Outpatient- Penile lesion

Question 1

A 77 y/o man with IDDM has been referred with a non-retractile foreskin. What is the clinical term used for this condition?

Answer 1

Phimosis

Question 2

A 77 y/o man with IDDM has been referred with a non-retractile foreskin. How would you assess this patient?

Answer 2

I would see this in a routine outpatient urology clinic and as patient to provide a urinalysis on arrival.
Clinical history: Duration, associated LUTs, VH, Scarring and bleeding on retraction. History of UTIs/STIs, previous trauma or urological surgery. issue with hygiene
PHx: IDDM control, general performance status
DHx: anticoagulants, history of potent steroid cream use for phimosis. allergies
Shx: Smoking, high UV exposure

Examination: general inspection, with chaperone assess foreskin retractability [if cant retract then palpate], check overlying skin changes erythema, lesions or ulcers, discharge. Check for lymphadenopathy

Question 3

What can be the cause of phimosis?

Answer 3

previous trauma

infection- BXO [balanitis Xerotica Obliterans/ Lichen Sclerosis]

Question 4

What are the possible treatment options of a phimosis?

Answer 4

Conservative: potent topical steroid to be given for 4 weeks and reassess in 4 weeks time
Surgical: Dorsal slit or Circumcision.

Question 5

How would you consent for a circumcision?

Answer 5

Confirm patient name, DOB and clarify indication for procedure. Ideally the patient should have had a BAUS leaflet prior to consent.
Risks/ Cx: bleeding, bruising, swelling, infection, poor cosmetic effect, altered glands sensitivity, potential biopsy once foreskin is off, meatal stenosis, GA risks [Cardio/resp, PE/DVT]

Question 6

After the circumcision [uncomplicates], the patient returned with a new erythematous lesion on his glans. What would you do?

Answer 6

After the circumcision there is a possibility that it could be residual lichen sclerosis therefore I would prescribe some potent steroid cream for 4 week and reassess after the course. If the lesion were to persist or progress I would perform a biopsy

Question 7

What pre-malignant lesions are you aware of in the context of penile cancer?

Answer 7

• cutaneous horn
• bowen’s disease
• extra mammary paget’s disease

Question 8

What are the risk factors of SCC of the penis

Answer 8

• HPV 16 &18
• uncircumcised males
• poor hygiene and retained Smegma
• pre malignant lesions [extra mammary pagets, cutaneous horn, bowen’s]
• high UV exposure
• smoking
• increasing age

Question 9

What treatment would you offer for a patient with a penile CIS?

Answer 9

Topical 5 FU [5% 5 Fluorouracil], an antimetabolite chemotherapeutic agent which acts at the S phase of the cell cycle causing arrest and apoptosis.

Question 10

What investigations would you perform for a patient with a likely penile tumour?

Answer 10

Bloods: FBC, U&Es, Coag
Imaging: penile MRI with intracavenosal prostaglandin [to induce artifical erection], CTCAP to assess enlarge lymph nodes