Male Genital Lesions Conrad L. Brimhall, MD, FAAD Kentucky Dermatology & Skin Cancer Clinic Lexinggyton & London, Kentucky Categories o f Les io ns Infectious Neoplastic Herpes Simplex BowenBowens’sDisease Disease Syphilis Squamous Cell Carcinoma Condyloma accuminata Verrucous Carcinoma Candida Extramammary Paget’s Pearly Penile Papules Other Other Inflammatory Traumatic Psoriasis Automobile Accidents Lichen Planus Crush Injuries Contact Dermatitis Suction/vacuum erection device FFedDugEuptoixed Drug Eruption PilTPenile Tourni quet tSd Syndrome Lichen Sclerosis et trophicus Zipper Entrapment Zoon’s Balanitis Sexually Induced Other Iatrogenic Differential Diagnosis Fixed drug eruption Allergic/irritant contact dermatitis IfInfecti on Neoplastic Trauma Psoriasiform/Papulosquamous Balanitides Mnemonic: F.A.I.N.T. with Psoriatic Balanitis Evaluation History Nature of complaints Circumcised or uncircumcised Recurrences and duration Sexual practices Coital partner complaints Prophylactic measures Dysuria Medications: oral and topical Allergies RiReview o f systems: S ystemi c comp lilaints Evaluation Physical Examination Inflammation Edema UthldihUrethral discharge Erosion Ulcers Chancres Atrophy HyperHyper--or Hypopigmentation Nodule or tumor Other cutaneous findings: generalized or scattered Evaluation Laboratory Evaluation DarkDark--fieldfield preparation Tzanck preparation Potassium hydroxide preparation Gram’s stain HIV/syphilis serology Bacterial/mycotic cultures Biopsy Embryology Anatomy Terminology Balanitis—inflammation of the glans . PosthitisPosthitis——inflammationinflammation of the prepuce. BlBalanoposthi hiitis—iflinflammati on of fbh both. Infections Mycotic Parasitic CdidCandida Entamoeba Histoplasma Trichomonas Blastomycosis Sarcoptes Cryptococcus Leishmaniasis Peni cilli um Bacterial Viral Streptococci Herpes Staphylococcus Human Papillomavirus Pseudomonas Molluscum contagiosum Chlamydia Mycoplasma Neisseria Treponema Haemophilus Calymmatobacterium Bacteroides Gardnerella Mycobacterium Infections: Herpes Simplex Herpes Simplex Genital Herppyypes caused by HSV type II. Lesions range from intact or ruptured vesicles on an erythematous base to chronic ulcerations. PiPain, b urni ng, prurit us. Lesions come and go; can recur in same place. Can have viral shedding in absence of visible lesions. Occasionally associated urethritis. Can have accompanying tender lymphadenitis, and constitutional symptoms. Can have associated aseptic meningitis. Herpes Simplex Chronic ulcerative HSV usually seen in setting of immunosuppresion, such as HIV, chemotherapy, org an transp lant, hematolo gic malignancies. Viral culture/PCR are more sensitive, though a positive Tzanck smear done by a knowledgeable examiner is very reliable, though does not identif y type o f HSV or V. Zoster. (negati ve Tzanck is uninformative.) Herpes Simplex Standard treatment is systemic antiviral agent: acyclovir, valacyclovir,valacyclovir, famcyclovirfamcyclovir.. Valacyclovir in immunosuppressed patients (HIV, bone marrow transplant, renal transplant) may increase risk of TTP/HUS . Syphilis and herpes simplex are the most common causes ofillf genital ulcers. Syphilis Syphilis Syphilis Caused by spirochete , Treponema palidum.. Has primary, secondary, latent, and tertiary stages. (Primary stage (chancre) emphasized here.) PiPrimary ch ancre i s pai nl ess. Syphilis: Diagnosis Typical skin lesions and history raise susp icion. Diagnosis based on 1. Direct detection of treponemes or treponemal DNA by MICROSCOPY (Dark field microscopy) or 2. Molecular biological techniques that detect antibody response to cardiolipins (non(non-- treponemal tests), or treponemal antigens (treponemal tests) (most common method); or 3. Silver stain of histopathologic sections. Syphilis: Diagnosis T. ppyallidum cannot be routinely cultured. Darkfield exam of material from a chancre can detect motile spirochetes, but is seldom available, so most practitioners rely on blood tests , of which there are many. RPR and VDRL are readily available nontreponemal tests. Titers correl ate wi th disease act iv ity, an d are useful in screening and monitoring, and revert to negative after treatment. Qualitative tests are OK for screening, but positive results have to be confirmed by antibody titer. Syphilis: Diagnosis Treponemal Tests: Usually done to confirm a reactive nonnon--treponemaltreponemal test. (TPHA, MHA-MHA- TP, FTAFTA--ABSABS) Biopsies of skin lesions can be stained with silver and spirochetes are identifiable. Limitations of non-treponemal tests Not reactive in early primary syphilis Can have false-false-negativesnegatives Can have temppygorary negative in secondary yyp syphilis in HIV Syphilis: Diagnosis Limitations of non-treponemal Biological false-false-positivespositives seen in: Pregnancy Autoimmune disease Drug abuse Lymphomas Infectious diseases Hepatitis and cirrhosis Antiphospholipid Syndrome Idiopathic, familial Syphilis: Diagnosis Limitations of treponemal tests Lack of reactivity in early darkfield positive primary syphilis Not useful for monitoring response to treatment, i.e. titiers indicate active OR past infection; titers persist after cure; do not revert to negative . False positive: endemic treponematoses and borreliosis (e.g. Lyme) Biological falsefalse--positive:positive: autoimmune disease, HIV infection When tests react 7070--80%80% VDRL/RPR + in primary syphilis 99% VDRL/RPR + for secondary syphilis 6565--85%85% FTAFTA--ABS/MHAABS/MHA--TPTP + in primary 100% in secondary Teaching point: Serology not 100% sensitive in primary syphilis Syphilis In ppyyprimary syphilis, chancre noted as follows: Glans 35% Prepuce 19% Frenulum 10% Syp hilit ic BlBalani iitissoof FllFollman --RareRare balanitis associated with primary syphilis; appears as a swollen glanscovered with partialy coalescent white flat papules and plaques. Standard Treatment for early syphilis: BenzathinePenicillin G 2.4 million units – 1 dose, if not PCN allergic and immunocompetentimmunocompetent.. HIV: Benzathine Penicillin G 2.4 million units weekly X 3 doses. Alternatives: Doxycycline200 mg daily x 14 days. TCN 500 md qid X 14 days, Erythro 500 mg qid X 14 days, Ceftriaxone 250 mg IM daily X 10 days Chancroid Chancroid Caused byyp Haemophilus ducrey i Found primarily in developing countries Associated with commercial sex workers and their clien tel e. In the U.S. found mostly in individuals who have visited countries where chancroid is known to occur. Outbreaks in the U.S. have occurred in association with crack cocaine use and prostitution. UUincircumc idized men are 3-4 ti mes more lik el y t o contract chancroid from an infected partner. Risk factor for contracting HIV. Chancroid One to two day incubation period after exposure. Lesions range from 3-50 mm across . Painful. Sharply defined, irregular or ragged, undermined borders. Base of lesion bleeds easily if traumatized. Half of infected men have only one ulcer. Chancroid CDC clinical definition includes all of the following: One or more painful ulcers; combination with tender adenoppyathy is suggestive. Suppurative adenopathy is almost pathognomonicpathognomonic.. No evidence of Treponoma pallidum by dark field exam or by serology performed at least 7 days after onset of ulcer. Presentation not typical of HSV II, or HSV culture is negative. Chancroid Treatment is singg()le oral dose (2 tablets) of azithromycin, or single IM dose of ceftriaxone, or oral erythromycin for 7 days. Similarites to chancre: Both originate as pustules at site of inoculation and progress to ulcers. Both typically 11--22 cm in diameter. Both are STDs. Both on genitals. Both can be present at multiple sites and with multiple lesions. Chancroid Differences from chancre: Different organisms are causative. Chancres are pppainless; chancroid is painful. Chancres are typically non-non-exudative;exudative; chancroid usually has grey or yellow purulent exudate. Chancres have a har d e dge; c hancro id has a so ft e dge. Chancres heal spontaneously even in the absence of treatment. Chancres can occur in the pharynx as well as on the genitals. Granuloma Inguinale Granuloma Inguinale Rare in the U.S., though could be seen in individuals who have hadddd sexual contact in third world countries. Found in underdeveloped regions. Caused byyg Klebsiella granulomatis ( (yformerly Calymmatobacterium granulomatis) Also known as Donovanosis. Causes s ma ll painless nodules. Nodules appear 1010--4040 days after sexual contact. Later the nodules burst, creating open, fleshy, oozing lesions. Infection then spreads causing mutilation of tissues . Will progress until treated. Lesions typically found on shaft of penis, labia, or perineum. Granuloma Inguinale Doctors exppgerienced with this condition can diagnose just by the appearance of the ulcers. However, a tissue sample can be obtained, including biopsy, aspirates , and scrapings . Stained tissue containing Donovan bodies is diagnostic. Nodules can be mistaken for lymph nodes, but true lhdhidiiihihiflymphadenopathy is rare, distinguishing this from Chancroid. Treatment: three wwyy,py,eeks of erythromycin, streptomycin, tetracycline, or 12 weeks of ampicillin. Must complete full course of treatment in spite of early improvement. Bacterial Balanitis Bacterial Balanitis Organisms Streptococcus spp. Group B betabeta--hemolytichemolytic Postpubertal uncircumcized