumpNoNo Possible PossibleNo
Rectal DischargeNoNo PossibleNo Possible
Painful DefaecationNoNo PossibleNoYes

Possible investigations

Likely: None

Possible: Skin swab, FBC, ESR, fasting glucose or HbA1c, 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, ESR: May be helpful if Crohn’s disease is suspected, but only as an adjunct to referral as the appropriate management
  • Fasting glucose or HbA1c is essential in recurrent or prolonged cases to exclude diabetes.
  • Proctoscopy is 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 a sexually transmitted disease contact. Refer to GUM clinic for contact tracing and treatment.
  • 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 bring the patient back to complete the assessment when more comfortable to do so. The patient is unlikely to want to return for this without understanding a clear explanation of why it is necessary

Red Flags

  • Four percent of women with lichen sclerosus et atrophicus go on to develop vulval cancer. Refer if the vulva is affected, or if treatment fails
  • Refer any suspicious anal lesion for biopsy.
  • Be confident to ask about recent sexual encounters and sexual practices if possibly relevant. Sexual history may be important.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.