Twenty-seven-year-old attorney concerned about skin growth at base of penis. Growth is nonpruritic, painless, and unchanged since he first noticed it 1 month ago. Has had one steady sexual partner in the last year; mutually faithful and monogamous. Uncertain about whether his consort has any asymptomatic genital lesions, but sure neither has ever had any painful lesions and that they have “no history of syphilis, gonorrhea, herpes, AIDS, or CHlamydia.” Both have had premarital laboratory studies for all these except herpes.
Penis looks well; somewhat apprehensive. Afebrile. Physical examination normal apart from the penile lesion shown. Lesion is soft, plaquelike to slightl warty, non-tender, and not ulcerated. No other lesions in or about the urethral orifice, the remainder of the penis, scrotum, perineum, or the anal region.
ANSWER: CONDYLOMA ACUMINATUM OF PENIS
Although a host of other genital lesions can occur in males, none is likely to look as flat, as flesh-colored, and as free of ulceration as this one did; the concyloma latum of syphilis is the only exception. Even though the relatively promixal location of the lesion and its partly exophytic look made the clinician think of other conditions as well, the preoperative diagnosis was condyloma acuminatum. This diagnosis was confirmed by an excisional biopsy.
Condyloma acuminatum, which is becoming more common every day, appears as a flat (later polypoid), fleshy, nonscaly, soft growth, which is unlikely to be confused with a malignancy on physical examination. It is painless unless abraded. The lesion results from chaotic epithelial overgrowth due to infection with certain strains of the human papillomavirus (HPV). If it looks a bit like an ordinary penis wart, that is because other strains of the same HPV cause common warts. Since only the “anogenital” HPV strains are prone to infect the moister environs of the perineum and penis in preference to other skin, ordinary warts occur only very rarely in or on the penis. Almost any surface may be affected by the anogenital strains, including the upper inner thighs; any part of the penis or scrotum, the areas of the corona and sulcus and under the foreskin in particular; the labia majora or minora; and the urethral orifice, perianal region, or anus itself in either sex.
The most characteristic appearance in men is of 1-3 mm sessile lesions on the penis; these are often a bit more whitish pink, more “sea anemone-like,” and more friable-looking than the one illustrated. It is very important to realize that the vagina and uterine cervix may harbor lesions that, although caused by the same organism as those in the male, are often flat and white rather than exophytic. There is compelling evidence that the virus is transmitted by sexual contact, with an average incubation of two months.
Why, then, did this patient develop his penis lesions when he did, assuming the sexual history was absolutely accurate? Perhaps he had had longer-standing tiny lesions that were grossly invisible by just looking at the penis; these are known to occur in either sex, and may be detectable only with the in-vivo microscopy of a colposcope. Also, sometimes flat lesions are rendered more visible on the penis by presoaking the genitals with dilute acetic acid. In any case, you must examine and treat both partners if you are to benefit either.
HPV lesions on the genitals are common in heterosexuals of either sex, gay men, and lesbians. Discovery of perianal lesions suggests anorectal sexual practices, which are part of the repertoire of many heterosexual couples as well as homosexual persons. The discovery of genital warts on the penis of a child should make you think about child sexual abuse, although other mechanisms, including peripartum transmission, have been implication in some cases, particularly in infants.