Chapter 77 Diseases and Disorders of the Male Genitalia

Question 1

Circumcision has been adopted as a measure to reduce _____ transmission

Benefits of circumcision?

Answer 1

human immunode ciency virus (HIV)

1. Reduced or abolished risk of penile cancer
2. Decreased risk of cervical cancer in partners
3. Protection from sexually transmitted infections, including HIV infection (controversial)
4. Reduced risk of urinary tract infections (controversial)
5. Reduced risk of inflammatory genital skin diseases

Question 2

perineal area is abundant in_____ and _____, usually in association with hair follicles as pilosebaceous units but also occurring as free glands at some sites such as the ___________

Answer 2

eccrine and apocrine (some functionless) sweat glands and holocrine sebaceous glands
anal rim or around the coronal sulcus (Tyson glands)

Question 3

The ____is a delicate, busy tissue that is in close contact with urine and exposed to sexual secretions, detergents, and infectious agents, especially opportunistic organisms and those that are sexually transmitted.

Of the latter, _____ is the most important known from the point of view of precancerous dermatoses and invasive squamous carcinoma.

Answer 3

foreskin 
human papillomavirus (HPV)

Question 4

All these congenital and acquired factors can conspire to produce a dysfunctional foreskin, often clinically expressed as male sexual dysfunction in the form of ______

Answer 4

male dyspareunia

Question 5

_____ - nonretractable foreskin

Causes of phimosis?

Answer 5

phimosis

Lichen sclerosus
Nonspecific balanoposthitis (in diabetes)
Lichen planus
Hidradenitis suppurativa
Crohn disease
Cicatricial pemphigoid
Chronic penile lymphoedema
Kaposi sarcoma

Question 6

_____ - foreskin fixed in retraction
- rarer and is usually an ____ presentation caused by vigorous sexual activity, acute contact urticaria, acute allergic contact dermatitis, and lichen sclerosus (LSc)

Answer 6

paraphimosis

acute emergency

Question 7

_____ - inflammation of the glans penis _____ - inflammation of the prepuce

Answer 7

balanitis
posthitis

confusing terms, used to signify the end stage of all chronic cases of balanitis and posthitis (e.g., scarring dermatoses such as LP and cicatricial pemphigoid), but these conditions are usually due to LSc and are therefore considered synonymous by some

Question 8

_______ - glans and shaft of penis ulcerated through the prepuce, which lies ventrally as an empty sleeve

- very rare and is caused by gross penile disease such as 
hidradenitis suppurativa, 
pyoderma gangrenosum, 
florid condylomata, 
chancroid, 
herpes simplex, 
idiopathic balanoposthitis, 
podophyllin misuse

Answer 8

dorsal perforation of the prepuce

Question 9

Wood’s light examination is helpful in the clinical diagnosis of ____, ____, ____

Answer 9

vitiligo, erythrasma, and fungal infections

Question 10

Examination of biopsy specimens should not be regarded as a substitute for clinical diagnosis. T/F?
It is safe and helpful to use small amounts of ______—the region is highly vascular

It is often necessary to suture a preputial punch biopsy site. T/F?

Answer 10

True
adrenaline
False (not often)

Question 11

_______ which may be found in between 15% and 48% of men, are flesh-colored, smooth, rounded papules (1–3 mm) occurring predominantly around the _______, rarely on the glans.
Often there are rows or rings of the papules. They are commoner in the _____ and _____

_____ should suffice, but ____ and ____ treatment have been used

Answer 11

Pearly or pink penile papules
coronal margin of the glans
uncircumcised male and regress with age
Reassurance
cryotherapy and laser

Question 12

________
common, normal variants of the skin of the scrotal sac and penile shaft, analogous to the situation on the vermillion of the lips

Answer 12

Sebaceous gland prominence, Tyson glands, sebaceous hyperplasia, and “ectopic” sebaceous glands (Fordyce condition)

Reassurance is usually adequate, but patients can be inordinately distressed

Question 13

possible that nevi on the penis occur more frequently in patients with the ________

Answer 13

atypical nevus syndrome

Question 14

______ are blue to purple, smooth, 2–5-mm papules on the scrotum, penile shaft, or glans. They generally appear and multiply during life but occasionally present as singletons

________ are smaller than common angiokeratomas, presenting as less hyperkeratotic pinhead lesions, and are found more extensively around the _____ and ______ from the navel to the knees

Electrocautery or laser ablation can be offered, but the lesions may recur

Answer 14

angiokeratomas

angiokeratomas of Fabry disease
lower limb girdle and upper thighs

Question 15

________
tightly adherent to the skin because their mouth parts are embedded in perifollicular blood vessels. Sometimes gray–blue macules (________) are seen on the affected sites.

Answer 15

pediculosis pubis

tache bleu, maculae caeruleae

Question 16

____ infection is a risk factor for anogenital cancer, particularly of the cervix and anus.

• associated with the clinical expressions of penile carcinoma in situ (PCIS), or Bowen disease of the penis, erythroplasia of Queyrat (EQ), or bowenoid papulosis (BP) and approximately 50% of cases of _______

high-grade dysplasia associated with high-risk types have been found in the urothelium and genital warts from HIV-positive individuals and the penis cancer risk is increased ______ (the anal cancer risk may be increased _______)

Answer 16

HPV
squamous carcinoma of the penis
three- to sixfold
by as much as 100

Question 17

_________
Inflammation and purulence may be due to infection but are a common phenomenon when individual lesions spontaneously involute

Answer 17

Mollusca

Question 18

Vitiligo has been reported after treatment of genital warts with ______.
An important rare differential diagnosis is depigmented ________
Phototherapy of vitiligo might lead to _____

Answer 18

imiquimod
extramammary Paget disease (EMPD)
squamous cell carcinoma (SCC)

Question 19

________
nonspecific psoriasiform or eczematous balanitis or balanoposthitis is found in conjunction with classic symptoms and extragenital manifestations of the diathesis

In severe cases, such as with concomitant seborrheic folliculitis or in acquired immunode ciency syndrome (AIDS), treatment with an ______ might be indicated

Answer 19

seborrheic dermatitis

oral imidazole

Question 20

Drugs such as _____, _____, _____, _____ may be responsible for the onset or exacerbation of psoriasis

In circumcised men, genital psoriasis presents with _________

On the glans or in the preputial sac of the uncircumcised patient, _________ because of the mucosal site

less commonly affected, the ______

Answer 20

lithium, β blockers, antimalarials, and angiotensin-converting enzyme inhibitors
variably itchy, silvery-scaled, erythematous patches or plaques
scale is absent from the patches or plaques
scrotum

Question 21

_______ 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

________ might indicate superinfection, especially with Candida. _________ would make one suspect another derma- tosis such as an eczematized dermatitis or tinea

Answer 21

Psoriatic balanoposthitis
Soreness
Inordinate itch

Question 22

Psoriasis
________ preparations should also therefore be avoided at this site because of the risk of genital cancer.
_____ application may lead to burning and so is usually avoided in this region. Vitamin D analogues and calcineurin inhibitors seem safe, but with the latter, the prescriber must _______
_______ is conventionally contraindicated because of the risk of anogenital cancer

Answer 22

Strong crude tar
Dithranol
be certain of the absence of PCIS
Phototherapy

Question 23

_______ may affect the penis (like the mouth, vulva, and anus) in isolation as the cause or consequence of foreskin dysfunction (by ______) and so present as dyspareunia and a nonspecific dermatosis

Answer 23

Lichen planus

“koebnerization”

Question 24

Although LP is self-limiting, some patients experience relapses and remissions. _____ can form. ________ can persist for months or years

Chronic mucosal erosive LP is associated with a risk of ___, although most reports linking the two concern oral LP.

_____ topical corticosteroids usually produce remission
________ are sometimes indicated for severely symptomatic disease, _____ orogenital involvement, and _________.
_____ may be necessary if there is phimosis and should be seriously considered in cases of refractory disease, especially the _____ form, because the removal of “koebnerizing” influences may allow the LP to remit

Answer 24

Adhesions
Postinflammatory hyperpigmentation

SCC

Potent or very potent
Systemic corticosteroids
erosive
scarring of the scalp and nails
Circumcision
erosive

Question 25

_______ is sometimes held simplistically and controversially to be a micropapular variant of LP. It has an affinity for the penis and can be difficult to diagnose because the signs may be subtle, even when the lesions are widespread

Answer 25

Lichen nitidus

Question 26

_______ Erythematous smooth, ovoid nodules of granuloma affecting the penis have been described. They are perhaps related to trauma and koebnerization, because circumcision can be curative

Answer 26

granuloma annulare

Question 27

_________ can be focalized to the male genitalia as a sore or painful annular erythematous eruption with a central glassy appearance and serpiginous border surrounded by scaling. It is a characteristic cutaneous manifestation of the _______

Answer 27

Necrolytic migratory erythema | glucagonoma syndrome

Question 28

Aphthae and idiopathic orogenital ulceration are more common and are worse, symptomatically and morphologically, in _______ individuals _______ may be efficacious treatment

Answer 28

HIV-infected | thalidomide

Question 29

To diagnose Behçet disease according to strict diagnostic criteria, ________ must be present; then patients must also either manifest _______ involvement or genital ulceration and__________

Answer 29

oral ulceration genital ulceration and ophthalmic skin signs (or a positive pathergy test result)

Question 30

_________ is a rare disease that must be in the differential diagnosis of blistering, erosions, ulcers, transcoronal adhesions, scarring, and phimosis. These manifestations can occur in isolation, but ____, _____, _____ lesions are more common than genital involvement

Answer 30

``` Mucous membrane (cicatricial) pemphigoid ophthalmic, oropharyngeal, and cutaneous ```

Question 31

_______ may represent a pathergic reaction after urologic surgery or complicate IBD or leukemia

Answer 31

pyoderma gangrenosum

Question 32

The penis is a classic site of predilection for ______ Ulceration due to ______ can occur when the drug is inadvertently injected subcutaneously for the treatment of erectile impotence. ______ have induced skin necrosis of the genitalia _____has been reported to induce genital ulceration in patients with hematologic malignancy ______ can create genital ulceration in HIV-infected patients due to the high urinary concentrations of the drug _____ is a newly-appreciated cause of anogenital and peristomal ulceration. _____ has been associated with genital angioedema

Answer 32

``` fixed drug eruptions papaverine Heparin and warfarin All- trans retinoic acid Foscarnet Nicorandil Lisinopril ```

Question 33

________ causing a perianal cellulitis is a recognized syndrome in children, but a similar clinical situation occasionally occurs in adults and might affect the genitalia alone

Answer 33

Streptococcal dermatitis

Question 34

________ is relatively rare but can be associated with severe morbidity due to nocturia, dysuria, acute urinary retention, constipation, and fecal retention Treatment in ______

Answer 34

Sacral herpes zoster | IV acyclovir

Question 35

______ is not common, and when it occurs it is usually associated with crural disease.

Answer 35

Tinea of the penis or scrotum

Question 36

_____ occur because of ova shed by worms that have entered the perineal vessels from the pelvic venous plexuses. Papules and nodules may be itchy; may be skin-colored, pink, or brown; may be scattered or grouped; and may affect the penis and scrotum. They can spread onto the perineum and around the anus and may develop into soft, warty, vegetating lesions but remain relatively asymptomatic.

Answer 36

Schistosomiasis

Question 37

The dermatologic genital consequences of onchocerciasis are ____, ____, ____, ____, including “lizard skin” lichenification, “hanging groin,” and scrotal enlargement

Answer 37

pruritus, “leopard skin” hypopigmentation (on shins and scrotum), nodules (on ileal crests, scrotum, and ribcage), dermatitis

Question 38

__________ Annular raised (double-rimmed) lesions have been found in the intergluteal cleft, on the scrotum, and on the penis, including the glans ____ and ____ can be used for treatment

Answer 38

Genital porokeratosis of Mibelli | Cryotherapy and topical 5-fluorouracil

Question 39

______ can present as a dull red patch or plaque on the glans penis or in the preputial sac and can also affect the penile shaft, scrotum, and perianal skin - classic manifestations—purple, slightly scaly patches or plaques, nodules, and ulcerative lesions. An engorged, “hypervascular” presentation has been described, as has ____, ____, ____

Answer 39

Kaposi sarcoma | penile lymphedema, acute phimosis, and rectourethral fistulation

Question 40

____, ____, ____ can be associated with hematologic malignancy. Although the groin is a classic site of involvement in _____, involvement of the penis is very rare. Metastases to the penis and scrotum occur uncommonly - usually secondary to cancer of the ____ or ____ or complicate other common cancers such as those of the lung

Answer 40

Pyoderma gangrenosum, Pseudomonas infection, and Fournier gangrene Langerhans cell histiocytosis urogenital tract or gastrointestinal system (e.g., rectum)

Question 41

Some if not all cases may represent PIH from previous disease or insult [e.g., phimosis, balanoposthitis, topical treatment, LSc, LP, circumcision]. It has been suggested that_______ is an essential element of the condition possibility of Addison or Nelson syndrome should be entertained, as should the possibility of a lentiginosis syndrome [____, ____, ____, ____], although idiopathic lentigines of the penis are recognized Laser treatment may be helpful

Answer 41

adjacent depigmentation Peutz–Jeghers, LAMB (lentigines, atrial myxoma, blue nevi), LEOPARD (multiple lentigines, elec- trocardiographic abnormalities, ocular hypertelorism, pulmonary stenosis, abnormalities of the genitalia, growth retardation, deafness), or Bannayan–Riley–Ruvalcaba syndrome

Question 42

________ Irritation is induced by__________ between two tightly apposed and infrequently and inadequately separated and/or infrequently or inappropriately bathed, commensally hypercolonized, desquamative, secretory epithelial surfaces An________ with _______ is classic Well-demarcated, glistening, moist, shiny, bright red, or autumn brown patches symmetrically involve the glans and inner prepuce, sparing the ______ or _____ histologic examination the epidermis is attenuated with absence of the _____ or _____, sparse dyskeratosis and spongiosis, and diamond- or lozenge-shaped ______. In the dermis there are variably seen a band of plasma cells infiltration, extravasated erythrocytes, hemosiderin, fibrosis, and vascular proliferation Definitive curative treatment is _______

Answer 42

zoon balanitis retention of urine and squames asymptomatic presentation with little or no dyspareunia keratinized penile shaft or foreskin granular and horny layers basal cell keratinocytes surgical circumcision

Question 43

The pathogenesis of LSc, particularly the role of autoimmunity. _________ have been found in the sera of male and female patients with genital LSc The principal presentation in men is of ______. The classic genital morphologic manifestations - atrophic white patches or plaques or lilac, slightly scaly patches with _____ and _____, like those of the classic clinical manifestations of extragenital LSc _______ is the most worrying complication of LSc: the published risk is 2%–12.5% and the latent period may be _____. ________ acheive remission in 50%–60% and the majority of the remainder are cured by _____

Answer 43

Antiextracellular matrix protein 1 antibodies dyspareunia telangiectasia and sparse purpura SCC of the penis 10–30 years Very potent topical steroids circumcision

Question 44

________ diagnosis of exclusion or as a descriptive term that indicates the limitations of diagnostic acumen ______ may be the end stage situation including in diabetes. _______ is the cause or consequence of probably all cases and many patients probably have ___ as the underlying morbid state The ultimate recourse is _____, which is curative in most instances

Answer 44

``` Nonspecific balanoposthitis Phimosis Preputial dysfunction LSc circumcision ```

Question 45

_______ should be considered when florid symptomatology is accompanied by a paucity or complete absence of any primary dermatologic signs ________ - persistent redness of the anterior half of the scrotum that may involve the base of the penis . . . usually accompanied by a persistent itching or burning sensation and hyperalgesia.” Accompanying the erythema there may be telangiectasia Contact urticaria, irritant and contact dermatitis, and scrotal rosacea due to ______ application should be considered. ____ and ____are causes of odd sensory symptoms. Some men with “idiopathic” anogenital pruritus may be found to have lumbosacral radiculopathy - significant improvement may be obtained by _______

Answer 45

Dermatologic nondisease red or burning scrotum syndrome topical steroid Angiokeratoma corporis diffusum and multiple sclerosis paravertebral injections of triamcinolone

Question 46

Scrotal rosacea should be treated with ___________ may be effective in the red scrotum syndrome

Answer 46

oral tetracycline’s and these (e.g., doxycycline)

Question 47

_________ Young men complain of penile spots or boils or blackheads and on examination have comedones, papules, pustules, and inflammatory nodules of the proximal penile shaft. An important differential diagnosis of acneiform disease presenting at any site is ______ caused by occlusion of the skin with machine oil

Answer 47

penile acne | chloracne

Question 48

_________ | swelling and intercurrent attacks of cellulitis and lymphangitis of the penis, scrotum, and pelvic girdle

Answer 48

Chronic idiopathic penile edema Long-term treatment with oral antibiotics such as erythromycin, clarithromycin, clindamycin, trimethoprim, cotrimoxazole, or ciprofloxacin is advocated

Question 49

______ is a medical and surgical emergency. Patients present with systemic upset and painful erythematous swelling of the____, ____ or ____ and may be in urinary retention. An ominous black spot may appear on the _____. There is gross systemic toxicity (peculiarly, sometimes absent in children) and no suppuration The process probably begins with ______, and polybacterial infection develops

Answer 49

Fournier gangrene genital, perianal, or lower abdominal skin scrotum appendageal or urethral infection Radical surgical débridement of all affected tissue is undertaken and broad systemic antibiotic therapy initiated

Question 50

________ large, serpiginous, foul-smelling ulcers in uncircumcised men, associated in some with nontender inguinal lymphadenopathy. Treatment is with ____ or ____

Answer 50

Nonsyphilitic spirochetal ulcerative balanoposthitis | penicillin or metronidazole

Question 51

________ rock-hard smooth white papules or nodules on the scrotum, multiple or solitary The differential diagnosis includes _____

Answer 51

scrotal calcinosis | epidermoid cyst