(Have we learned anything?)

Pruritus Ani is not a new disease. It has been a steady medical problem for at least the last 100+ years that one can easily research on the internet. Around the year 1900, a doctor by the name of Sir Charles Bent Ball invented what became known as “Balls Operation”, a surgery to stop the itching of chronic pruritus ani. This surgery left the patient numb in the area for a long while, but was said at the time to relieve the itching even after feeling returned.

In 1910, Dr. Patrick Leighton reported in an article that he performed two successful Ball Operations. Why would anyone go through surgery back in 1910 when the slightest infection could kill you? The itching must have been horrendous and as us sufferers know; it truly is a nightmare affliction. Here is a quote from the first paragraph describing the situation: “I venture to record the following two cases, on which I operated this year, as since endless remedies have been tried for this horrid affection…” He goes on in the third paragraph: “The malady is looked on as a neurosis” (Definition of neurosis is: mild mental illness, hypochondria, not a real physical problem, it’s all in the head!) The surgery didn’t cut nerves and leave permanent paralysis, it temporarily numbed the area to give the patient a break in the scratching and then the hope was that the “neurosis” of scratching would be forgotten.

There is one article that shows up with a quick search that explains this operation and other prescribed medical treatments for patients with pruritus ani. It’s a published medical paper written in December 1934 by J.P. Lockhart-Mummery, FRCS, the senior surgeon for diseases of the bowel at St. Marks Hospital. The reason someone would go under the knife in 1910 to relieve this itching becomes immediately obvious as he speaks of madness and insanity: “In various degrees pruritus ani is a very common complaint. It may only be a slight itching lasting a few days and then passing off, or easily amenable to treatment, or it may be a most serious condition, coming on in paroxysms which drive the patient nearly mad and prevent him from obtaining any proper sleep, often for weeks at a time.” Here is another: “The itching comes on in violent paroxysms, without cause, at any time of the day or night, and is so severe as to drive the patient to the verge of insanity.”

I personally find Dr Lockhart-Mummery’s article extremely interesting. In 1934 he lays out the way to treat pruritus ani and it happens to be just like it’s done today! First of all, find the cause if you can and eliminate it. He and I agree one aspect of this… 85 years apart… about the cause of pruritus ani: “I am convinced that the exciting cause of pruritus is a local one in all cases, and that constitutional states have merely a predisposing or secondary influence in causing the itching. It must be admitted that in some cases the most careful search fails to discover any local cause; but this is because our knowledge is insufficient to enable us to discover it, or, perhaps, to recognize it when seen.”

The Pranicura Treatment, the most successful documented treatment for chronic pruritus ani ever developed, follows his theory from 1934! It assumes that there IS a local cause in the anal area whenever the itch presents itself, even though no one has yet identified it. The anal area is then cleaned with a baby wipe (moist disposable towelette) and patted dry. If the itch is gone then the patient is done. If the itch is still there, a special ointment is applied.

Unfortunately, Dr. Lockhart-Mummery doesn’t come to any great conclusion for severe sufferers. He lists over 25 possible remedies to try…and ends up recommending those with severe cases to undergo Xray treatment (radiation), chemical injections to numb the nerves for a while, or Ball’s surgery. (He performed the surgery himself since 1905). Here is a quote: “ It has been my experience that where the itching is of recent origin the removal of the cause is followed by prompt and permanent relief of the irritation, and such cases are easily cured; but the most difficult cases are those in which no local cause can be discovered, where no application seems to do any good, and more particularly the paroxysmal cases, which drive the patient to the verge of insanity.” (I’ve communicated with hundreds of these “paroxysmal patients” over the last nine years, myself being one of them, and we all agree, his “verge of insanity” statement is an apt description.) He goes on: “In considering the treatment of pruritus ani as a whole, certain definite facts seem to me to stand out. Firstly, cases of pruritus with a history dating back for more than two years are very difficult to cure, and the removal of the local lesion, even if present, seldom stops the itching. From this it seems to me we have to conclude that if pruritus ani has existed in at all an aggravated form for a long time, definite changes take place in the skin, or more probably in the nerve endings in the skin, which render the condition more or less permanent…”

What happened to Ball’s Operation? All I can find is an article written two years after the above was written. In August, 1936, Dr. Ronald W. Raven wrote an article “Pain in the Rectum and Anus”, and on the last page he agrees with surgery for extreme cases, just not Ball’s Operation: “In intractable pruritus ani it may be necessary finally to resort to operative surgery. Recently an operation found to give good results is division of certain fibres of the perineal nerve. Ball's operation, involving undercutting of the anal and pen-anal skin in order to section the sensory nerve supply gives unsatisfactory results.” So, Ball’s Operation must have finally lost favor after 30 years with surgeons and after hundreds (or thousands?) of patients were willing to do anything to stop the insanity and get rid of the itching.

If we fast forward to the 21st Century, the medical profession does a great job of quickly eliminating known causes of anal itching such as worms, bacteria and yeast, but they aren’t any further along in treating the difficult idiopathic patients. Today, they first put patients through years of try this and try that as summarized in this 2008 medical paper, and then doctors are still recommending injections (methylene blue) as the last resort with the worst afflicted patients. This “modern” procedure does roughly the same thing as the injections and surgeries from 1900+, as they all temporarily paralyze the nerves for a few months (or even a year or two) but eventually the feeling returns along with the itching. So, after 100+ years of surgical and injection failure, it seems obvious that nerve numbing is not the answer and that pruritus ani is always a physical condition and not a neurosis. In addition, knowing that this affliction has been around for at least well over a century points to the high probability that this medical issue is not caused by changes in our diet over the past few decades. In addition, since penicillin and all subsequent antibiotics weren’t available to the public until the 1940’s, it’s obvious that over-use of antibiotics cannot be the cause of pruritus ani.

Have we learned anything? In 2017 a medical paper was published “ A Review of the Therapeutic Interventions in the Management of Pruritus Ani” summarizing that anal tattooing (methylene blue injections) showed the most promise in treating the worst cases of idiopathic pruritus ani. 115 years of injection and surgical failure and yet some doctors still won’t give that up. I personally had this procedure done twice with barely 10 weeks of relief. When you dive into the literature, it’s not a permanent solution. Same as 1905.

The Pranicura Treatment, by far, has shown by user survey, to work on almost 100% of idiopathic pruritus ani patients who followed it for 5+ weeks. Patients who had suffered for decades finally found relief. (Pranicura Reviews)

A scientific study proving The Pranicura Treatment’s effectiveness (to the medical community) needs to be done. Once that is successful it will bolster the theory of Dr Lockhart-Mummery that “all causes of pruritus ani are local”, and then we’ll work to identify that cause and eliminate it, bringing a real cure to all of us pruritus ani sufferers.