Genital lesions in the male
Genital lesions in the male: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Among the diverse lesions that may affect the male genitalia are warts, papules, ulcers, scales, and pustules. These common lesions may be painful or painless, singular or multiple. They may be limited to the genitalia or may also occur elsewhere on the body. (See Recognizing common male genital lesions.)
Genital lesions may result from infection, neoplasms, parasites, allergy, or the effects of drugs. These lesions can profoundly affect the patient’s self-image and relationships. In fact, the patient may hesitate to seek medical attention because he fears cancer or a sexually transmitted disease (STD).
Genital lesions that arise from an STD could mean that the patient is at risk for human immunodeficiency virus (HIV) infection. Genital ulcers make HIV transmission between sexual partners more likely. Unfortunately, if the patient is treating himself, he may alter the lesions, making differential diagnosis especially difficult.
History and physical examination
Begin by asking the patient when he first noticed the lesion. Did it erupt after he began taking a new drug or after a trip out of the country? Has he had similar lesions before? If so, did he get medical treatment for them? Find out if he has been treating the lesion himself. If so, how? Does the lesion itch? If so, is the itching constant or does it bother him only at night? Note whether the lesion is painful. Ask for a description of any drainage from the lesion. Next, take a complete sexual history, noting the frequency of relations, the number of sexual partners, and the pattern of condom use.
Before you examine the patient, observe his clothing. Do his pants fit properly? Tight pants or underwear, especially those made of nonabsorbent fabrics, can promote the growth of bacteria and fungi. Examine the entire skin surface, noting the location, size, color, and pattern of the lesions. Do genital lesions resemble lesions on other parts of the body? Palpate for nodules, masses, and tenderness. Also, look for bleeding, edema, or signs of infection, such as purulent drainage or erythema. Finally, take the patient’s vital signs.
Medical causes
Balanitis and balanoposthitis
Typically, balanitis (glans infection) and posthitis (prepuce infection) occur together (balanoposthitis), causing painful ulceration on the glans, foreskin, or penile shaft. Ulceration is usually preceded by 2 to 3 days of prepuce irritation and soreness, followed by a foul discharge and edema. The patient may then develop features of acute infection, such as fever with chills, malaise, and dysuria. Without treatment, the ulcers may deepen and multiply. Eventually, the entire penis and scrotum may become gangrenous, resulting in life-threatening sepsis.
Bowen’s disease
This painless, premalignant lesion usually occurs on the penis or scrotum but may appear elsewhere. It appears as a brownish red, raised, scaly, indurated, well-defined plaque, which may have an ulcerated center.
Candidiasis
When this infection involves the anogenital area, it produces erythematous, weepy, circumscribed lesions, usually under the prepuce. Vesicles and pustules may also develop.
Chancroid
This STD is characterized by the eruption of one or more lesions, usually on the groin, inner thigh, or penis. Within 24 hours, the lesion changes from a reddened area to a small papule. (A similar papule may erupt on the tongue, lip, breast, or umbilicus.) It then becomes an inflamed pustule that rapidly ulcerates. This painful—and usually deep—ulcer bleeds easily and commonly has a purulent gray or yellow exudate covering its base. Rarely more than 2 cm in diameter, it’s typically irregular in shape. The inguinal lymph nodes also enlarge, become very tender, and may drain pus.
Erythroplasia of Queyrat
This premalignant lesion is a form of Bowen’s disease that appears exclusively under the foreskin of an uncircumcised penis. It typically appears as a red, raised, well-defined, velvety, indurated plaque, which may have an ulcerated center.
Folliculitis and furunculosis
Hair follicle infection may cause red, sharply pointed, tender and swollen lesions with central pustules. If folliculitis progresses to furunculosis, these lesions become hard, painful nodules that may gradually enlarge and rupture, discharging pus and necrotic material. Rupture relieves the pain, but erythema and edema may persist for days or weeks.
Fournier’s gangrene
In this life-threatening form of cellulitis, the scrotum suddenly becomes tense, swollen, painful, red, warm, and glossy. As gangrene develops, the scrotum also becomes moist. Fever and malaise may accompany these scrotal changes.
Genital herpes
Caused by herpesvirus type I or II, this STD produces fluid-filled vesicles on the glans penis, foreskin, or penile shaft and, occasionally, on the mouth or anus. Usually painless at first, these vesicles may rupture and become extensive, shallow, painful ulcers accompanied by redness, marked edema, and tender, inguinal lymph nodes. Other findings may include fever, malaise, and dysuria. If the vesicles recur in the same area, the patient usually feels localized numbness and tingling before they erupt. Associated inflammation is typically less marked.
Genital warts
Most common in sexually active males, genital warts initially develop on the subpreputial sac, urethral meatus or, less commonly, the penile shaft and then spread to the perineum and the perianal area. These painless warts start as tiny red or pink swellings that may grow to 10 cm and become pedunculated. Multiple swellings are common, giving the warts a cauliflower-like appearance. Infected warts are also malodorous.
Granuloma inguinale
Initially, this rare, chronic STD causes a single painless macule or papule on the external genitalia that ulcerates and becomes a raised, beefy red lesion with a granulated, friable border. Later, other painless lesions may erupt and blend together on the glans penis, foreskin, or penile shaft. Lesions may also develop on the nose, mouth, or pharynx. Eventually, these lesions become infected, malodorous, and painful and may be accompanied by fever, weight loss, malaise, and signs of anemia such as weakness. Later, they’re marked by fibrosis, keloidal scarring, and depigmentation.
Leukoplakia
This precancerous disorder is characterized by white, scaly patches on the glans and prepuce accompanied by skin thickening and occasionally fissures.
Lichen planus
Small, shiny, polygonal, violet papules develop on the glans penis in this disorder. These papules are less than 3 cm in diameter and have white, lacy, milky striations. They may be linear or coalesce into plaques. Occasionally, oral lesions precede genital lesions; lesions may also appear on the lower back, ankles, and lower legs. Accompanying findings may include pruritus, distorted nails, and alopecia.
Lymphogranuloma venereum
One to three weeks after sexual exposure, this STD may produce a penile erosion or papule that heals rapidly and spontaneously; in fact, it often goes unnoticed. A few days or weeks later, the inguinal and subinguinal nodes enlarge, becoming painful, fluctuant masses. If these nodes become infected, they rupture and form sinus tracts, discharging a thick, yellow, granular secretion. Eventually, a scar or chronic indurated mass forms in the inguinal area. Systemic signs and symptoms include a rash, fever with chills, headache, migratory joint and muscle pain, malaise, and weight loss.
Pediculosis pubis
This parasitic infestation is characterized by erythematous, pruritic papules in the pubic area and around the anus, abdomen, and thigh. Inspection may detect grayish white specks (lice eggs) attached to hair shafts. Skin irritation from scratching in these areas is common.
Penile cancer
This cancer usually produces a painless, enlarging wartlike lesion on the glans or foreskin. The patient may experience localized pain, however, if the foreskin becomes unretractable. Examination may reveal a foul-smelling discharge from the prepuce, a firm lump in the glans, and enlarged lymph nodes. Late signs and symptoms may include dysuria, pain, bleeding from the lesion, and urine retention and bladder distention associated with obstruction of the urinary tract.
Psoriasis
Red, raised, scaly plaques typically affect the scalp, chest, knees, elbows, and lower back. When they occur on the groin or on the shaft and glans of the penis, the plaques are usually redder; on an uncircumcised penis, the characteristic silver scales are absent. The patient commonly reports itching and, possibly, pain from dry, cracked, encrusted lesions. Nail pitting and joint stiffness may also occur.
Scabies
In this disorder, mites that burrow under the skin may cause crusted lesions or large papules on the glans and shaft of the penis and on the scrotum. Lesions may also occur on the wrists, elbows, axillae, and waist. They’re usually raised, threadlike, and 1 to 10 cm long and have a swollen nodule or red papule that contains the mite. Nocturnal pruritus is typical and commonly causes excoriation.
Seborrheic dermatitis
Initially, this disorder causes erythematous, dry or moist, greasy, scaling papules with yellow crusts that enlarge to form annular plaques. These pruritic plaques may affect the glans and shaft of the penis, scrotum, and groin as well as the scalp, chest, eyebrows, back, axillae, and umbilicus.
Syphilis
Two to four weeks after exposure to the spirochete Treponema pallidum, one or more primary lesions, or chancres, may erupt on the genitalia; occasionally, they also erupt elsewhere on the body, typically on the mouth or perianal area. The chancre usually starts as a small, red, fluid-filled papule and then erodes to form a painless, firm, indurated, shallow ulcer with a clear base and a scant yellow serous discharge or, less commonly, a hard papule. This lesion gradually involutes and disappears. Painless, unilateral regional lymphadenopathy is also typical.
Tinea cruris
Also called “jock itch,” this superficial fungal infection usually causes sharply defined, slightly raised, scaling patches on the inner thigh or groin (often bilaterally) and, less commonly, on the scrotum and penis. Pruritus may be severe.
Urticaria
This common allergic reaction is characterized by intensely pruritic hives, which may appear on the genitalia, especially on the foreskin or shaft of the penis. These distinct, raised, evanescent wheals are surrounded by an erythematous flare.
Other causes
Drugs
Barbiturates and certain broad-spectrum antibiotics, such as tetracycline and sulfonamides, may cause a fixed drug eruption and a genital lesion.
Special considerations
Many disorders produce penile lesions that resemble those of syphilis. Expect to screen every patient with penile lesions for STDs, using the dark-field examination and the Venereal Disease Research Laboratory test. In addition, you may need to prepare the patient for a biopsy to confirm or rule out penile cancer. Provide emotional support, especially if cancer is suspected.
To prevent cross-contamination, wash your hands before and after every patient contact. Wear gloves when handling urine or performing catheter care. Dispose of all needles carefully, and double-bag all material contaminated by secretions.
Pediatric pointers
In infants, contact dermatitis (“diaper rash”) may produce minor irritation or bright red, weepy, excoriated lesions. Use of disposable diapers and careful cleaning of the penis and scrotum can help reduce diaper rash.
In children, impetigo may cause pustules with thick, yellow, weepy crusts. Like adults, children may develop genital warts, but they’ll need more reassurance that the treatment (excision) won’t hurt or castrate them. Children with an STD must be evaluated for signs of sexual abuse.
Adolescents ages 15 to 19 have a high incidence of STDs and related genital lesions. The spirochete that causes syphilis can pass through the human placenta, producing congenital syphilis.
Geriatric pointers
Elderly adults who are sexually active with multiple partners have as high a risk of developing STDs as do younger adults. However, because of decreased immunity, poor hygiene, poor symptom reporting and, possibly, several concurrent conditions, they may present with different symptoms. Seborrheic dermatitis lasts longer and is more extensive in bedridden patients and those with Parkinson’s disease.
Patient counseling
Explain to the patient how to use prescribed ointments or creams. Advise him to use a heat lamp to dry moist lesions or to take sitz baths to relieve crusting and itching. Also, instruct him to report any changes in the lesions.
Explain to male patients that condoms effectively prevent many STDs when used correctly. Advise them to use a new condom for each coitus; to avoid damaging the condom with a sharp object, such as fingernails or teeth; to put the condom on the erect penis before any genital contact; to use only water-based lubricants; to hold the condom firmly while withdrawing the penis; to always withdraw the penis while it’s still erect to avoid premature condom loss; and to check the expiration date on the individual condom packet. Teach the patient that hormonal contraceptives, diaphragms, foams, and jellies don’t protect against STDs.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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