Doctor: chronic genital itching without infection may be driven by brain — and often responds to therapy

A long-standing case of severe genital itching with repeated negative tests can be the result of psychogenic pruritus, a condition in which psychological factors and altered brain processing perpetuate the sensation of itch, Dr. Martin Scurr said in a column addressing patient questions.

Scurr wrote that men who have endured persistent genital itching despite extensive investigation are often not helped by further tests alone. He described a case of a 78-year-old man who reported intense, painful itching at the tip of his penis for more than five decades after an episode in his early 20s. Multiple specialist examinations and tests had not identified infection or other disease as the cause.

Psychogenic pruritus is characterised by chronic itch that is out of proportion to, or persists after resolution of, any detectable skin disease. Scurr said research, including functional brain imaging, shows altered activity in regions that process itch sensations among people with this condition. He suggested the patient’s symptoms may have begun with a minor skin infection such as thrush and then been perpetuated by a distressing clinical episode that acted as a psychological trigger.

For management, Scurr recommended discussing the diagnosis with a general practitioner and seeking referral to a clinical psychologist for cognitive behavioural therapy (CBT). He also noted that certain medications can reduce chronic itch in these circumstances: low-dose antidepressants and gabapentin, which affect the nervous system’s processing of sensory signals, have shown benefit. If patients accept a psychological explanation and follow through with referral and treatment, Scurr wrote, symptoms can remit within months.

He emphasised that such a diagnosis should follow thorough investigation to exclude infection and other organic causes. Scurr advised that patients present their full medical history and test results to their GP and request appropriate referrals rather than undergoing repeated, low-yield testing.

In the same column Scurr addressed other concerns, including unexplained weight loss accompanied by an isolated rise in lactate dehydrogenase (LDH), and a little-known potential side effect of statins.

LDH is an enzyme present in many body tissues that rises in the blood when cells are damaged. Scurr said a solitary abnormal LDH, in the absence of other symptoms, makes many serious causes less likely but not impossible. He recommended that a patient whose partner had lost more than a stone with only an elevated LDH should ask the GP to arrange a Rapid Diagnosis Team review. That review should include repeated weighing at home and in clinic, repeat imaging if advised, and further blood tests aimed at uncovering occult infections or other causes. Scurr advised weekly home weighing at the same time of day and a formal review within about three months of the last CT scan if symptoms persist.

On male breast enlargement, Scurr noted that most cases are due to hormonal changes — in younger men sometimes linked to anabolic steroid use and in older men to age-related hormonal shifts and increased body fat. He added that statins, widely prescribed to reduce cardiovascular risk, have occasionally been linked to breast enlargement in men. The phenomenon appears rare and may reverse after stopping the statin, but stopping a statin requires discussion about alternative lipid-lowering strategies such as ezetimibe and lifestyle measures to manage cardiovascular risk.

Scurr’s guidance underscores a central theme: clinicians should balance thorough exclusion of organic disease with recognition of neuropsychological mechanisms when symptoms persist despite negative tests. He advised patients to maintain clear records of symptoms, weight and test results, to raise the possibility of psychogenic pruritus with their GP if investigations are unrevealing, and to pursue recommended psychological and pharmacological treatments when appropriate.

Patients experiencing new or worsening symptoms, unexplained weight loss, a new breast lump, or any other concerning signs should seek prompt medical assessment. Clinicians can then determine which investigations are necessary and whether referral to specialist diagnostic or psychological services is warranted.