An overview of male genital presentations

11 Mar 08

Scabies

Red papules on the glans penis, shaft of the penis and the scrotum are said to be pathognomonic of scabies in men. It is unusual for scabies just to affect the genitals and other body sites will almost certainly be affected. Burrows can often be detected in the web spaces of the fingers, the flexures, axillae, umbilicus, buttocks and the feet.

The diagnosis of scabies can be extremely difficult if burrows are not visible. There are only 10 to 15 mites on average. Burrows are often scratched, changing their appearance. It is not uncommon for patients with scabies to develop secondary bacterial infection and eczema because of the constant scratching. Again, these secondary signs may disguise or destroy burrows. In addition, patients may have been treated with anti-pruritic agents and topical steroids. This tends to alter the appearance of the rash.

All household members and close personal and sexual contacts should be treated, whether or not they exhibit signs or itch. Topical therapies have to be left on for prolonged periods. Treatment failures may occur if therapies are washed off, for example from the hands, and not reapplied.

Lichen sclerosus

Lichen sclerosus is also known as lichen sclerosus et atrophicus and balanitis xerotica obliterans (BXO). The disease is now commonly known by the shorter term lichen sclerosus since atrophy is not always present. It is a chronic inflammatory dermatosis, mainly affecting the genitalia. Untreated, the disease often progresses to scarring.

There are a large number of symptoms and men often present with symptoms of phimosis.

Clinically, lesions may present as white, porcelain-like plaques on the glans penis or foreskin where scarring is present. Active inflammation is seen as red patches or plaques, sometimes with purpura.

There are both medical and surgical treatments for lichen sclerosus. In most cases ultrapotent topical steroids (used under close specialist supervision) will improve symptoms.

It is possible for lichen sclerosus to recur in a surgical scar following circumcision.

Bowenoid papulosis

Bowenoid papulosis is a papular eruption

of the genitals seen in both sexes, thought to be caused by infection with human papilloma virus (HPV). It may be considered as an epidermal cellular atypia somewhere in the spectrum between viral warts and Bowen’s disease. Although a number of HPV subtypes are linked to Bowenoid papulosis, the strongest link is with HPV 16.

Treatment is necessary since there is a low risk of malignant change (unknown but probably less than 2%) and a theoretical risk of transmission of HPV to sexual partners.

Cryosurgery is usually successful as is curettage and cautery, although there is a recurrence rate. Topical agents such as imiquimod, trichloroacetic acid and 5-fluoracil cream may be used but are usually highly irritant.

Psoriasis

Psoriasis on the genitals may be the only presentation of the disease on the skin. However, careful examination of patients usually reveals skin lesions elsewhere.

Genital psoriasis tends not to be itchy but may be sore.

It is relatively common for psoriasis to affect the flexures (natal cleft, groin), perianal skin and the shaft, glans and prepuce of the penis. In the circumcised man the lesions tend to be typical plaques. In the uncircumcised man it may resemble a non-specific balanitis with mild or no scarring.

Standard treatment is topical emollients, soap substitutes and topical steroids for limited periods. Unfortunately, most topical therapies designed for psoriasis are too irritant for the genital skin.

Lichenoid drug eruptions

There are several drugs that can give rise to a lichen planus-like eruption on the skin. Although they tend to cause a widespread lichenoid eruption, the rash may be localised just to the genitals.

The eruption may be clinically identical to lichen planus and may occur several months after starting the drug. A large number of drugs have been reported to cause a lichen planus-like eruption. These include:

• aciclovir

• antimalarials

• ß-blockers including metoprolol and propranolol

• captopril

• carbamazepine

• phenothiazines

• temazepam

• tetracyclines

• thiazide diuretics