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190 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract I.8.3 Penile 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 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 . tant contact 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 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 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 and Balanoposthitis The disease is caused by a thrombosed or sclerosed I.8.3.4.1 lymphatic vessel. Definition Balanoposthitis is the 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 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 et atrophicus Group A q -haemolytic streptococci Pemphigus Staphylococcus aureus Staphylococcus epidermidis Streptococcus milleri,groupHB5 Escherichia coli human immunodeficiency , 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 . Glans Morganella penis and lesions (balanoposthitis) occurred Gardnerella vaginalis in 34% of 46 males with and were pre- Bacteroides species dominantly of the erosive type (Michalowski 1981). Mycobacterium tuberculosis Mycobacterium celatum trachomatis I.8.3.4.3 Clinical Findings Balanitis can be acute or chronic. Typical symptoms of Calymmatobacterium granulomatis balanitis are erythema (100%), swelling (91%), dis- Viral infections virus charge (73%), (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 virus atous, excoriated papules of the penis are typical for Parasitic infections Entamoeba histolytica scabies. 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 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 , 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 , 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 men (Meffert et al. 1995; English et I.8.3.5.5 al.1997).However,clinicalexaminationsof100boys Treatment before circumcision due to demonstrated li- chen sclerosus et atrophicus in 14 cases (Chalmers et al. Treatment includes circumcision, local therapy with 1984). In general, lichen sclerosus et atrophicus is corticosteroids (clobetasol) or immunomodulators found in 3.6–19% of removed for various (), carbon dioxide laser vaporization and reasons (English et al. 1997). topical application of antimicrobic agents in cases of The disease is characterized by erythematous mac- superinfection (Neill and Ridley 2001). Therapy with ules and plaques, which progress to white atrophic and testosterone propionate is not a generally recommend- sclerotic papules and plaques of the glans penis and the ed option nowadays. Patients with lichen sclerosus et prepuce (Fig. I.8.6). While early lesions are asymptom- atrophicus should be monitored regularly. atic, later patients report pruritus, burning, diminished I.8 sensation of the glans, painful erections, meatal steno- I.8.3.5.6 sis, adhesions between prepuce and glans penis and Prognosis phimosis. Haemorrhages, erosions and ulcerations mayalsobefoundintheselesions. In rare cases, verrucous or squamous cell carcinoma can develop in lesions of lichen sclerosus et atrophicus.

I.8.3.6 Balanitis Circumscripta Plasmacellularis (Zoon’s Balanitis) I.8.3.6.1 Definition Plasma cell balanitis is a chronic disease in uncircum- cised middle-aged and older men. The prevailing histological feature is the predominance of plasma cells.

I.8.3.6.2 Aetiology and Pathogenesis The aetiology is unknown. Poor and chronic infection with Mycobacterium smegmatis, physical fac- tors such as heat, friction or trauma, unknown exoge- Fig. I.8.6. Lichen sclerosus et atrophicus nous agents and immunological processes involving 194 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

IgE class antibodies have been postulated to play a role I.8.3.6.6 in the pathogenesis of Zoon’s balanitis (English et al. Prognosis 1997). Chronic disease with poor response to treatment. No association with penile . I.8.3.6.3 Clinical Findings The disease appears as solitary, shiny, erythematous, I.8.3.7 smooth plaque of the glans penis and/or the prepuce Balanitis Circinata (Kumar et al. 1995). Sometimes the colour is similar to I.8.3.7.1 that of cayenne pepper. Clinical variations with erosive Definition and vegetative types are known (Johnson 1993). The le- sion is asymptomatic with the exception of mild pruri- Reiter’s syndrome is defined as the triad of reactive ar- tus. The diagnosis of plasma cell balanitis has to be thritis, conjunctivitis and ; in addition, a vari- confirmed by biopsies and histopathological examina- ety of minor symptoms such as diarrhoea, inflammato- tions. Histological findings are epidermal atrophy, loss ry eye diseases and mucocutaneous lesions can be pre- of rete ridges, spongiosis, dense dermal infiltrate with sent. plasma cells and scattered lymphocytes. Erythrocyte extravasation and haemosiderin deposition cannot al- I.8.3.7.2 ways be found (Fig. I.8.7; Kumar et al. 1995). Aetiology and Pathogenesis The pathogenesis of this disease is not completely un- I.8.3.6.4 derstood. Certain genital and gastrointestinal infec- Differential Diagnosis tions trigger the syndrome in genetically predisposed The differential diagnosis of plasma cell balanitis in- patients (HLA-B27 positivity in up to 90%). The infec- cludes erythroplasia of Queyrat, extramammary Pa- tiousagentsimplicatedincludeChlamydia trachoma- get’s disease, fixed drug eruption, allergic contact der- tis, Shigella flexneri, Salmonella species, Yersinia ent- matitis, psoriasis, eczema, lichen planus, lichen sim- erocolitica, Campylobacter species, Ureaplasma urealy- plex chronicus, lichen sclerosus et atrophicus, HPV in- ticum and Neisseria gonorrhoeae (Adimora et al. 1994). fection, Kaposi’s , secondary , Candida Genitalchlamydialinfectionsarethemostfrequently I.8 balanitis, Reiter’s disease and pemphigus vulgaris. occurring infections associated with Reiter’s syndrome (50% of male patients). The incidence and prevalence of Reiter’s syndrome vary geographically. It is still I.8.3.6.5 speculative whether males are more commonly affect- Treatment ed than females. Positive effects on the disease have been reported by treatment with corticosteroids, circumcision, antimi- I.8.3.7.3 crobic agents and carbon dioxide laser. Clinical Findings Most patients are between 30 and 40 years old. The inci- dence of Reiter’s syndrome in men younger than 50 years is 3.5 per 100,000 (Michet et al. 1988). Balanitis circinata is the most common skin finding in patients with this disease; it is found in 12–70% of all patients with Reiter’s syndrome (English et al. 1997). The le- sions are painless and appear as serpiginous, erythem- atous, sometimes also erosive plaques with ragged margins(Fig.I.8.8).Theyarelocatedattheglanspenis in uncircumcised men. In circumcised men, the lesions are dry and scaling, resembling psoriasis (Johnson 1993). The histopathological pattern is psoriatic.

I.8.3.7.4 Differential Diagnosis Fig. I.8.7. Balanitis circumscripta plasmacellularis (Zoon’s ba- lanitis) Candida balanitis. I.8.3 Penile Inflammations 195

I.8.3.8.2 Aetiology and Pathogenesis Psoriatic lesions are characterized by keratocyte prolif- eration (reduction of epidermal cell cycle from 311 h to 36 h) and inflammation/immune mechanisms (in- creased numbers of activated T cells within the altered epidermis and dermis. Early onset psoriasis is associat- ed with class I and II HLA markers (B13, Bw57, Cw6, DR7), late onset psoriasis with A2 and B27. Trigger fac- tors are trauma (Koebner phenomenon), (streptococ- cal) infections, stress and drugs (beta-adrenergic blockers). Infection with human immunodeficiency vi- Fig. I.8.8. Balanitis circinata rus also seems to be a trigger for anogenital psoriasis (Weitzul and Duvic 1997). I.8.3.7.5 Treatment I.8.3.8.3 Clinical Findings Treatment of first choice is local application of mild corticosteroids. The incidence of psoriasis in Western countries ranges between 1% and 2%. Psoriasis was diagnosed histolog- ically in 3% of 60 male patients attending a genitouri- I.8.3.7.6 nary medicine clinic (Hillman et al. 1992). Psoriatic le- Prognosis sions of the genital region occur in all age groups from Subacute or chronic disease. infancy to the elderly. Approximately 25–50% of epi- demiologic studies report that genital psoriasis is pre- sent with a higher frequency in males than in females I.8.3.8 (Farber and Nall 1992). The clinical pattern of penile Psoriasis Vulgaris psoriasis varies between circumcised and uncircum- cised men. While psoriatic lesions appear as well-de- I.8.3.8.1 marcated erythematous plaques without scale in oc- Definition I.8 cluded skin (intact foreskin, Figs. I.8.9, I.8.10), psoriat- Psoriasis vulgaris is a chronic relapsing skin disease ic plaques are erythematous, with varying accumula- with erythrosquamous lesions. In addition to lichen tions of scale in circumcised men (Fig. I.8.11; Johnson planus, it is the most frequently occurring syste- 1993). With the exception of optional pruritus or in- mic dermatosis with optional genital manifestation (Table I.8.8).

Table I.8.8. Papulosquamous and systemic diseases with lesions at the glans penis and prepuce (according to Johnson 1993; En- glish et al. 1997; Köhn et al. 1999)

Psoriasis vulgaris Dermatitis herpetiformis Lichen planus Henoch-Schönlein-purpura Lichen nitidus Wegener’s granulomatosis Seborrhoeic dermatitis Neurofibromatosis Atopic dermatitis Necrobiosis lipoidica Pityriasis rosea Hypereosinophilic syndrome Crohn’s disease Beh¸cet’s syndrome Ulcerative colitis Angiokeratoma corporis Sarcoidosis diffusum Amyloidosis Erythema multiforme Vitiligo Lichen sclerosus et atrophicus Pemphigus variants Balanitis circinata Bullous pemphigoid Mastocytosis

Fig. I.8.9. Psoriasisvulgarisofthepeniswithwell-demarcated nonscaling plaques 196 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

I.8.3.8.4 Differential Diagnosis Zoon’ balanitis, lichen planus, erythroplasia of Queyrat and extramammary Paget’s disease.

I.8.3.8.5 Treatment Treatment includes topical application of corticoste- roids, Castellani’s paint or vitamin D analogues.

I.8.3.8.6 Prognosis Chronic and relapsing disease. Genital complications associated with the therapy of psoriasis such as devel- opment of squamous cell carcinoma or genital ulcera- tions were demonstrated after PUVAtherapy and local treatment with tazarotene, respectively (De la Brassin- ne and Richert 1992; Wollina 1998).

I.8.3.9 Lichen Planus

Fig. I.8.10. Psoriasisvulgarisofthepenis I.8.3.9.1 Definition Lichen planus is an inflammatory dermatosis affecting both mucosal and keratinized epithelium. The male I.8 genitalia are affected in 25% of cases.

I.8.3.9.2 Aetiology and Pathogenesis The aetiology of lichen planus is unknown. Immuno- logic mechanisms seem to play a major role. Associa- tion with has been reported (Tanei et al. 1997).

I.8.3.9.3 Clinical Findings Penile lichen planus appears as typical polygonal, flat- topped papules with annular configuration and white striae (Figs. I.8.12, I.8.13). Erosive variants are also known. Although genital lesions are usually associated with lichen planus of other skin regions, they may de- velop as initial or exclusive manifestation of lichen pla- nus. In typical cases diagnosis is made clinically; other- Fig. I.8.11. Psoriasisvulgarisofthepeniswithascalingplaque wise histological examinations of biopsies are neces- sary. creased sensitivity during sexual intercourse, psoriatic lesions of the penis are asymptomatic. I.8.3 Penile Inflammations 197

Fig. I.8.14. Fixed drug eruption with a well-demarcated ery- thematous macule and blistering

lesions have also been systemically treated with ciclo- sporin or thalidomide (Perez-Alfonzo et al. 1987; Jemec and Baadsgaard 1993).

Fig. I.8.12. Penile lichen planus of the glans penis showing typi- cal polygonal, flat-topped papules with annular configuration I.8.3.9.6 and white striae Prognosis While spontaneous remission with postinflammatory hyperpigmentation can be expected in most cases, ero- sive variants of this disease may persist for decades (Johnson 1993). Squamous cell carcinoma developing in penile lichen planus is extremely rare (Leal-Khouri and Hruza 1994). I.8 I.8.3.10 Fixed Drug Eruption I.8.3.10.1 Definition After sensitization to a drug, fixed drug eruptions ap- pear as solitary or multiple well-demarcated erythema- tous macules or plaques, which may also develop bullae (Fig.I.8.14).Thelesionstypicallyrecuratthesamean- atomic sites after exposure to the same drug. Fig. I.8.13. Penile lichen planus of the penile shaft I.8.3.10.2 Aetiology and Pathogenesis I.8.3.9.4 Drugs causing penile fixed drug eruptions are tetracy- Differential Diagnosis cline, doxycycline, penicillins, phenolphthalein, sul- Psoriasis, Zoon’s balanitis, lichen sclerosus, viral fonamides, barbiturates, salicylates, dapsone, griseo- (including ), porokeratosis. fulvin, carbamazepine, dimenhydrinate, metamizole, hydroxyzine hydrochloride and colchicine. Fixed drug eruptions have also been reported after history of sexu- I.8.3.9.5 alcontactwithwomenwhowerefoundtobereceiving Treatment the same medication to which their partners were hy- Treatment of penile lichen planus includes topical ap- persensitive (Zawar et al. 2004). plication of corticosteroids. In individual cases, erosive 198 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

I.8.3.10.3 I.8.3.12 Clinical Findings Allergic and Irritant Contact Dermatitis of the Penis Pandhi et al. (1984) investigated fixed drug eruptions exclusively involving the genitalia of 60 male patients. I.8.3.12.1 The sites affected were the glans penis, coronal sulcus Definition and preputial skin. Superficial ulceration or pigmented AllergiccontactdermatitisiscausedbyatypeIV,cell- areas surrounded by an erythematous halo were the mediated, delayed hypersensitivity to allergens. In con- main clinical findings. Even ulcerations have been de- trast, irritant contact dermatitis is a nonimmunologic scribed. inflammatory reaction after exposure to a chemical or physical agent. I.8.3.10.4 Differential Diagnosis I.8.3.12.2 Aetiology and Pathogenesis All other differential diagnoses of acute balanitis or ba- lanoposthitishavetobeconsidered. According to Johnson (1993), contact dermatitis of the penis may develop after hand-to-penis contact, sexual intercourse (feminine hygiene deodorant sprays and I.8.3.10.5 douches, lubricants containing propylene glycol) and Treatment as local manifestation of a generalized contact dermati- Topical application of corticosteroids. Identification tis. The agents causing allergic reactions depend on and withdrawal of the responsible drug. geographical aspects. In the United States, for example, a common cause of penile contact dermatitis are penta- decylcatechol congeners (poison ivy; Fisher 1996). I.8.3.10.6 Other frequently occurring allergens in condoms or Prognosis rubber diaphragms are mercaptobenzothiazole, tetra- Fixed drug eruptions heal within 2–3 weeks, leaving methylthiuram, zinc dithiocarbamate and latex (John- postinflammatory hyperpigmentation. son 1993; English et al. 1997). The source of the allergen may be the condom material, the lubricant (paraben I.8.3.11 preservatives) or the spermicidal agent (Johnson 1993). I.8 Patients with spinal cord injury using rubber condom Other Drug-Induced Lesions of the Penis urinals have a higher chance of developing penile con- Prolonged topical application of corticosteroids causes tact dermatitis against rubber or latex articles (Brans- epithelial and dermal atrophy of the genital region bury 1979). Some condoms contain local anaesthetics (Stankler 1982). Local penile ulceration has been re- such as benzocaine, which is known to cause allergic ported after irregular subcutaneous injection of pa- contact dermatitis of the penis (Placucci et al. 1996). In paverine (Borgström 1988). Penile ulcerations may al- contrast to allergic penile dermatitis, irritant lesions of so appear after use of dequalinium and in 5–28% of this region occur more frequently. Irritant dermatitis patients with AIDS who are treated with foscarnet, a was diagnosed in 72% of patients with recurrent or un- retroviral reverse transcriptase inhibitor (Braun-Falco responsive balanitis (Birley et al. 1993). The most fre- and Lukacs 1970; English et al. 1997). Since foscarnet quently occurring irritant penile dermatitis is caused is excreted unchanged in the urine, it may be respon- by over-washing (extensive use of soaps) or over-treat- sible for an irritant contact dermatitis resulting in pe- ment (extensive use of ointments). Diagnostic proce- riurethral ulcerations. Coumarins including warfarin dures include patch testing, histological and microbio- may induce penile necrosis (Weinberg et al. 1983). logical examinations. Coumarin-induced necrosis of the penis is found in patients with relative protein C deficiency and starts I.8.3.12.3 between the 3rd and 10th days of therapy (Barkley et Clinical Findings al. 1989). Since penile vascularization is better than in most oth- er skin regions, allergic contact dermatitis of the penis is more florid and symptomatic with erythema, oede- ma, microvesiculation, erosions and exudation (Fig. I.8.15). Older lesions are covered by crusts. Scratches due to intense pruritus are subject to secondary bacte- rial infection. Especially in cases of to latex, I.8.3 Penile Inflammations 199

I.8.3.13.2 Aetiology and Pathogenesis Atopic dermatitis is a multifactorial disease with a ge- netic background, environmental and immunologic factors (IgE-mediated sensitization to a variety of aller- gens) and sebostasis.

I.8.3.13.3 Clinical Findings Frequently occurring symptoms of the skin are erythe- ma, lichenification, excoriation after scratching due to severe itching, superinfection with impetiginization. Fig. I.8.15. Acute contact dermatitis of the penis Atopic diathesis was found in more than 70% of men with irritant balanitis (Birley et al. 1993). local swelling and itching may be accompanied with I.8.3.13.4 systemic (urticaria) or respiratory symptoms. Differential Diagnosis Seborrhoeic dermatitis, psoriasis, irritant or contact I.8.3.12.4 dermatitis. Differential Diagnosis All other differential diagnoses of balanitis or balano- I.8.3.13.5 posthitis have to be considered. Treatment Atopic eczema of the penis is treated by local applica- I.8.3.12.5 tion of corticosteroids, immunomodulators (tacroli- Treatment mus, ) or antimicrobic agents. In severe Irritant or allergic penile dermatitis is treated by local cases, corticosteroids, ciclosporin, antibiotics or anti- application of corticosteroids or antimicrobic agents. histamines are given systemically. I.8 In severe cases, corticosteroids or antihistamines are given systemically. I.8.3.13.6 Prognosis I.8.3.12.6 Chronic and relapsing disease, sometimes self-limit- Prognosis ing. Men with irritant penile dermatitis had a greater life- time incidence of atopic illness and more frequent daily genital washing with soap. For the majority (90%) of I.8.3.14 thesepatients,useofcreamsandrestrictionofsoap Seborrhoeic Dermatitis washing alone reduced symptoms. I.8.3.14.1 Definition I.8.3.13 Chronic erythrosquamous dermatosis of sebaceous Atopic Dermatitis follicle-rich regions of the skin (scalp, face, trunk and genital region). I.8.3.13.1 Definition I.8.3.14.2 The terms “dermatitis” and “eczema” are often used Aetiology and Pathogenesis synonymously.Atopicdermatitisisoneconditionof atopic diathesis; other symptoms can be IgE-mediated Pityrosporum ovale, a commensal yeast of the epider- such as rhinitis, conjunctivitis or asthma, in- misandfollicles,playsanimportantroleinthepatho- creased serum IgE-levels, dry skin (sebostasis) or fa- genesis of seborrhoeic eczema. Seborrhoeic eczema is milial predisposition. more frequently found in men with HIV infection. 200 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

Escala JM, Rickwood AM (1989) Balanitis. Br J Urol 63:196– I.8.3.14.3 197 Clinical Findings Fakjian N, Hunter S, Cole GW, Miller J (1990) An argument for circumcision. Prevention of balanitis in the adult. Arch Der- Typical locations of this disease are scalp, glabella, eye matol 126:1046–1047 brows, nasolabial folds and external auditory canal, but Farber EM, Nall L (1992) Genital psoriasis. Cutis 50:263–266 also the genital region. Clinical symptoms are salmon- Fisher AA (1996) Poison ivy/oak/sumac. Part II: specific fea- coloured erythemas with scaling. tures. Cutis 58:22–24 Hillman RJ, Walker MM, Harris JR, Taylor-Robinson D (1992) Penile dermatoses: a clinical and histopathological study. I.8.3.14.4 Genitourin Med 68:166–169 Jemec GB, Baadsgaard O (1993) Effect of cyclosporine on geni- Differential Diagnosis tal psoriasis and lichen planus. J Am Acad Dermatol 29: Atopic dermatitis, psoriasis, irritant or contact derma- 1048–1049 Johnson RA (1993) Diseases and disorders of the anogenitalia titis. of males. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF (eds) Dermatology in general medicine. McGraw-Hill, New York, pp 1417–1462 I.8.3.14.5 Köhn FM, Pflieger-Bruss S, Schill WB (1999) Penile skin dis- Treatment eases. Andrologia 31 [Suppl 1]:3–11 Kumar B, Sharma R, Rajagopalan M, Radotra BD (1995) Plas- Treatment includes local application of corticosteroids ma cell balanitis: clinical and histopathological features- or antifungals such as imidazoles. response to circumcision. Genitourin Med 71:32–34 Lane JE, Peterson CM, Ratz JL (2002) Treatment of pearly pe- nile papules with CO2 laser. Dermatol Surg 28:617–618 I.8.3.14.6 Leal-Khouri S, Hruza GJ (1994) Squamous cell carcinoma de- Prognosis veloping within lichen planus of the penis. Treatment with Mohsmicrographicsurgery.JDermatolSurgOncol20: In most cases, mild disease; treatment is not manda- 272–276 tory. Magid M, Garden JM (1989) Pearly penile papules: treatment withthecarbondioxidelaser.JDermatolSurgOncol 15:552–554 References Masfari AN, Kinghorn GR, Duerden BI (1983) Anaerobes in genitourinary infections in men. Br J Vener Dis 59:255–259 Ackerman AB, Kronberg R (1973) Pearly penile papules. Acral Meffert JJ, Davis BM, Grimwood RE (1995) Lichen sclerosus. J angiofibromas. Arch Dermatol 108:673–675 Am Acad Dermatol 32:393–416 Adimora AA, Hamilton H, Holmes KK, Sparling PF (1994) Sex- Michalowski R (1981) Trichomonal balano-posthitis. Report I.8 ually transmitted diseases. McGraw-Hill, New York of 16 cases. Ann Dermatol Venereol 108:731–738 Barkley C, Badalament RA, Metz EN, Nesbitt J, Drago JR (1989) Michet CJ, Machado EB, Ballard DJ, McKenna CH (1988) Epi- Coumarin necrosis of the penis. 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Stankler L (1982) Striae of the penis. Br J Dermatol 107:371– Weinberg AC, Lieskovsky G, McGehee WG, Skinner DG (1983) 372 Warfarin necrosis of the skin and subcutaneous tissue of the Tanei R, Ohta Y, Katsuoka K (1997) Lichen planus and Sjögren- male external genitalia. J Urol 130:352–354 type sicca syndrome in a patient with chronic hepatitis C. Weitzul S, Duvic M (1997) HIV-related psoriasis and Reiter’s J Dermatol 24:20–27 syndrome. Semin Cutan Med Surg 16:213–218 Velazquez EF, Cubilla AL (2003) Lichen sclerosus in 68 patients Wollina U (1998) Genital ulcers in a psoriasis patient using with squamous cell carcinoma of the penis: frequent atypias topical tazarotene. Br J Dermatol 138:713–714 and correlation with special carcinoma variants suggest a Zawar V, Kirloskar M, Chuh A (2004) Fixed drug eruption – a precancerous role. Am J Surg Pathol 27:1448–1453 sexually inducible reaction? Int J STD AIDS 15:560–563

I.8.4 Penile Cancer I.D.C. Mitchell

Key Messages penile cancer is almost unknown. It has been noted, ■ Rare male malignancy may have delayed however, that later circumcision does not appear to of- presentation. fer any protection, for example as seen in the Bantu ■ Ninety-five per cent of malignancies are squa- peoples of South Africa. Recent data from the SEER mous cell carcinoma. programme has not found any racial differences in the ■ Treatment of local disease and loco-regional incidence of penile cancer between white and African- nodes both need consideration in management American populations. This study also did not find any of disease. differences in incidence between married men and ■ Multi-modality treatment is being investigated men who have never married. for treatment of advanced disease. Further investigation of the pathogenesis of this tu- mour has found human virus (HPV) in asso- ciation with this tumour. In particular, HPV types 16, I.8.4.1 18 and 33 have been implicated. Definition I.8.4.3 Penile cancer is rare, with a reported incidence of Clinical Findings around 1 per 100,000, representing 0.4–0.6% of can- I.8 cers involving men in Western societies. This tumour Patients with these tumours are often described as hav- usually affects the glans and/or prepuce of the penis. In ing delayed presentation and this has been borne out by over 90% of cases, this is a squamous cell cancer, investigation. The delayed presentation may be in- though other tumours have been reported, for exam- duced by embarrassment, but also a nonretractile pre- ple, . It is very rare in Western countries but puce may hide the primary lesion. When a lesion is hid- is more prevalent in other countries such as or den by the prepuce, the presentation may be bleeding, India. foul-smelling discharge, an indurated lump arising from under the prepuce, or even by the detection of I.8.4.2 pathological inguinal nodes. The primary lesions may be ulcerative or exophytic. It is recommended that any Aetiology and Pathogenesis patient who has a persistent lesion on his penis should It is thought that chronic infection or inflammation have a biopsy taken. gives rise to the changes that lead to malignant trans- In addition to the localized lesion on the penis, a sig- formation. Associations have therefore been made with nificant proportion of up to 50% of patients will have age, phimosis, viral infection, poor socioeconomic sta- palpable inguinal lymphadenopathy and accordingly tus and . the groins should be carefully examined at the time of Itshouldbenotedthatwhilstincreasedageisafac- presentation. When these nodes are histologically ex- tor, the median age of presentation is around 60 years amined, 30–60% have been reported to be inflamma- old, and therefore this disease is not uncommon in tory; however, a recent study has suggested that the younger men. The presence of phimosis is an extremely percentage of palpable nodes demonstrating spread is commonfindinginpatientswiththisdisease.Itisfelt considerably higher. that the conditions found under the prepuce lead to the There are two staging systems used to describe these development of the tumour. This relationship is sup- tumours: Jackson (1966) and the TNM (1997), both ported when one investigates cultures that advocate shown in Table I.8.9. early circumcision such as the Jewish faith, and here