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LIVE BLOG: Penile Disease

In this live blog, Dr. Joseph C. English III lectured on Male Anogenital Disease at the SDPA Summer Conference.  Using the helpful Pneumonic: “F.A.I.N.T with Psoriatic Balanitis” he provided lots of helpful information on an often-missed topic.

 

Terminology

+ Balanitis – inflammation of the glans penis

+ Posthitis – inflammation of the penile foreskin

+ Balanoposthitis – inflammation of both

+ Prepuce – foreskin.

 

Pearls

+ Not all male anogenital disease is sexually related.

+ If you look at the front you got to look at the back.

+All uncircumscribed foreskins needs to be retracted during physical exam.

+ Anogenital disease may be a marker of systemic disease

 

Male Anogenital Disease Pneumonic

DifferentialDiagnosis:

+ Fixed drug/drug reactions

+ Allergic/irritant dermatitis/other

+ Infection

+ Neoplastic

+ Traumatic

+ Psoriasiform

+ Balanitis (specific)

“F.A.I.N.T with Psoriatic Balanitis”

 

F: Fixed drug reactions

450 cases of FDE

73% due to Co-trimoxazole

20.2% located on genitalia

 

Some drugs cause FDE changes because:

1. New drugs

2. GeographicVarianceofDisease

Most Common:

Antibiotics

Antifungals

Antiphyscotics

Non-narcotic analgesics

 

Other Drug Reactions in Anogenital Area:

1. TEN – Sulfa

– Allopurinol

2. Granulomatous

– Isotretinoin

3. Erosive (non-FDE)

– Foscarnet

– Imiquimod

4. Purpuric

– Coumadin necrosis

 

A: Allergic/Irritant/Other Dermatits

 

Top Five Allergens:

1. Balsum of Peru(10.8%)

2. Frangrance mix (8.1%)

3. Tolu balsam (8.1%)

4. Phenylmercuric acetate (8.1%)

5. Neomycin (5.4%)

 

+ Sub-Acute Genital Edema

Varicocle

Crohn’s Disease

Testicular CA

Metastasis

+ Chronic Genital Edema

Milroy’s disease

Cellulitis

Non-veneral penile/scrotal edema

 

 

I: Infection

Helpful Website for STD education is MMWR: www.cdc.gov/mmwr

 

Classic STD

+ Syphilis

Treponema pallidum

TX2:4 Million Units Benzzathine PCN G

Look for “kissing lesions”

 

If you see one STD, that may mean that there is more than one.   Look for more.

 

+ Genital Herpes

Herpes simplex virus 1, 2

TX: Acyclovir, Famciclovir, Valacyclovir

 

+ Non-HSV penile ulcerations

Complex Aphthous

Behcet’s Disease

+ Recurrent oral and genital ulcerations

Complex aphthosis: Excluded Behcets, Idiopathic, IBD, Vitamin Def.

 

Non-HSV perianal ulcerations

1.Viral -CMV 2. Deep Fungal Infection -Hisotplasmosis -Paracoccidiomycosis 3.Mycobacterium Tuberculosis

 

Treating Other Classic STDs

Gonorrhea:

Neisseria gonorrhoeae

IC gram (-) diplococci

Tx: Ceftriaxone, Cefixime,

Single dose injectable cephalosporin with Doxycycline or Azithromycin

 

Granuloma inquinale

Klebsiella (formerly Calymmatobacterium) granulomatosis

Gram(-) rod

Tx: Azithro, Cipro, E-mycin, Bactrim

 

Chancroid:

Haemophilus ducreyi

Gram(-) bacillus

Tx: Azithromycin, Ceftriaxone, Ciprofloxacin, Erythromycin

 

Other Infections:

HPV

Candidiasis

Dermatophytosis

Impetigo

Anaerobic Erosive Balanaitis

Necrotizing Fasciitis

Scabies

Pubic lice

 

N: Neoplasia

 

SCC of the Penis

Common location in Asia/Africa/S. America

Risk factors:

Phimosis

Chronic inflammation

Trauma

Smoking

HIV (8 fold increased risk HPV (16,18)

Tx:

Surgery

Radiation Chemo

Bleomycin

Methotrexate

Other Benign Neoplasms

+ Porokeratosis

+ Pigmented macules

+ Epidermoid cysts

+ Median Raphe cyst

+ Nevus flameus simplex

+ Lymphangiomas

+ Angiofibromas

+ Angiokeratomas

 

 

T: Trauma

 

Sclerosing lymphangitis of the penis

+ Transient cord like structure

+ Coronal sulcus

+ Age 20-40 yrs, Sexually active

+ Aymptomatic but may have pain with erection

+ Unknown etiology – probable traumatic Resolves with abstinence

+ May have temporal relation to an STD

 

Dysesthetic Anogenital Syndrome

+ Abnormal sensation (tingling/burning/numbess/pruritus/pain) in anogenital area

+ Etiology:

Neurogenic (CNS)

Neuropathic (PNS) – Small fiber sensory neuropathy (SFSN)

Psychogenic

+ Chronic/Recurrent

+ No primary dermatoses

-R/O hemorrhoids/fissures/trauma/infection/malignancy

-Evaluate for skeleto-muscular and neurologic disease

Examples:

-Levator ani syndrome

-Proctalgia fugax

-Coccydynia

-Male genital pain syndrome

-Koro syndrome

 

P: Psoriasiform Dermatitis

Psoriasiform Dermatitis

Psoriasis

Lichen Planus

Lichen nitidus

Lichen Simplex chronicus

 

B: Balanitides

Diagnosis and Treatment of Lichen Sclerosis

 

Lichen sclerosus

Incidence:

+ 0.1-0.3% of population

Pathogenesis:

+ Unknown

+ ? Trauma/Genetics/Autoimmunity

+ Thyroid dz, AA, Pernicous anemia

Course:

+ Chronic Progressive/Relapsing/ Remitting

+ Develop phimosis, urethral strictures, SCC, sexual dysfunction

Treatment:

+ Hygeine

+ Moisturization

+ Treatment of secondary infections

+ Ultra-potent corticosteroids

Other:

+ Circumcision

+ Topical calcineurin inhbitors

+ Topical retinoids

+ Systemic retinoids

+ PDT

 

Other Balanitides

+ Plasma cell balanitis

+ Zoon’s balanitis

+ Reactive arthritis

 

[image by Giampolo Macorig]




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