Diseases of the Penis
7.1 Balanitis and Balanoposthitis
Cause: Inflammation of glans penis (balanitis) and prepuce (balanoposthitis). May be bacterial (Pediatr Dermatol 1994;11:168), intertrigo, irritant dermatitis, maceration injury, or candidal (most common) in etiology (Genitourin Med 1994;70:345; 1993;69:400).
Epidem: Common condition affecting 11% of male gu clinic attendees in one study (Genitourin Med 1993;69:4003). More common in uncircumcised males. May be seen in children and adults. Most often occurs in males with poorly retractile foreskin.
Si/Sx: Redness, edema, discharge, pain, may be associated with voiding difficulties.
Diff Dx: Neoplasm, psoriasis, Zoon’s balanitis, papillomavirus, other sexually transmitted diseases (Genitourin Med 1994;70:175)
Lab: KOH prep; Tzanck prep; fungal, bacterial, or viral cultures as dictated by clinical examination
Rx: Eliminate irritants, improve personal hygiene, topical antifungals if fungal related, short crs of low-potency topical steroids, retraction of foreskin to allow glans and prepuce to dry after cleansing, circumcision if recurrent.
7.2 Lichen Sclerosis
Cause: Exact cause is uncertain, but genetic predisposition, infections, and autoimmune factors have been implicated. It may be related to abnormal regulation of IL-1 (Hum Genet 1994;94:407).
Epidem: Occurs commonly on genital skin. Females more than males. In males, more common in older males (J Am Acad Derm 1992;26:951); may occur in children. High prevalence of autoimmune disease. In males, referred to as balanitis xerotica obliterans. In females, affects the genital skin and may affect any age group but more common in elderly women (Am J Clin Dermatol 2004;5:105).
Pathophys: Lesions well circumscribed white macules or plaques. Epidermis often atrophic and prone to ulceration. More common on moist skin of foreskin and in females in the vulva and perianal area. May lead to scar formation and destruction and contraction of foreskin, clitoral prepuce, and vulva. In males, white plaques noted on glans and often involves prepuce, which becomes thickened and nonretractile (Lancet 1999;353:1777). Histology shows a thickened epidermis, followed by atrophy and follicular hyperkeratosis.
Cmplc: Squamous cell carcinoma reported in pts with balanitis xerotica obliterans. Malignant changes less common than in lichen sclerosis et atrophicus in females (J Dermatol Surg Oncol 1978;4:556; Br J Vener Dis 1978;54:350). There is a 5% risk of developing squamous cell carcinoma of the vulva in females with vulvar lichen sclerosis (Am J Clin Dermatol 2004;5:105); urethral stenosis in males.
Si/Sx: May be asx but often associated with itching and burning. Males may note pain with urination or erection.
Diff Dx: Vitiligo, postinflammatory hypopigmentation, scar, genital herpes, syphilis, fixed drug eruption, Reiter’s syndrome, squamous cell carcinoma, and erythroplasia of Queyrat
Lab: Dx often made by physical examination. If question, bx is helpful.
Rx: In males, rx is circumcision; may be needed if phimosis present. High-potency topical steroids are the treatment of choice in males with balanitis xerotica obliterans. Intralesional corticosteroid injections have also been used. If there is urethral involvement and stenosis, meatotomy or urethral dilation may be needed. In females, high-potency topical steroids (ie, clobetasol 0.05% ointment) are effective (J Reprod Med 1993;39:25). Because of the risk of developing squamous cell carcinoma, pts need regular f/u visits (J Acad Dermatol 1993;29:469).
7.3 Fixed Drug Eruption
Cause: Cutaneous eruption that can be reproduced at the same site(s) by the same drug(s) (J Pediatr 1999;135:396). Predilection for the glans penis.
Epidem: More commonly related to therapy with antibiotics such as tetracyclines and sulphonamides. Other causes include salicylates, phenacetin, phenolphthalein, and some hypnotics (Lancet 1999;353:1777).
Pathophys: T-cell independent ag-specific triggering of mast cells or keratinocyte cytokine release (TNF-alpha, IL-2, IL-6) after administration of causative drug (Dermatology 1995;191:185)
Sx: May be painful
Si: Genital lesions usually solitary, well-demarcated, inflammatory; may be bullous and subsequently ulcerated. Shaft and glans of penis are common sites. Recurrent with repeat medication exposure
at same site; postinflammatory hyperpigmentation common in recurrent lesions.
at same site; postinflammatory hyperpigmentation common in recurrent lesions.
Crs: Most lesions fade spontaneously without treatment but may leave an area of residual hyperpigmentation.
Lab: Bx: papillary-dermal mononuclear cell infiltrate near dermoepidermal junction
Rx: Discontinue offending medication; topical care; rarely systemic steroids
7.4 Zoon’s Balanitis
Cause: Plasma-cell mediated. Etiology is unknown; may be related to chronic infection with Mycobacterium smegmatis.
Epidem: Uncircumcised males only. Lesions found on glans or prepuce.
Pathophys: Histopathol: band of plasma cells in dermis; may be chronic
Sx: Usually asx but may have pain, irritation, and discharge
Si: Solitary, orange-red, distinct borders; may be erosive; up to 2 cm in size (Urol Int 1993;50:182)
Diff Dx: Squamous cell carcinoma in situ, other forms of balanitis
Lab: Bx helpful to confirm dx
Rx: Often chronic and poorly responsive to topical treatment but can resolve completely with circumcision (Br J Dermatol 1982;105:585; Genitourin Med 1995;71:32)
7.5 Behçet’s Syndrome
Cause: Systemic vasculitis of small and large vessels
Epidem: Genetic? Associated (27%) with HLA B51 and 27; viral? though isolated occurrence argues against it. Male-to-female ratio: 1.7:1 in eastern Mediterranean type, 1:2 in United States at Mayo Clinic. Although rare, may be increasing.
Pathophys: Immune complex with small vessel vasculitis
Sx: Onset in 20s
Si: Recurrent: oral ulceration primary criterion for illness. Ulcerations either aphthous type, deep, painful, numerous, may scar; or herpetic type, especially in females, 1-2 mm, will respond to tetracycline oral rinse rx. Recurrent, painful. Painful genital ulcers occur in most, which is one of four secondary criteria for dx (J Am Acad Derm 1995;32:968); does not always occur concurrently with oral lesions; may involve scrotum, prepuce, or glans; may be herpetiform, major (< 1 cm), or minor. Uveitis.
Cmplc: Blindness (Bull Rheum Dis 1985;35:1) (rx often titrated to the uveitis), multiple cardiac (Ann Intern Med 1983;98:639), inflammatory arthritis with polys < 200,000, aseptic meningitis, thrombophlebitis, colitis, skin pustules and delayed hypersensitivity reaction to saline or any shot
Diff Dx: Aphthous ulcers, syphilis, herpes simplex, chancroid
Lab: Heme: ESR elevated. Serol: increased acute phase reactants. Skin tests: (1) delayed hypersensitivity reaction to a saline shot is diagnostic; 1/3 pts have thrombophilia.
Rx: Rx of genital lesions is both local and systemic. Local: moisture-retaining dressings, intralesional injection of corticosteroids, topical anesthetics. Systemic: (1) ASA, indomethacin, or pentoxifylline 300 mg po bid (Ann Intern Med 1996;124:891); (2) high-dose steroids; (3) azathioprine (N Engl J Med 1990;322:281), cyclophosphamide, or chlorambucil; (4)
thalidomide 100 mg po qd (Ann Intern Med 1998;128:443). Cmplc: teratogenicity in pregnant female, polyneuropathy. Other therapies include colchicine, FK 506, hydroxychloroquine (J Ocul Pharmacol 1994;10:553; Curr Opin Rheum 1994;6:39). Interferon alpha has demonstrated promising results in clinical trials (Arch Dermatol 2002;138:467; Br J Ophthalmol 2003;87:423). Dapsone and rebamipide have also been used in small series and have demonstrated efficacy in treatment of the mucocutaneous lesions (J Dermatol 2002;29:267; 2004;31:806).
thalidomide 100 mg po qd (Ann Intern Med 1998;128:443). Cmplc: teratogenicity in pregnant female, polyneuropathy. Other therapies include colchicine, FK 506, hydroxychloroquine (J Ocul Pharmacol 1994;10:553; Curr Opin Rheum 1994;6:39). Interferon alpha has demonstrated promising results in clinical trials (Arch Dermatol 2002;138:467; Br J Ophthalmol 2003;87:423). Dapsone and rebamipide have also been used in small series and have demonstrated efficacy in treatment of the mucocutaneous lesions (J Dermatol 2002;29:267; 2004;31:806).
7.6 Sclerosing Lymphangitis
Cause: Local trauma
Epidem: Males 20-40 yr (BJU 1987;59:194). Associated with vigorous sexual activity (Br J Vener Dis 1972;48:545).
Pathophys: Thrombosed lymphatic vessels
Sx: Usually painless
Si: Translucent, flesh/red-colored lesion on shaft/glans of penis (Arch Dermatol 1993;129:366; Cutis 1991;47:421). Swelling proximal and parallel to the corona (J Urol 1982;127:987).
Rx: Avoidance of vigorous sexual activity. If persists, excise (J Urol 1982;127:987).
7.7 Erythema Multiforme
Cause: Many drugs (sulfonamides, penicillin, phenytoin, phenylbutazone) have been reported to cause erythema multiforme (J Invest Dermatol 1994;102:285; N Engl J Med 1994;331:1272). May occur secondary to opiates, NSAIDs, IVP dye (steroids protect), thiamine, curare, dextrans, hormonal fluctuations. Associated
infectious agents include Mycoplasma pneumoniae, Histoplasma capsulatum, Coccidioides immitis, Yersinia enterocolitica, echovirus, Coxsackie virus, Epstein-Barr, influenza virus, herpes simplex.
infectious agents include Mycoplasma pneumoniae, Histoplasma capsulatum, Coccidioides immitis, Yersinia enterocolitica, echovirus, Coxsackie virus, Epstein-Barr, influenza virus, herpes simplex.
Epidem: Affects all cutaneous skin surfaces. Stevens-Johnson syndrome more severe form.
Pathophys: With herpes infection, lesions appear 7-12 d after viral eruption.
Sx: Sore throat, malaise
Si: Red iris or target lesions 1-2 cm in diameter. Stevens-Johnson syndrome: targetoid lesions, blisters, mucosal membrane involvement. Toxic epidermal necrolysis: Sloughing of the epidermis and blistering.
Crs: Usually resolves over 3-6 wk but may be recurrent
Cmplc: Epidermal detachment of mucous membranes, locally in Stevens-Johnson syndrome with 5% mortality or extensively in toxic epidermal necrolysis with 30% mortality (N Engl J Med 1995; 333:1660)
Diff Dx: R/o systemic diseases like SLE, dermatomyositis, scarlet fever.
Rx: Eliminate causative agent, rx denuded skin, systemic immunosuppression controversial
7.8 Tuberculosis of the Penis
Cause: Mycobacterium tuberculosis
Epidem: Rare manifestation of TB in adults; may be primary or secondary
Pathophys: Primary TB of penis occurs after sexual contact with organism present in female genital tract or by contamination from infected clothing (J Urol 1980;124:927; BJU 1976;48:274). Rarely, may develop secondary to inoculation through an infected ejaculate.
Si/Sx: Superficial ulcer of glans or solid penile nodule (J Urol 1989; 141:1430)
Cmplc: Tubercular cavernositis
Diff Dx: Malignant penile lesions
Lab: Bx of lesion to confirm dx
Rx: Antituberculosis chemotherapy
7.9 Molluscum Contagiosum
Dermatol Online J 2003;9:2
Cause: Virus belonging to the DNA pox family
Epidem: Worldwide incidence of 2-8%. Genitalia commonly involved but can affect other areas of body; confined to skin and mucous membranes. Higher incidence in children, sexually active adults, and those who are immunodeficient. Transmitted primarily through direct skin contact, but fomites have been suggested as another source of infection. Incubation period usually 2-7 wk, up to 6 mo.
Crs: Usually a self-limiting, benign skin lesion (Dermatology 1994;189:65); can be more severe in immunocompromised
Sx/Si: Small, firm umbilicated skin papules, discrete, smooth, and dome shaped; skin colored with an opalescent character
Rx: Excise, freeze, burn, or laser lesions. Topical therapies include 0.05 mL of 5% podofilox in lactate-buffered ethanol bid for 3 d (Dermatol Ther 2000;13:285); Cantharidin (0.9% solution of collodion and acetone) applied to area for at least 4 hr, repeated every week until lesions clear (J Am Acad Dermatol 2000;43:503), can cause blistering; iodine solution and salicylic acid plaster (Int J Dermatol 1990;29:443); tretinoin 0.05-0.1% cream; aqueous solution 5-10% KOH; imiquimod 5% cream; cidofovir 3% cream (Pediatr Dermatol 1999;16:414).
7.10 Pearly Penile Papules
Cause: Possibly viral origin or phylogenetic residua
Epidem: Occurs in 30% of men (Cutis 1977;19:54); more frequently found in young adults and uncircumcised (J Dermatol Surg Oncol 1989;15:552)
Pathophys: Histopathol: acralangiofibromas (Arch Dermatol 1973; 108:673)
Sx: Painless
Si: Appears as 1- to 2-mm pink/white/yellow or transparent papules that encircle corona and are more prominent on dorsal surface (GU Med 1997;73:137)
Crs: Lesions may resolve with age.
Diff Dx: Condyloma acuminatum, molluscum contagiosum
7.14 Kaposi’s Sarcoma
See Table 7.1.
Table 7.1 Nonsquamous Cell Carcinomas of the Penis | |||||||||||||||||||||||||||||||||||
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