1. GTN versus placebo

2. GTN versus Botox

3. Anal fistula/abscess

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

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

7. Pruritis ani

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

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

10. 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

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

12. 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

13. 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

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

15. 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