Table of Contents   This Chapter   All Chapters

PENIS

Pearly penile papules

Two or three rows of uniform, flesh-colored papules running circumferentially about the corona (Fig.20.50) are characteristic. Onset is typically noted in the twenties and thirties. Rarely, these papules may also occur on the shaft. The patient should be assured that the lesions are not infectious and that no treatment is needed. Podophyllin does not work. CO2 laser has been performed.

Figure 20.61 Pseudoepitheliomatous, micaceous, and keratotic balanitis is usually seen in the older man. The skin is thickened and rough. It has been considered premalignant.

Ectopic sebaceous glands

Uniformly distributed, 1–2-mm papules on the penile shaft occur in approximately one-third of men (Fig.20.51). They may number more than 100 and are more common on the ventral surface. They represent ectopic sebaceous glands (Tyson glands) and appear unassociated with the hair follicle. Knowledge of their existence helps prevent confusion with condyloma. No treatment is needed.

Candidal balanitis

Bright-red erythema initially, followed by minute pustules on the glans penis, is characteristic (Fig.20.52). Uncircumcised men are at higher risk. A white, creamy coating may develop. The organism may have been obtained from the patient's own gastrointestinal tract or from a sexual partner's vagina. In severe cases, dysuria, dyspareunia, or phimosis may occur.

    Application of a topical antifungal cream is usually sufficient. The patient should be educated on good hygiene (i.e. daily cleansing under the foreskin). Application of an antifungal medication weekly and postcoitally may be necessary prophylactically.

Scabies

Nodules occur on the penis (see Fig. 27.10).

Fixed drug eruption

The glans penis is a common site (see Fig.18.25).

Allergic contact dermatitis

The Rhus allergen (poison ivy and oak) is often carried to the penis by the ngers when the man urinates. Massive swelling may occur (Fig. 20.53).

PRACTICE POINTS

Psoriasis

Red, scaly papules and plaques of the glans, shaft, or scrotum may occur in the patient with psoriasis (Fig. 20.54 and Ch.7). In women, the labia and adjacent areas may be affected. Loose-fitting undergarments to decrease friction are important. A moderate-potency topical steroid such as clobetasone butyrate or triamcinolone 0.025% cream once or twice daily is usually effective. To prevent atrophy, such medication should be used only intermittently.

Figure 20.62 Lichen sclerosus (LS). (a,b) LS in an older woman before and only 26 days after nightly clobetasol. Note the dramatic improvement. The pruritus disappeared almost immediately.

Figure 20.63 Lichen sclerosus with labial fusion.

Figure 20.64 Lichen sclerosus with edematous labia minora.

Lichen planus

Annular lichen planus (Fig.20.55) has a predilection for the penis and scrotum. Lichen planus of the penis may also present as purple papules covered by lace-like Wickham's striae. A mild topical steroid may be prescribed for symptomatic lesions (see Ch. 8).

Penile melanosis

See Figure 20.56.

Balanitis xerotica obliterans

Balanitis xerotica obliterans (BXO) is a term sometimes used for lichen sclerosus of the penis. The glans or foreskin becomes white, smooth, and atrophic (Fig.20.57). Erosions, hemorrhage, decreased sensation of the glans, painful erections, and scarring with phimosis may occur. This disease represents a common cause of phimosis in boys. SCC may rarely occur. Involvement of the urethral meatus may cause stenosis and difficulty urinating.

Figure 20.65 Childhood lichen sclerosus that was confused with sexual abuse.

    Clobetasol propionate cream twice daily should be tried initially and can obviate the need for surgical correction of phimosis in young boys. Circumcision in the uncircumcised is effective in reducing functional symptoms, although it does not alter the disease per se, and indeed it may recur in the circumcision scar.

Erythroplasia of Queyrat

A fixed red, moist patch or plaque on the glans of an uncircumcised elderly man is characteristic of this disease (Fig.20.58), which represents SCC in situ. An underlying invasive SCC may be found. Evaluation of the intraurethral area should be done if the lesion is contiguous with that area. Several risk factors have been noted, including lack of circumcision in infancy or early childhood, HPV infection, balanitis, and smoking. Other factors may be related, including the chronic presence of smegma (which may be converted to carcinogenic agents by Mycobacterium smegmatis ), phimosis, PUVA therapy, and the presence of lichen sclerosus.

    Surgical excision may be done. Laser ablation with the CO2 or the neodymium:yttrium–aluminum–garnet (Nd:YAG) laser, with or without acetic acid presoak, is also appropriate. Topical imiquimod therapy has been reported to clear lesions. Other approaches include 5-fluorouracil or Mohs surgery.

Zoon balanitis

A moist, shiny, erythematous, well-demarcated plaque on the glans penis in an older uncircumcised man is characteristic of Zoon balanitis, also known as balanitis plasmocellularis (Fig.20.59). A biopsy is needed to establish the diagnosis and to exclude malignancy. Nearly all cases occur in uncircumcised men, and nearly all are cured by circumcision. CO2 laser has also been used, as has topical fusidic acid.

Verrucous carcinoma of the penis (Buschke–Loewenstein tumor)

Verrucous carcinoma is the term given to certain, typically slow-growing, SCCs of the genitalia (Fig.20.60). Often HPV-6 or 11 may be found, but also HPV-16. The patient is usually uncircumcised. It has been proposed that a continuum extends from condylomata to larger precancerous lesions to invasive SCC. A large, cauliflower-like growth on the glans penis is characteristic of this low-grade, well-differentiated SCC. Standard excision or Mohs surgery is the treatment of choice. Other destructive modalities (e.g. cautery and cryotherapy) have been used.

Figure 20.66 Lichen simplex chronicus (LSC). This older woman had irregular areas of thickened skin and erosions on the labia. A biopsy is important here to exclude malignancy (histologic examination showed only LSC).

Figure 20.67 Lichen simplex chronicus of the scrotum.

Metastatic tumors

Multiple tumors in the genital area may represent metastatic disease (e.g. prostate cancer).

Pseudoepitheliomatous, micaceous, and keratotic balanitis

Pseudoepitheliomatous, micaceous, and keratotic balanitis is thought to represent a spectrum from hypertrophic atypia to verrucous carcinoma. It develops soon after circumcision in older men. The skin of the head of
the penis is rough and keratotic (Fig.20.61). Individual plaques may be present. A biopsy is mandatory to exclude SCC. In fact, some consider
this a premalignant condition and recommend complete surgical excision even if frank malignancy is not seen on biopsy. More conservative approaches have included observation, topical 5-fluorouracil, and cryotherapy.

Sclerosing lymphangitis of the penis

In sclerosing lymphangitis, previously known as non-venereal sclerosing lymphangitis, a firm cord develops on the penile shaft, often developing parallel to the corona. It may follow any cause of inflammation, including syphilis, prolonged sexual intercourse, masturbation, herpes genitalis, gonorrheal urethritis, lymphogranuloma venereum, granuloma inguinale, sporotrichosis, or candidiasis. Work-up for a sexually transmitted infection is mandatory. It may take many months to resolve, but the lesion itself is benign.

White/Cox: Diseases of the Skin, 2ed.(c) 2006, Elsevier Inc. All rights reserved.