introduction Clinical considerations of penile cutaneous lesions Juan Chipollini, MD1; Mounsif Azizi, MD2 1Department of Surgery, the University of Arizona College of Medicine, Tucson, AZ, United States; 2Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, United States t is not uncommon for family physicians, dermatologists, of carcinoma in situ. Most benign lesions can be managed and urologists to encounter patients in their practices with with observation or corticosteroids, while neoplastic lesions Ipenile cutaneous lesions. The differentiation of premalig- typically will require more extensive excision, along with a nant lesions from benign dermatosis can be a challenging thorough workup. task due to the rarity of some of these conditions, as well This review aims to provide a practical approach to the as the overall low incidence of penile neoplasms in indus- various aspects of diagnosis and management of penile cuta- trialized nations.1 A retrospective British study found that neous lesions. It is not a complete list of diagnoses, but rather one-fifth of patients with penile carcinoma are first referred a compilation of some of the most encountered ailments in to specialists other than urology.2 Thus, early investigation is a community practice. In some cases, a multidisciplinary fundamental for the treatment of these lesions, which may approach in formulating treatment recommendations for have already suffered significant diagnostic delays due to those with suspected or confirmed cancer is also recom- either lack of knowledge for these conditions or patient- mended. It is hoped that this primer will provide clinicians related stress/embarrassment from genital malady. with a basic understanding of the different diagnostic and The etiology for these cutaneous lesions can range from therapeutic approaches in the management of penile lesions. benign causes, which can be classified as infectious vs. non- infectious, to neoplastic conditions, along with associated References risks of morbidity and psychosocial distress. Clinical presen- tation of these lesions can guide diagnosis and treatment in 1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7-30. the majority of cases. A biopsy is indicated whenever diag- https://doi.org/10.3322/caac.21332 2. Lucky MA, Rogers B, Parr NJ. Referrals into a dedicated British penile cancer centre and sources of possible nosis is in doubt. Irregular erythematous patches or keratotic delay. Sex Transm Infect 2009;85:527-30. https://doi.org/10.1136/sti.2009.036061 plaques should have prompt evaluation due to the possibility CUAJ • February 2019 • Volume 13, Issue 2(Suppl1) S1 © 2019 Canadian Urological Association rEViEW Patient presentation, differential diagnosis, and management of penile lesions Juan Chipollini, MD1; Alfredo Harb De la Rosa, MD1; Mounsif Azizi, MD2; Bobby Shayegan, MD3; Kevin C. Zorn, MD4; Philippe E. Spiess, MD2 1Division of Urology, Department of Surgery, the University of Arizona, Tucson, AZ, United States; 2Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, United States; 3Division of Urology, Department of Surgery, McMaster University, Hamilton, ON, Canada; 4Division of Urology, Department of Surgery, Université de Montréal, Montreal, QC, Canada Cite as: Can Urol Assoc J 2019;13(2Suppl1):S1-8. http://dx.doi.org/10.5489/cuaj.5712 Classification of penile conditions Benign conditions Introduction The most relevant benign penile growths include cysts, Penile lesions may arise from the squamous epithelium of syringomas, seborrheic dermatitis, pearly papules, and the glans, prepuce, or shaft. Due to often delayed medical Fordyce spots.1 Penile cysts are rare lesions, typically presentation after initial onset, it is necessary for the urolo- asymptomatic, and usually do not interfere with sexual or gist to appropriately and effectively diagnose and manage urinary function. Most of them are present since birth and these lesions in order to optimize outcomes and minimize are classified as acquired or pseudocyst and true cysts, morbidity. Herein, we review the differential diagnosis and which are mostly congenital.2 The most common cystic basic diagnostic approaches of penile lesions. We empha- lesion of the penis and prepuce is the smegma cyst, some- size the need for awareness of premalignant and malignant times called “smegmoma.” These cysts are usually found tumours. We also review common office-based treatment under the unretractable foreskin and they appear as small, modalities for benign and malignant lesions. yellowish lumps due to smegma content. Preputial cysts are generally classified as median raphe or urethroid cysts Diagnostic evaluation of a penile lesion and epidermoid or follicular cysts.3 Most penile cysts are harmless and do not require any treatment. A thorough history and physical examination is required, Penile syringomas are benign, small, soft, flesh-to-yellow- with attention to previous sexual history, including contra- coloured, dermal papules that are derived from the intraepi- ceptive use and any previous sexually transmitted infec- dermal portion of eccrine sweat ducts. They are extremely tions. Other useful information includes previous tobacco rare and are typically asymptomatic. Syringomas of the penis and drug use, circumcision status, and associated sexual and usually present as multiple lesions (Fig. 1) on the dorsal and urinary symptomatology. A thorough genital examination lateral aspect of the penile shaft in about 91% of patients. with a complete skin survey should be enough to character- Treatment of penile syringomas is elective and similarly to ize most cutaneous anomalies. Assessment of the inguinal penile cysts, is performed based on the patient’s preferences.4 nodes for nodularity or fixation can also be noted at this Penile Fordyce spots are heterotopic sebaceous glands time. For indeterminate lesions, workup can involve different that can occur on the penile shaft, usually the ventral sur- diagnostic considerations, especially when systemic findings face. They were named after an American dermatologist, are present. Biopsy is reserved for an unclear diagnosis, John Addison Fordyce, who first described them in 1896. and should be promptly performed if neoplasm is high in Typically presenting after puberty, they become a concern to the differential diagnosis. If a malignant tumour is found, adolescent and adult men given the occasional resemblance consideration for magnetic resonance imaging (MRI), with to genital warts. Treatment is not necessary other than for possibly induced erection, may be performed to rule out cosmetic reasons, since it is an anatomical variation and a corporal invasion and improved clinical staging. A tertiary benign condition.5 referral centre should also be considered for larger size Hirsuties coronae glandis, also known as pearly penile lesions requiring further evaluation. papules, are benign lesions of the penis. They are consid- ered a normal anatomical variant. The prevalence of penile pearly papules is diversely appreciated and ranges from S2 CUAJ • February 2019 • Volume 13, Issue 2(Suppl1) © 2019 Canadian Urological Association Penile lesions 14–48% of males.6 The HPV papules are flesh-coloured or white, dome-shaped or The prevalence of virologically detectable subclinical or filiform (Fig. 2). Because of latent HPV infection may be as high as 30–50%.9 Currently, the benign nature of pearly there are over 60 different HPV types, with genital types char- penile papules, as well as acterized as either low‐ or high‐risk.10 Genital warts are com- their possible resolution monly produced by HPV serotypes 6 and 11, which have a with age, treatment is not strong tendency to induce condyloma (Fig. 3). Condylomata indicated unless for cos- acuminata refers to soft, papillomatous growths considered metic reasons. Healthcare to be benign. In males, it occurs most commonly on the providers may use ablative glans, penile shaft, and the prepuce. About 5% of patients lasers for removal or liquid can have urethral involvement. HPV 16 and 18 are more nitrogen as cryotherapy. likely to be present in subclinical infection and are the types Seborrheic dermatitis is a most commonly associated with genital cancer.11 Risk fac- papulo-squamous disorder tors that may increase rates of infection with HPV include of the skin, which usually presence of foreskin, increasing numbers of sexual partners, Fig. 1. Penile syringomas present affects the oily areas where lack of condom use, and smoking. as multiple flesh-coloured papules. Adapted from: Cohen PR, et al. Penile sebum production is high. It Several treatment modalities exist for the treatment of syringoma: Reports and review of may be caused by the pro- genital warts. These include topical agents, such as imiqui- patients with syringoma located on liferation of a skin pathogen mod cream, podofilox, and sinecatechins ointment, as well the penis. J Clin Aesthet Dermatol known as Malassezia in its as photodynamic therapy with 5-aminolevulinic acid (ALA/ 2013;6:38-42. yeast form, although this is PDT) and energy-based treatments, such cryotherapy, laser controversial.7 Seborrheic ablation, and electro-fulguration. Table 1 lists commonly dermatitis of the penis appears as red plaques that are scaly used treatments and other relevant information. in nature and run along the glans of the penis and its shaft. Treatment mainly consists of keratolytic agents, topical or HSV oral antifungals, or topical