Male genital diseases

 

 

 

Lichen sclerosus of penis

 

Introduction

 

Lichen sclerosus is a common idiopathic inflammatory scarring dermatosis with a predilection for ano‐genital skin. It is principally a disease of uncircumcised men, although it can persist or recur after circumcision. LSc can be the cause of significant morbidity expressed as preputial dysfunction and male dyspareunia.

In male patients, familial cases are uncommon, and HLA and autoimmune associations are rarely observed.

 

Epidemiology

 

In adults, ano‐genital lichen sclerosus is said to be about 10 times more common in women than men. Perianal disease is very rare in the male.

 

The age of presentation is bimodal, school‐age boys and men in the 4th or 5th decade. LSc may be much more frequent than is generally supposed in young boys. In boys, persistent primary phimosis or the secondary development of phimosis in a previously retractable foreskin should be viewed with suspicion: some, many, or most of such cases will be due to LSc.

 

Pathophysiology

 

The predilection is for the male genitalia in the uncircumcised. Male genital lichen sclerosus being due to chronic occluded exposure of susceptible epithelium to urine due to post micturition micro‐incontinence (‘dribbling’) seen in 90–100% patients and meticulous physical examination often reveals distortion naviculo‐meatal anatomy causing dysfunction of the naviculomeatal valve. Of note, lichen sclerosus of the penis does not occur in men circumcised at birth.

 

Pathology

 

The epidermis is atrophic with basal cell hydropic degeneration. The superficial dermis is edematous and hyalinized. Deep to the hyalinized zone is a band‐like lymphohistiocytic infiltrate. Telangiectatic vessels are common, as is purpura.

 

Clinical features

 

Lichen sclerosus of the penis may be asymptomatic, but patients may describe itching, burning, bleeding, tearing, splitting, hemorrhagic blisters, dyspareunia, discomfort with urination and narrowing of the urinary stream, and/or they may be concerned about the changing anatomy of their genitalia.

In boys and men, acquired phimosis or recurrent balanitis are the primary presenting features. In uncircumcised males, the glans and the inner aspect of the foreskin may show smooth, atrophic, shining bluish white sclerotic patches or plaques, with telangiectasia, purpura, bullae, erosions and even ulceration may be encountered. The constriction may cause pain on erection and, at advanced stages, dysuria and urinary obstruction due to meatal ‘pin hole’ narrowing as the disease encroaches into the urinary meatus. If the foreskin is affected, lichen sclerosus invariably leads to phimosis (difficulty in retracting the foreskin to uncover the glans), with the additional risk of paraphimosis (when a foreskin retracted behind the glans cannot be returned to its original position); the latter represents a urologic emergency. A constrictive lichenoid posthitis is commonly seen associated with a fibrotic preputial band causing “hourglass” “waisting” of the penile shaft. Progressive disease can lead to effacement of the normally sharply defined structures, especially of the frenulum and the coronal sulcus and rim. While circumcision is clearly a first-line therapy, lichen sclerosus may recur at the site of a circumcision.

Posthitis xerotica obliterans refers to chronic damage to the prepuce by lichen sclerosus, whereas balanitis xerotica obliterans properly describes involvement of the glans penis. Balanitis xerotica obliterans can be a consequence of other scarring dermatoses such as lichen planus and cicatricial pemphigoid.

Most cases of LSc can be diagnosed clinically. If there is clinical doubt, then a biopsy should be performed.

 

Symptoms and Signs of Male Genital Lichen Sclerosus

Asymptomatic Spontaneous ·       Itching, burning, soreness, pain, adhesions, blisters, white patches, purpura, balanoposthitis, phimosis Dyspareunia ·       Itching, burning, soreness, pain, bleeding, tearing, splitting, Effacement of normal architectural features ·       Phimosis, narrow meatus, dissolution of frenulum, short frenulum, broad frenulum, “bunched” frenulum, white papules and patches, loss of coronal definition, adhesions, telangiectasia, scarring, fibrotic band (“waisting” or “bunching”), constrictive posthitis ·       Posthitis and balanitis xerotica Dysuria, voiding difficulties, urinary retention Renal failure Cancer

 

Complications

SCC of the penis is the most worrying complication of LSc: the risk is 2%–12.5% and the latent period may be 10–30 years. Involvement of the glans with LSc is a significant risk.

 

Treatment

 

The aims in male genital disease are to minimize or abolish male sexual dysfunction (dyspareunia), urinary dysfunction, and the risk of penis cancer. Contact with soap, urine and pubic hair should be avoided by use of a soap substitute and a barrier preparation. Very potent topical steroids achieve remission in 50%–60% and the majority of the remainder is cured by circumcision. An ultrapotent topical corticosteroid (usually clobetasol propionate) used under supervision for a finite course is effective, but herpes simplex and wart reactivation do occur. Patients with a history of genital herpes simplex virus (HSV) should be prescribed prophylactic aciclovir. There is significant remodelling of the plasticity of the male genital epithelium with the relief of phimosis, paraphimosis or constrictive posthitis and avoidance of circumcision.  Secondary candidal and bacterial infection should be treated. The use of topical calcineurin inhibitors is restricted because of the risk of accelerated carcinogenesis. If medical treatment with ultrapotent topical steroid is not possible or fails, then surgery is indicated. Circumcision, frenuloplasty, meatotomy and sophisticated plastic repair, depending upon the clinical presentation, can be offered.  Carbon dioxide laser circumcision has been described. In both boys and adult male patients, complete circumcision is the treatment of choice because all affected tissue is removed and any secondary involvement of the glans probably regresses or resolves. Surgery works in male genital lichen sclerosus if it relieves susceptible epithelium from chronic occluded exposure to urine. Surgery fails if it does not achieve this goal.  About 40% of patients will respond to medical treatment: the majority of the remainder will be cured by surgery, usually circumcision.

Squmous cell carcinoma is the most serious potential complication of LS. Involvement of the glans penis confers a greater risk. Patients should be followed‐up long term, especially if circumcision has not been performed or if symptoms persist or recur after any form of treatment.

 

 

 

Lichen planus of penis

 

Introduction 

 

It is a common idiopathic inflammatory dermatosis with a particular predilection for the oro‐genital epithelium. Approximately 25% of men with cutaneous lichen planus have genital involvement.

Clinical features

 

LP has a particular predilection for the mucosa, which is perhaps partly explained by the Koebner phenomenon. Lichen planus can present in, and remain localized to, the ano‐genital area, including the groins and perianal skin. Like the classical disease at other sites, it presents as itchy red‐purple papules, plaques and annular lesions with Wickham striae on the glans and shaft of the penis. It may also present as phimosis. The male genitalia represent the commonest site for the annular subtype of lichen planus. Occasionally, an erosive form is encountered.

Although LP is self-limiting, some patients experience relapses and remissions. Adhesions can form. Post‐inflammatory hyperpigmentation can persist for months or years. Chronic mucosal erosive lichen planus is associated with a risk of progression to squamous carcinoma.

 

Investigations

 

A biopsy is frequently necessary for diagnostic purposes.

 

Treatment

 

Potent and ultrapotent topical corticosteroids usually suffice and the treatment should be continued until the lesions are non‐itchy and flat; they are warned about post‐inflammatory hyperpigmentation. Reactivation of genital warts may occur. Topical calcineurin inhibitors should be used with caution. Circumcision may be necessary if there is phimosis and should be seriously considered in cases of refractory disease, especially the erosive form, because the removal of “koebnerizing” influences may allow the LP to remit.

 

 

Psoriasis of penis

 

Introduction

 

Psoriasis is probably the most common dermatosis of the male anogenitalia, either in isolation or in association with frank or mild, subtle extragenital disease. The Koebner phenomenon is a likely factor in site predilection. Drugs such as lithium, β blockers, antimalarials, and angiotensin-converting enzyme inhibitors may be responsible for the onset or exacerbation of psoriasis. The penile lesions have the same histopathology as psoriasis.

 

Epidemiology

 

Approximately 2% of the population are said to have psoriasis but it is possible that many more than 2% of men may develop ano‐genital psoriasis at some time.

 

Clinical features

Psoriasis of the anogenital region may look quite different from psoriasis at other sites. It is not usually itchy; significant itch should arouse suspicions of another dermatosis such as an eczema or tinea. Soreness occurs with super infection, especially with Candida. Other typically affected sites should be examined for signs of the disease.

The diagnosis is usually easier in the circumcised male where the morphology is similar to extragenital lesions. In circumcised men, genital psoriasis presents with silvery-scaled, erythematous well-defined patches or plaques on the glans and also seen on the shaft of the penis. Persistent, painful fissuring of the perianal area and the intergluteal cleft can be a severe problem.

The diagnosis is difficult especially in the uncircumcised patient, because a mucosal site is affected rather than keratinized skin. On the glans or in the preputial sac of the uncircumcised patient, the typical silvery scale is absent from the patches or plaques, where its occurrence is probably brought about by the Koebner phenomenon.

Psoriatic balanoposthitis can be part of the spectrum of inverse-pattern psoriasis and may be associated with intertriginous disease of the axillae, intergluteal cleft, gluteal folds, and groin.

 

Investigations

 

Usually, the diagnosis of psoriasis is clinical, but a biopsy may be necessary (e.g. of a solitary mucosal lesion in an uncircumcised individual) to distinguish psoriasis from Zoon balanitis, lichen planus, carcinoma in situ (Bowen disease, erythroplasia of Queyrat) or Kaposi sarcoma.

 

Treatment

 

Topical treatment includes emollients, soap substitutes, corticosteroids combined with antibiotic and antifungal agents. Atrophy is a risk with long-term use of potent topical steroids, and anogenital skin has a heightened tendency to absorb topical agents. The vitamin D analogue calcipotriol can be helpful. Topical ciclosporin (100 mg/ml in wet dressings three times daily) has been advocated. Topical calcineurin inhibitors may be helpful and appear to be well tolerated but should be used with caution in the uncircumcised because of the squamous cancer risk. Severe ano‐genital psoriasis can be an indication for systemic treatment.

 

 

Balanitis, plasma cell (Zoon)

 

Overview

 

·       Zoon plasma cell balanitis (ZB; properly balanoposthitis) affects the middle-aged and older uncircumcised male.

·       ZB is a chronic, reactive, irritant mucositis.

·       ZB is characterized by silent symptomatology and florid signs.

·       Zoonoid inflammation is a common corollary of other dermatoses that cause a dysfunctional prepuce. Asymmetric, atypical, or unusual morphology should be viewed with suspicion.

·       Circumcision is the definitive treatment in the majority of cases.

 

Introduction

 

It is an asymptomatic, inflammatory and irritant condition of the glans and mucosal prepuce.

 

Epidemiology

 

Zoon plasma cell balanitis is usually seen from the third decade onwards in uncircumcised men.

 

Pathophysiology

 

ZB is a chronic, reactive, principally irritant mucositis that causes, or is due to, a dysfunctional foreskin. Irritation is induced by retention of urine, squames, commensally hypercolonized and increased secretion between two tightly apposed and infrequently and inadequately separated and/or infrequently or inappropriately bathed, epithelial surfaces due to poor penile hygiene that leads to a disturbed ‘preputial ecology’ and excessive frictional trauma (Zoon balanitis is often located on the dorsal aspect of the glans and the adjacent prepuce, sites of maximal friction on foreskin retraction). The condition does not occur in circumcised men.

 

Pathology

 

The classic histology is of epidermal attenuation with absent granular and horny layers, sparse dyskeratosis and spongiosis, and diamond- or lozenge-shaped basal cell keratinocytes. In the dermis, there is a band of plasma cells infiltration in the upper and mid dermis, extravasated erythrocytes, hemosiderin, fibrosis, and vascular proliferation.

 

Clinical features

 

The presentation is classically asymptomatic, or gives rise to pruritus or dysuria and staining of the underclothes with blood has been reported. Well‐demarcated, glistening, moist, shiny, bright red discrete patches with a dark red stippling or “cayenne pepper” spots and an orange hue due to hemosiderin deposition symmetrically involving the glans and inner prepuce, sparing the keratinized penile shaft or foreskin are seen. The navicular fossa may be involved. “Kissing” lesions are typical with involvement of adjacent, touching areas, e.g. around the urethral meatus. Shallow erosions may resolve slowly, leaving a rusty stain.

Investigations

The diagnosis is usually clinical.

 

Treatment

 

Although Zoon balanitis can improve with altered washing habits and micturition practices and the intermittent application of a mild or potent topical corticosteroid (with or without an antibiotic and anticandidal agent) and topical tacrolimus, it usually persists or relapses. The use of topical calcineurin inhibitors should be restricted as there is risk of penis cancer in the long term. Definitive curative treatment is surgical circumcision.