190 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract I.8.3 Penile Inflammations F.-M. Köhn Key Messages In contrast, men may also be worried because they have ■ Since andrologists pay special attention to the discovered penile alterations which are physiological inspection and palpation of the male genital variations such as heterotopic sebaceous glands (Fig. region, they should have knowledge about I.8.2) or pearly penile papules. dermatologically relevant penile lesions. ■ Inflammatory dermatoses of the penis may be symptoms of general diseases or specific alter- I.8.3.2 ations of the genital region. Pearly Penile Papules ■ The differential diagnoses of penile derma- I.8.3.2.1 toses include infections, balanitides, neoplastic Definition diseases, trauma, papulosquamous or systemic diseases, fixed drug reactions, allergic or irri- Normal anatomic structures located at the glans penis. tant contact dermatitis and miscellaneous lesions. I.8.3.2.2 ■ Some men may also be worried because they Aetiology and Pathogenesis have discovered penile alterations which are physiological variations such as heterotopic Histologically, these papules are acral angiofibromas sebaceous glands or pearly penile papules. with acanthosis, dense connective tissue and a rich vas- cular complex (Ackerman and Kronberg 1973). I.8.3.1 I.8.3.2.3 Introduction Clinical Findings Inflammatory dermatoses of the penis may be symp- Pearly penile papules are skin-coloured, asymptomatic toms of general diseases or specific alterations of the and sometimes hyperkeratotic 1- to 2-mm papules with genital region. The differential diagnosis includes in- circumferential distribution around the corona of the I.8 fectious diseases or benign and malignant neoplasias. glans penis (Fig. I.8.3). Their incidence was found to be Often patients consult their physicians only if the pe- more than 30% (Rehbein 1977; Rufli et al. 1978). nile disorders cause pain or affect sexual intercourse. The differential diagnoses of penile dermatoses include I.8.3.2.4 infections, balanitides, neoplastic diseases, trauma, pa- Differential Diagnosis pulosquamous or systemic diseases, fixed drug reac- tions, allergic or irritant contact dermatitis and miscel- Although pearly penile papules are typical, they are fre- laneous lesions (English et al. 1997; Köhn et al. 1999; quently misdiagnosed as condylomata or ectopic seba- Buechner 2002; Bunker 2001, 2004). This section will ceous glands. only focus on the most important inflammatory penile diseases. Fig. I.8.2. Heterotopic sebaceous glands Fig. I.8.3. Pearly penile papules I.8.3 Penile Inflammations 191 I.8.3.2.5 I.8.3.3.5 Treatment Treatment Treatment is not indicated and patients should be assured Treatment is usually not indicated. Topical treatment about the harmlessness of pearly penile papules. Howev- with corticosteroids is recommended in chronic cases er, they have also been treated by carbon dioxide laser with pain. and cryosurgery (Magid and Garden 1989; Ocampo-Can- diani and Cueva-Rodriguez 1996; Lane et al. 2002). I.8.3.3.6 Prognosis I.8.3.3 Self-limiting course. Sclerosing Lymphangitis of the Penis I.8.3.3.1 I.8.3.4 Definition Balanitis and Balanoposthitis The disease is caused by a thrombosed or sclerosed I.8.3.4.1 lymphatic vessel. Definition Balanoposthitis is the inflammation of the contiguous I.8.3.3.2 and opposing mucosa of the glans penis (balanitis) and Aetiology and Pathogenesis the prepuce (posthitis, Fig. I.8.5). This disorder most often occurs after vigorous sexual activity and resolves spontaneously. However, it may I.8.3.4.2 also be associated with underlying sexually transmit- Aetiology and Pathogenesis ted diseases (Rosen and Hwong 2003). The differential diagnosis of balanoposthitis includes many infectious and noninfectious diseases (Table I.8.3.3.3 I.8.6). Some cases of balanoposthitis cannot be classi- Clinical Findings fied. However, it could be demonstrated that they show The typical symptom of the nonvenereal sclerosing common clinical and histopathological features. Bala- lymphangitis is a minimally tender, indurated cord in- nitis was diagnosed in 11% of 2,006 patients attending I.8 volving the coronal sulcus (Fig. I.8.4). a genitourinary medicine clinic (Birley et al. 1993). In the general population, the incidence of balanitis depends on whether patients are circumcised or not. I.8.3.3.4 Differential Diagnosis Sudden and almost painless cord-like induration on thepeniledorsalsurfaceisduetopenileMondor’sdis- ease which may be treated with nonsteroidal anti- inflammatory drugs (Sasso et al. 1996). Fig. I.8.4. Sclerosing lymphangitis of the penis Fig. I.8.5. Acute balanoposthitis after infection with Candida albicans (several days after start of antimycotic treatment) 192 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract Table I.8.6. Dermatologically relevant penile infections (accord- Table I.8.7. Differential diagnosis of balanitis and balano- ing to English et al. 1997; Köhn et al. 1999) posthitis (according to Johnson 1993, Köhn et al. 1999) Mycotic infections Candida species Infections Malassezia furfur Nonspecific intertrigo Trichophyton rubrum Traumatic injury Trichophyton mentagrophytes Allergic or irritant contact dermatitis Histoplasma capsulatum Psoriasis vulgaris Blastomycosis dermatitidis Balanitis circinata of Reiter’s syndrome Cryptococcus neoformans Fixed drug eruption Penicillium marneffei Malignant neoplasias Plasma cell balanitis Bacterial infections Group B q -haemolytic streptococci Lichen sclerosus et atrophicus Group A q -haemolytic streptococci Pemphigus Staphylococcus aureus Staphylococcus epidermidis Streptococcus milleri,groupHB5 Escherichia coli human immunodeficiency virus, even rare infections Pseudomonas aeruginosa of the penis have to be considered (e.g. leishmaniasis, Haemophilus parainfluenza leprosy, mycobacteriosis). Klebsiella Dermatologically relevant parasitic infections of the Enterococcus faecalis Proteus mirabilis penis are those with Trichomonas and scabies. Glans Morganella penis and foreskin lesions (balanoposthitis) occurred Gardnerella vaginalis in 34% of 46 males with trichomoniasis and were pre- Bacteroides species dominantly of the erosive type (Michalowski 1981). Mycobacterium tuberculosis Mycobacterium celatum Chlamydia trachomatis I.8.3.4.3 Mycoplasma hominis Neisseria gonorrhoeae Clinical Findings Treponema pallidum Haemophilus ducreyi Balanitis can be acute or chronic. Typical symptoms of Calymmatobacterium granulomatis balanitis are erythema (100%), swelling (91%), dis- Viral infections Herpes simplex virus charge (73%), dysuria (13%), bleeding (2%) and Human papillomavirus sometimes ulceration of the glans penis (1%) (Escala Varicella-zoster virus and Rickwood 1989). Nocturnal pruritus and erythem- I.8 Molluscum contagiosum virus atous, excoriated papules of the penis are typical for Parasitic infections Entamoeba histolytica scabies. Trichomonas vaginalis Sarcoptes scabiei Leishmania species I.8.3.4.4 Differential Diagnosis ThedifferentialdiagnosesaresummarizedinTable A cross-sectional study with a randomly selected group I.8.6. of 398 dermatology patients demonstrated that balani- tis was present in 2.3% of circumcised men and in I.8.3.4.5 12.5% of uncircumcised men. In patients with diabetes Treatment mellitus, balanitis occurred with a higher prevalence of 34.8% in the uncircumcised population (Fakjian et al. Treatment of balanoposthitis depends on aetiological 1990). agents or diseases. Therefore, antimicrobic, anti- The group of microorganisms causing penile lesions inflammatory therapy or circumcision, especially in is heterogeneous and includes mycotic, bacterial, para- cases of recurrent balanoposthitis, are performed. sitic and viral infections (Table I.8.7). Mycotic and bac- terial infections become mainly manifest as balanitis or I.8.3.4.6 balanoposthitis and sometimes as ulcerations or gan- Prognosis grene. The most frequent causes of infectious balanitis or balanoposthitis are Candida and Streptococcus spe- The prognosis depends on the aetiology of balanitis. cies. However, anaerobes were also often found in un- circumcised men (76%) with balanoposthitis (Masfari et al. 1983). Bacteroides species were the predominant microorganisms in anaerobic balanitis (Cree et al. 1982). In tropical countries or in patients infected with I.8.3 Penile Inflammations 193 I.8.3.5 Lichen sclerosus was found in 68 of 207 patients with Lichen Sclerosus et Atrophicus squamous cell carcinomas and giant condylomas. The preferential anatomic site of lichen sclerosus was the I.8.3.5.1 foreskin (Velazquez and Cubilla 2003). In contrast, 5 of Definition 86 uncircumcised men with genital lichen sclerosus Lichen sclerosus et atrophicus is a chronic sclerotic showed malignant or premalignant histopathologic process with unknown aetiology. features (three squamous cell carcinoma, one erythro- plasia of Queyrat, one verrucous carcinoma). The aver- age lag time from onset of lichen sclerosus was 17 years. I.8.3.5.2 HPV 16 infection was detected by polymerase chain re- Aetiology and Pathogenesis action (PCR) in four of these patients (Nasca et al. Traumatic factors, autoimmune disease, genetic factors 1999). and hormonal factors have been discussed. I.8.3.5.4 I.8.3.5.3 Differential Diagnosis Clinical Findings Vitiligo, postinflammatory hypopigmentation, post- The disease shows a predominant localization (83%) in traumatic or surgical scars, cicatrizing pemphigoid. the genital region and is mostly found in uncircum- cised middle-aged