What’s Your Diagnosis?

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.

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PHYSICAL EXAMINATION

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.

DIAGNOSTIC POINTS

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.

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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.

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When the Urethra of the Penis is Too Short

In a boy born with hypospadias, the urethra is too short: Its terminal opening, called the urinary meatus, is on the underside of the penis. In the mildest cases, the meatus may just be off-center; in severe hypospadias, it may actually be located on the perineum. The shorter the urethra, the more likely it is that the child will also have chordee, a downward curvature of the penis. When the child grows up, severe chordee may render him unable to procreate or even to insert his penis during sexual intercourse.

Extenze Reviews

To prevent these problems as the child matures, a surgeon will extend the urethra of the penis. Because most preop evaluation and counseling is done by the physician in his office, you will probably meet the patient for the first time when he arrives from the post-anesthesia care unit after surgery. His penis will be well bandaged. In our hospital, physicians wrap a pressure dressing of Xeroform gauze coated with antibiotic ointment around the penis, cover that with many layers of gauze sponges and hold it all in place with Elastoplast. The Elastoplast is cut with four “feet” at the bottom to attach to the child’s groin and abdomen.

Repairing moderate or severe hypospadias-when the urethral opening is in the proximal half or base of the penis usually requires skin grafts from the foreskin to lengthen the urethra. Postop, these boys may have suprapubic catheters connected to gravity drainage in addition to the urethral stent. They must be kept supine for at least three days. Four-point restraints are usually called for to prevent the child from pulling at his catheters or rolling over onto his penis and rupturing the graft. Older children with good self-control may be freed from wrist restraints when anesthesia wears off. With parental supervision younger children’s hands can be released to eat or play.

Explain the purpose of the operation to these children in words they can understand. Emphasize that the doctor has tried to fix, not remove, the penis. Show the boy his bandage and let him touch it carefully to reinforce the fact that he still has his penis. A child-life specialist can help the boy express his feelings through play.

The freshly uncovered penis is usually slightly edematous and may be blue and misshapen. A small amount of blood may ooze around the suture line. Warn the parents beforehand what they’ll see, and assure them that these are expected.

Edema usually fluctuates for a few days and subsides gradually. Make sure you instruct the parents to notify the physician immediately if the penis becomes grossly swollen.

An adult should observe the child’s first voiding to see if the stream is straight. Spray may occur due to scabbing on the urethra. Scabs may be softened and floated off in a sitz bath or broken down by applying a gauze sponge soaked with half-strength hydrogen peroxide. If the urine stream still veers after repeated voiding, the doctor should be notified. The penis may have a fistula, needing another operation.

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