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PRURITUS ANI IN INDIAN PATIENTS
M Munshi*, OP Kapoor**
*Externee, Dept. of Skin and VD, Bombay Hospital. **Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Itching or irritation of the perianal skin may be encountered either by a dermatologist, proctologist or a physician and is usually accompanied by psychological undertones.
Perianal dermatitis, in a large number of cases is a self-inflicted injury caused either due to inadequate cleansing of the anus or over vigorous attempts to polish it clean. Anal cleanliness is an art since the time of our ancestors. In fact in the East it is practised with greater cared art and tradition than in other parts of the world. But an overzealous aptly named 'bottom polisher' is usually a 'sufferer'.
Peculiar to an Indian setting are factors such as a hot and humid climate leading to increased sweating. Once maceration sets in, fungus and saprophyte organisms proliferate and the person experiences 'itching'. Scraching is the worst and of course the perpetuating factor in pruritus ani. The 'dhoti' and 'sari', our Traditional Indian dress allow greater access to the anogenital area than the tight-fitting trousers and skirt of the, West. Today's fashion dictates that 'the tighter', the 'better'. With synthetic fabrics in vogue, the trendy youngster now comes with what is popularly called the Jock itch'.
Once one experiences the sensation to scratch, and it is a powerful one, as the perianal skin has a rich nerve supply, it takes will power not to. Of course it is not considered 'proper' in society to do so either, but a poor uneducated, ignorant man of the East just gives in and scratches the anogenital area quite uninhibitedly. Contaminated water, bad personal hygiene, poor sanitation and ignorance are predominant features of underdeveloped countries like India and are certainly predisposing factors. Dysentery both amoebic and bacterial, helminthiasis and scabies can never be far away under such circumstances and have a high recurrence rate due to inadequate or incomplete treatment.
Certain communities in India indulge in oil massages, repeated shaving and application of home remedies for any local problem. All these are potential irritants and start a vicious cycle that keeps up the 'itch'. In fact a person belonging to this group is a bottom polisher as mentioned earlier. He thinks that polishing his bottom is the right way to keep it clean when actually he is traumatising the sensitive perianal skin and preparing the ground for pruritus ani to set in. Constipation especially in polished rice caters along the Indian coastline can be indirectly responsible as subsequent straining while defaecating and relief sought in the form of purgatives are contributory factors. People eating diet rich in fibre like the wheat and grain are spared of this problem at least. Indians love hot, spicy food which would predispose them to perianal irritation. Candidiasis can be one of the most persistent opportunistic infections and in our country the beat, chronic illness and debilitation worsen the situation.
Donovanosis and chancroid are sexually transmitted diseases especially seen in the tropics and are rampant in our country. Perianal involvement is commonly seen in women due to close proximity of the va(vagina to the anus, bad hygiene and sodomised individuals. Being an intertriginous site, macertion and secondary infection by anaerobes occur rapidly, complicating the case.
Common to, all races and also seen here are obesity, diabetes, herpes progenitalis (the incidence of which is on the rise in India), piles, rectal prolapse, purulent discharge with an associated fistula in ano, excess alcohol consumption and tendency to an eczematoid skin, In women parturition especially performed by "dais" at home leaves behind incontinence, urinary leakage due to fistula and profuse vaginal discharge due to unattended infections. In the old when the skin is furrowed by the ravages of time it causes faecal particles to be often left behind. Even babies are not spared as diarrhoea or frequent rubbing of the perianal skin by an anxious mother, make this list a long one.
But the most incriminating of these all is "washing habits" which vary from race to race but usually determine whether an individual is going to be 'spared' or 'scratch'. At least in this respect we score over the West. The traditional Indian mode is to wash with water, paper is hardly ever used while in the West except for the French who are famous for the 'bidet' (second toilet placed next to the main with water spout aimed at the anus) paper is the mainstay. Repeated, vigorous use of dry paper for postdefaecation cleansing is bound to cause a break in the continuity of the perianal skin and be a predisposing cause.
Once he scratches, he suffers and the harassed, uncomfortable individual looks for treatment. In India home remedies are first sought for. Haldi mixed with oil, plain oil and herbal mixtures are some examples. A more knowledgeable person tries out the numerous over the counter ointments and local applications but invariably lands up with an irritant dermatitis. It is at this stage that he qualifies as a patient and presents himself to a clinician. A detailed history must be taken to acquaint oneself with the personal habits of the patient as well as determined an underlying cause if present, as even a thorough examination may not reveal the same due to secondary infection and maceration masking the original picture.
A 'scratcher', especially a habitual one definitely deserves attention and to treat such a case one has to delve into all the aspects of its causeology. The first most in,)ortant step is to stop all medication. The next would be to educate the patient in the ways of cleansing the perianal areas, in keeping it dry at all times and removing an underlying cause, if any. Misconcepts usually abound galore in the average patient's mind and he must be made to realise that usually he is a victim of his own fallacies. Regular follow-up and close observation of the patient's habits would prevent recurrences.
Summarising to say, that pruritus ani commonly encountered in our country is a largely preventable symptom complex. It would be worthwhile for the treating doctor to keep in mind the special features peculiar to an Indian setting, as discussed above, while approaching such a case as he would be able to convert many a 'sufferer' into an "itchfree, relaxed" individual.
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