Genital lesions in the male
Genital lesions in the male: Excerpt from Handbook of Signs & Symptoms (Third 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, page 300.)
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). 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 lesions. Next, take a complete sexual history, noting the frequency of relations, number of sexual partners, and 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 a 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
Bowen’s disease is a painless, premalignant lesion that commonly occurs on the penis or scrotum, but may also appear elsewhere. It appears as a brownish red, raised, scaly, indurated plaque with well-defined borders, which may ulcerate at its center.
Chancroid
Chancroid is an STD that’s 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.
Folliculitis and furunculosis
Hair follicle infection may cause red, sharply pointed lesions that are tender and swollen 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.
Genital herpes
Caused by herpesvirus type 1 or 2, genital herpes is an STD that 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 a 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 or urethral meatus, and less commonly on the penile shaft; they then spread to the perineum and perianal area. These painless warts start as tiny red or pink swellings that may grow to 4" (10 cm) and become pedunculated. Multiple swellings are common, giving the warts a cauliflower appearance. Infected warts are also malodorous.
Leukoplakia
Leukoplakia is a precancerous disorder that’s characterized by white, scaly patches on the glans and prepuce accompanied by skin thickening and occasionally fissures.
Pediculosis pubis
Pediculosis pubis is a parasitic infestation that’s characterized by erythematous, itching 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
Penile cancer usually produces a painless, enlarging wartlike lesion on the glans or foreskin. However, if the foreskin becomes unretractable, the patient may experience localized pain. 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 urinary tract obstruction.
Scabies
Mites that burrow under the skin in scabies 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 itching is typical and commonly causes excoriation.
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, tinea cruris is a superficial fungal infection that usually causes sharply defined, slightly raised, scaling patches on the inner thigh or groin (typically bilaterally) and, less commonly, on the scrotum and penis. Pruritus may be severe.
Urticaria
Urticaria is a common allergic reaction that’s 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
Phenolphthalein, 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. Using disposable diapers and carefully cleaning 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 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 patients who are bedridden and those with Parkinson’s disease.
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Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third 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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