GTN versus placebo

GTN versus Botox

Anal fistula/abscess

Faecal incontinence 1 stool 5 2 rectum 3 sphincters 4 local reflexes 5 descending control 5 1 2 4 3

Faecal incontinence 3 L’s Loperamide Low fibre diet ‘levator’ exercises

Pruritis ani

symptom complex intense itch and burning discomfort of the perianal skin frequently associated with varying degrees of skin breakdown, weeping, maceration, lichenification, and superinfection

Aetiology Primary Secondary diet personal hygiene systemic disease anatomic compromise diarrheal states radiation psychological gynaecologic conditions diet systemic disease drugs dermatologic conditions infections neoplasms

Diet may represent the most significant cause of secondary pruritus ani may cause symptoms due to consistency of the stool direct irritation by components of the diet watery stools if an excessive volume of liquid is consumed

many with diet-induced PA relate their symptoms to ingestion of coffee or dairy products apparent threshold of 2 - 4 cups per day Milk arises at the ingestion of 6 - 10 oz daily Chocolate, tea, and cola ?due to the xanthine content nonabsorbed, oily food additive e.g. Olestra, a fat substitute

Systemic Diseases Jaundice Other Chronic renal failure cholestyramine may help Chronic renal failure cause of the itching is unclear UVB radiation is the most successful treatment Diabetes mellitus vulvar and anogenital pruritus frequent association of the disease with candidiasis Other iron deficiency usually resolves with replacement thyrotoxicosis or myxedema predisposed to generalized pruritus Hodgkin's disease polycythemia vera reportedly aggravated by bathing and showering with warm water ?symptoms are related to elevated blood histamine levels. antihistamines or antiserotonin medications are often effective

Drugs cause PA through both contact irritation and increased leakage of faecal material Quinidine and colchicine Tetracycline topical ointments, creams, or cleansing agents scented soaps, deodorants, coloured toilet tissues, and laundry detergents contain chemicals such as formaldehyde, alcohol, perfumes, and astringents alcohol-based anal wipes

Neoplasms Viral/bacterial infections Mycoses/candidiasis Parasites Pinworms (Enterobius vermicularis) Scabies Pediculosis pubis (crab or louse) Neoplasms

Avoid creams and ointments   Avoid soaps Dry well Wear cotton Use soft but strong toilet paper Avoid excessive cleaning Sweating problem Take care of your diet Dry skin Avoid scratching