Neuropathic scrotal pruritus: Anogenital pruritus is a symptom of lumbosacral radiculopathy

doi:10.1016/j.jaad.2004.04.039

Journal of the American Academy of Dermatology

Volume 52, Issue 1, January 2005, Pages 61-66

https://doi.org/10.1016/j.jaad.2004.04.039 Get rights and content

Background

Anogenital pruritus is defined as an itch localized to the anus, perianal, and genital skin. Anogenital pruritus is usually a symptom of an underlying disorder of the skin or mucosa or a consequence of anorectal pathology. When no demonstrable cause is found, anogenital pruritus is often described as “idiopathic”.

Objective

To investigate the role of lumbosacral radiculopathy in the pathogenesis of anogenital pruritus.

Methods

Included in the study were consecutive patients with anogenital pruritus. Radiographs and nerved conduction studies were performed in all patients. Needle electromyography studies and computerized tomography were performed when necessary. Nerve conduction studies included measurement of distal sensory and motor latency, conduction velocity, and F-responses of the peroneal and tibial nerves. Patients with confirmed radiculopathy were treated with paravertebral injection of a mixture of triamcinolne acetonide and lidocaine. Response to the injections was assessed using visual analogue scales by the patients. Mean scores before and after treatment were compared using paired t tests.

Results

Included in the study were 20 patients with anogenital pruritus. There were 18 men (90%) and 2 (10%) women. The mean age was 52.7 years (standard deviation [SD] 11.7 years). In 16 patients (80%), radiographs demonstrated degenerative changes of the lower spine. In 16 patients (80%) the presence of lumbosacral radiculopathy was confirmed by nerve conduction studies. Fifteen patients (75%) were treated with paravertebral injections, with significant decrease in mean pruritus score as assessed by the patients (6.3 [±2.8]; 4.5 [±2.7], before and after treatment, respectively, P = .033).

Conclusion

“Idiopathic” anogenital pruritus may be attributable to lumbosacral radiculopathy. Paravertebral blockade may be used for alleviation of symptoms in patients with anogenital pruritus.

Section snippets

Patients and methods

The study was performed within the Dermatology Service, Southern District, Clalit Health Services HMO, covering a population of approximately 450,000 enrollees. Included in the study were consecutive patients who presented with persistent and “idiopathic” anogenital pruritus between December 2002 and August 2003. All patients were examined by a dermatologist and a neurologist. Excluded from the study were patients with clinical signs of inflammatory dermatoses (eg, psoriasis, contact

Results

Twenty patients with anogenital pruritus were included in the study. There were 18 men (90%) and 2 (10%) women. The mean age was 52.7 years (standard deviation [SD] 11.7 years, range 34-71 years). The mean duration of pruritus was 60.8 months (SD 87.1 months, median 16.0 months, range 2-270 months). Eleven patients (55%) had anogenital pruritus for less then 18 months and 9 patients (45%) had anogenital pruritus for more then 18 months (range 3-22 years).

Two patients (10%) had diabetes

Discussion

In the current study, it was observed that 16 of 20 consecutive patients (80%) with “idiopathic” anogenital pruritus had lumbosacral radiculopathy, representing nerve or nerve root compression at the level of L4 to S2 vertebrae. The location of the pruritus was correlated with location of the neuropathic changes, as observed in the EMG studies. A literature search failed to identify studies in which anogenital pruritus was attributed to radiculopathy. To our knowledge, our results are the first

References (25)

A.D. Cohen et al.
Brachioradial pruritus: a symptom of neuropathy
J Am Acad Dermatol
(2003)
R. Goodkin et al.
Brachioradial pruritus: cervical spine disease and neurogenic/neuropathic [corrected] pruritus
J Am Acad Dermatol
(2003)
A. Kavak et al.
Can a spinal cord tumor cause brachioradial pruritus?
J Am Acad Dermatol
(2002)
J. Wallengren
Brachioradial pruritus: a recurrent solar dermopathy
J Am Acad Dermatol
(1998)
G. Yosipovitch et al.
Itch
Lancet
(2003)
G.L. Daniel et al.
Pruritus ani. Causes and concerns
Dis Colon Rectum
(1994)
S. Dasan et al.
Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic
Br J Surg
(1999)
P. Doucet
Pruritus ani
Int J Psychoanal
(1988)
W.G. Friend
The cause and treatment of idiopathic pruritus ani
Dis Colon Rectum
(1977)
M. Giordano et al.
Pruritus ani
Minerva Chir
(1999)

C.I. Harrington et al.

Dermatological causes of pruritus ani

BMJ

(1992)

L.E. Smith et al.

Prospective studies on the etiology and treatment of pruritus ani

Dis Colon Rectum

(1982)

Cited by (61)

Itch: Epidemiology, clinical presentation, and diagnostic workup
2022, Journal of the American Academy of Dermatology
Citation Excerpt :
Although the healthy scalp normally has decreased sensitivity of C-fibers to itch,111 scalp dysesthesia can result from degenerative changes at C2-C7 levels.112,113 Similarly, anogenital pruritus is associated with degenerative changes of the lower spine at L4-S2 levels.114 The other neurologic conditions associated with itch include trigeminal trophic syndrome, cerebrovascular events, brain infections (eg, encephalitis, Creutzfeldt-Jakob disease), and small fiber neuropathies.102
Itch, or pruritus, is the uncomfortable sensation underlying the desire to scratch. Itch is a very common complaint in the general population that can result from dermatologic, systemic (eg, renal, hepatobiliary, endocrine), paraneoplastic, neuropathic, and psychogenic etiologies. Chronic itch is associated with significant sleep disturbances and profoundly reduces overall quality of life. Certain populations, including elderly and African Americans, are at increased risk of experiencing heightened burden of itch. Because of the variable clinical presentation and wide-ranging etiologies, itch presents a challenge for clinicians. The initial evaluation should include a complete blood count, with differential, hepatic, renal, and thyroid function testing along with diabetes screening. Further testing should be guided by history and physical examination findings. There should be a heightened concern for underlying malignancy in individuals older than 60 years of age who have a history of liver disease and diffuse itch less than 12 months of duration. For individuals with chronic pruritus of unknown origin, increased blood eosinophils may serve as a biomarker of T helper cell type 2 polarization and response to immunomodulator therapies. In this first part of a 2-part continuing medical education series, we describe the broader epidemiology and specific conditions associated with itch and the clinical presentation and diagnostic workup for patients with itch.
Clinical features of idiopathic anogenital pruritus in adult men: A case-control study
2021, Journal of the American Academy of Dermatology
Treatment of male genital dysesthesia with botulinum toxin
2021, JAAD Case Reports
Citation Excerpt :
In light of this patient's history of lumbosacral radiculopathy, a diagnosis of neuropathic scrotal dysesthesia due to nerve or nerve root compression was favored. Diagnosis is clinical, as there are no specific histological findings.2 The management of scrotal dysesthesia can be challenging as no treatment has been found to be universally effective in scrotal pain management.1
Recalcitrant anal and genital pruritus treated with dupilumab
2018, International Journal of Women's Dermatology
Citation Excerpt :
However, these patients often have other concomitant anogenital diseases that may require further intervention (Trivedi et al., 2018). One often overlooked cause of idiopathic anogenital pruritus, particularly in older patients, is lumbosacral radiculopathy (Berger et al., 2013; Cohen et al., 2005). Spinal trauma or degenerative disc disease can cause severe itching in the genital area in the absence of a primary rash.
Chronic anogenital pruritus can significantly impair affected patients’ quality of life by disrupting their sleep, mood, sexual function, and personal relationships. Although a significant portion of these patients can be managed with hygiene measures, topical therapy, oral anti-pruritics, and allergen avoidance after patch testing, guidelines to treat patients who do not respond to standard therapy have yet to be established. We describe the therapeutic response of a case of anogenital pruritus recalcitrant to multiple topical and systemic therapies. Treatment of this patient with dupilumab, an interleukin-4 receptor alpha blocker, resulted in clinical remission at 1 year from the initiation of the therapy, without significant adverse effects.
Clinical presentation, management, and pathophysiology of neuropathic itch
2018, The Lancet Neurology
Unlike conventional itch, neuropathic itch develops in normal skin from excess peripheral firing or dampened central inhibition of itch pathway neurons. Neuropathic itch is a symptom of the same central and peripheral nervous system disorders that cause neuropathic pain, such as sensory polyneuropathy, radiculopathy, herpes zoster, stroke, or multiple sclerosis, and lesion location affects symptoms more than aetiology. The causes of neuropathic itch are heterogeneous, and thus diagnosis is based primarily on recognising characteristic, disease-specific clinical presentations. However, the diagnosis of neuropathic itch is challenging, different subforms exist (eg, focal vs widespread, peripheral vs central), and the mechanisms of neuropathic itch are poorly understood, resulting in reduced treatment availability. Currently available strategies include treating or preventing causal diseases, such as diabetes or herpes zoster, and topical or systemic medications that calm excess neuronal firing. Discovery of itch mediators such as gastrin releasing peptide, receptors (eg, neurokinin-1), and pathways (eg, Janus kinases) might encourage much needed new research into targeted treatments of neuropathic itch.
Diagnosis and Management of Neuropathic Itch
2018, Dermatologic Clinics
Citation Excerpt :
There have been reported benefits with peripheral nerve stimulation in a case of notalgia paresthetica,86 and with targeted nerve blocks in cases of postherpetic itch87 and notalgia paresthetica.88 Additionally, a paravertebral injection of a mixture of triamcinolone acetonide and lidocaine has been reported to reduce pruritus in patients suffering from neuropathic anogenital pruritus.18 Given the limited evidence and the inherent risks of surgery, neurosurgical decompression is rarely indicated.

View all citing articles on Scopus

Funding sources: None.

Conflicts of interest: None identified.

Reprints not available from the authors.

View full text

ReportNeuropathic scrotal pruritus: Anogenital pruritus is a symptom of lumbosacral radiculopathy

Background

Objective

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

Lancet

Pruritus ani. Causes and concerns

Dis Colon Rectum

Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic

Br J Surg

Pruritus ani

Int J Psychoanal

The cause and treatment of idiopathic pruritus ani

Dis Colon Rectum

Pruritus ani

Minerva Chir

Dermatological causes of pruritus ani

BMJ

Prospective studies on the etiology and treatment of pruritus ani

Dis Colon Rectum

Report
Neuropathic scrotal pruritus: Anogenital pruritus is a symptom of lumbosacral radiculopathy