Anal/Rectal Diseases

Introduction
Signs and Symptoms
Causes
Risk Factors
Screening and Diagnosis
Treatment

Proctitis is an inflammation of the lining of the rectum (rectal mucosa). Sexually transmitted diseases are the most common cause, but other causes include inflammatory bowel diseases, such as ulcerative colitis, and non-sexually transmitted infections.

Proctitis also may be a side effect of some medical treatments, including radiation therapy directed at or near the rectum for conditions such as prostate, cervical or uterine cancer, or antibiotic use.

Sexually transmitted proctitis is most common in people who engage in anal or oral-anal intercourse, particularly if they have multiple partners. Proctitis in general mainly affects adult males.

Proctitis may be short-lived, or it may become chronic, lasting for months or longer. In most cases, proctitis clears up with treatment. Treatment for proctitis depends on the cause.

Anal itching is an intense itching around your anus - the canal that's the outlet for your rectum. The itch, located in your anus or on the skin just around your anus, may be accompanied by a strong urge to scratch. It can be an embarrassing and an uncomfortable situation.

Also called pruritus ani, anal itching has many causes. Numerous factors may cause anal itching to be more intense - including moisture, the abrasion caused by your clothing, and the pressure of sitting. Symptoms may be worse at night or right after a bowel movement.

Anal itching is a common problem that many people have experienced. Don't be afraid to talk with your doctor about this condition. With proper treatment and self-care measures, most people can achieve complete relief from anal itching.

Signs and symptoms of proctitis may include:

• Frequent or continuous urge to have a bowel movement
• Rectal bleeding
• Passing mucus through the rectum
• Anal and rectal pain
• Pain in the lower left abdomen
• A feeling of rectal fullness
• Diarrhea, usually frequent, small amounts

Anal itching is associated with other similar symptoms in and around the anus, including:

• Burning
• Soreness

The itching and irritation in and around your anus may be a temporary condition, or it may be a more persistent and bothersome problem. For some people, the irritation is so intense that the urge to scratch is both irresistible and a source of embarrassment.

The causes of proctitis fall into several categories:

• Sexually transmitted infections. The most common type, sexually transmitted proctitis, is contracted through anal or oral-anal intercourse. Sexually transmitted diseases (STDs) that can cause proctitis include gonorrhea, syphilis, genital herpes, anal warts and chlamydia.
• Non-sexually transmitted bacterial infections. Proctitis is rare in children, but it can occur as a result of the same organism that causes strep throat (streptococcus). Salmonella, shigella and campylobacter, which are usually associated with food-borne illnesses, are other bacteria that can cause proctitis.
• Inflammatory bowel disease (IBD). If you have ulcerative colitis or Crohn's disease, you may be more vulnerable to proctitis. Ulcerative colitis involves inflammation of the inner lining of the large intestine, often including the rectum, the lowest portion of your colon. Crohn's disease involves chronic inflammation of any part of the gastrointestinal tract.

Other causes
Proctitis can result from a number of agents that can damage the rectal mucosa. These may include:

• Chemicals, such as hydrogen peroxide enemas, medications or objects placed inside the rectum
• Trauma to the anal-rectal area
• Radiation therapy directed at or near the rectum, such as for treatment of rectal or prostate cancer
• Antibiotic use for another ailment, which can destroy protective bacteria in the gastrointestinal tract

Most cases of anal itching are caused by a harmless problem. Occasionally, however, anal itching can be a sign of more serious medical issues. Possible causes include:

• Dry skin. As you age, skin in and around your anus is more prone to dryness. Dry skin can cause persistent, intense anal itching.
• Too much moisture. Moisture around your anus from excessive sweating or from moist, sticky stools can be irritating. Anal itching can also be caused by frequent diarrhea or the escape of small amounts of stool (fecal incontinence).
• Excessive washing. Excessive wiping with dry, harsh toilet paper or excessive scrubbing with harsh soaps can cause or aggravate anal itching. Failure to rinse away the soap completely also may cause irritation.
• Chemical irritants. Certain laundry soaps, colognes, douches and birth control products contain chemicals that can irritate skin in and around your anus. Scented or colored toilet paper can be irritating to people with sensitive skin.
• Food irritants. Anal itching may be the result of irritating chemicals in some foods, such as those found in spices and hot sauces. Similarly, some foods may directly or indirectly irritate your anus as they exit your colon. Common culprits include chocolate, fruits, tomatoes, nuts and popcorn. Consuming certain beverages, including milk or caffeinated drinks, may cause some people to experience diarrhea followed by anal itching.
• Medications. Anal itching may be a side effect of certain medications, including some antibiotics, that can cause frequent diarrhea.
• Overuse of laxatives. Excessive or improper use of laxatives can lead to chronic diarrhea and the risk of anal irritation and itching.
• Hemorrhoids. Hemorrhoids are engorged veins located just under the membrane that lines the lowest part of your rectum and anus. They often occur as a result of straining during a bowel movement. Anal itching can be a symptom of hemorrhoids. However, most hemorrhoids don't itch.
• Infections. Sexually transmitted diseases may also involve the anus and can cause anal itching. In children, the parasite that causes pinworms can cause persistent anal itching. Other parasites may cause similar itching.
• Skin disorders. Common skin problems - such as psoriasis, seborrhea and eczema - can involve and irritate the area in and around your anus.
• Yeast infections. This common infection, which usually affects women, can irritate your genital and anal areas.
• Anal abrasions and fissures. An anal abrasion is a small tear in your anus, usually caused by forced bowel movements through a tight anus. An anal fissure is a deeper tear. Both conditions can cause anal itching, as well as painful bowel movements and bleeding.
• Anal tumors. Rarely, benign or cancerous tumors in or around the anus may be a cause of anal itching.
• Other causes. Anal itching may be related to anxiety or stress. Sometimes, the cause remains undetermined.

Although anal itching is almost never a problem of cleanliness, your own actions may contribute to the problem. Whatever the cause of anal itching, your natural reaction is to scratch the area. But scratching worsens the problem by removing superficial layers of skin. In addition, the natural tendency in response to an irritation is to wash the area frequently with soap and a washcloth. However, excessive washing can aggravate the condition by removing your skin's natural protective oils.

High-risk sexual behaviors put you at risk of sexually transmitted proctitis. They include:

• Being the recipient of anal and oral-anal sex
• Having multiple sex partners
• Having anal sex with a partner who has an STD
• Having anal sex without a condom

Risk factors for non-sexually transmitted proctitis include:

• Having an inflammatory bowel disease, such as ulcerative colitis or Crohn's disease
• Using antibiotics for another ailment
• Having radiation therapy directed at or near the rectum

Your doctor will take a history of your condition, including your sexual history, and conduct a physical exam. The exam may include the following:

• Blood tests. Your doctor may suggest blood tests to check for signs of infection or anemia, if you've lost blood.
• Colonoscopy. This test allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis. Risks of this procedure include perforation of the colon wall and bleeding, especially when a biopsy is taken.
• Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last 2 feet of your colon, including the rectum. Your doctor also can take a biopsy during this test. The test usually takes just a few minutes. It's somewhat uncomfortable, and there's a slight risk of perforating the colon wall.
• STD screening. This involves obtaining a sample of discharge from the tube (urethra) that drains urine from your bladder. If the cause of your proctitis is likely to be an STD, your doctor may insert a narrow swab into the end of your penis or anus to obtain the sample, which is then tested for the presence of bacteria or other infectious organisms. The results can be used to select the most effective antibiotic for treatment.

Your doctor may be able to pinpoint the cause of your itching simply by asking you questions about your symptoms.

If the cause of your itching isn't obvious, your doctor may refer you to a dermatologist or a doctor who specializes in treating rectal and anal problems (proctologist) for further evaluation. A rectal exam may be all that's required for you to get an answer - and a solution - to a very uncomfortable problem.

Other tests, such as proctoscopy or colonoscopy to view more of the digestive tract, are sometimes needed to identify an underlying cause of anal itching. However, the precise cause of the itching may never be identified.

Treatment for proctitis depends on the cause.

Infectious proctitis
Your doctor is likely to prescribe medications to alleviate the cause of the infection. The specific medication depends on the cause of the infection.

• Antibiotics. For bacterial STDs, the antibiotic depends on the STD. For non-sexually transmitted infections, your doctor will likely prescribe an oral antibiotic, such as ciprofloxacin (Cipro), levofloxacin (Levaquin), penicillin, amoxicillin (Amoxil, Trimox), azithromycin (Zithromax), clarithromycin (Biaxin), clindamycin (Cleocin) or an antibiotic from the cephalosporin class (Keflex, Ceclor).
• Antivirals. For viral STDs, such as herpes-related proctitis, your doctor may prescribe an antiviral medication, such as acyclovir (Zovirax). If taken within 48 hours, antiviral medication may lessen pain and shorten the duration of signs and symptoms.

Noninfectious proctitis
The most common cause of noninfectious proctitis is a side effect from radiation treatment to the pelvis. Mild signs and symptoms may require no treatment. However, more severe cases, particularly those involving bleeding, may need treatment:

• Corticosteroids. These medications, which suppress inflammation, may be given as enemas. In some cases, your doctor may prescribe oral corticosteroids.
• Laser therapy. A relatively new procedure uses a laser on the rectal lining to destroy newly formed blood vessels, thereby reducing inflammation and bleeding.

For proctitis caused by antibiotic use, your doctor may prescribe metronidazole (Flagyl, Protostat) or vancomycin (Vancocin) to destroy harmful bacteria that have developed in place of normal intestinal bacteria.

Proctitis caused by inflammatory bowel disease
Proctitis related to Crohn's disease or ulcerative colitis may require ongoing treatment directed at the underlying condition. The goal of treatment is to reduce the inflammation that causes the signs and symptoms.

• Anti-inflammatory medications. Your doctor may prescribe corticosteroids or other anti-inflammatory agents, such as sulfasalazine (Azulfidine) or mesalamine (Asacol, Rowasa, others), in pill, suppository or enema form. Steroid suppositories or enemas may ease inflammation in your rectum.
• Anti-diarrheals. If you have diarrhea, your doctor may prescribe a fiber supplement, such as psyllium powder (Metamucil) or methylcellulose (Citrucel), to add bulk to your stool. For more severe diarrhea, loperamide (Imodium) or a combination of diphenoxylate and atropine (Lomotil) may be effective. However, these drugs may cause serious side effects, such as colon dilation and rupture, especially if taken over time or in high doses. If your IBD symptoms tend to flare, these treatments can cause your disease to spread farther up your colon. Talk to your doctor before using them.
• Surgery. If drug therapy doesn't relieve your signs and symptoms, your doctor may recommend surgery to remove a damaged portion of your digestive tract.

Treatment of anal itching depends on the cause of the problem. It may include self-care measures, changes to your diet, treatment of infections or, rarely, surgery to correct an underlying problem.

Medications also may be part of your treatment plan. An over-the-counter (OTC) cream or ointment containing hydrocortisone (Cortaid, Preparation H), applied sparingly to the affected area may reduce inflammation and itching. A protective ointment that contains zinc oxide (Desitin, Balmex) also may help. If your symptoms are worse at night, your doctor may also prescribe an antihistamine to reduce itching until topical treatments take effect. With proper treatment, most people experience complete relief from anal itching in less than a month.