gastrointestinal disorders
Pruritus Ani (Anal Itching)
Physical examination
General examinationshould be done to obtain a sense of overall hygiene and note any signs of anxiety or obsessive-compulsive behavior. Physical examinationis focused on the anal region, particularly looking for perianal skin changes, signs of fecal staining or soilage (suggesting inadequate hygiene), and hemorrhoids. External inspection should also note the integrity of the perianal skin, whether it appears dull or thickened (suggesting chronicity), and the presence of any cutaneous lesions, fistulas, excoriations, or signs of local infection. Sphincter tone is assessed by having the patient contract the sphincter during digital rectal examination. The patient should then be asked to bear down as if for a bowel movement, which may show prolapsing internal hemorrhoids. Anoscopy may be necessary to further evaluate the anorectum for hemorrhoids. Dermatologic examinationmay reveal scabies burrows in the interdigital webbing or scalp or signs of any other contributing systemic skin disease. 