Sexual Health and Genital Medicine in Clinical Practice

Chapter 18. Genital "Lumps"

18.1 GENITAL WARTS

The most frequently seen genital "lumps" in general practice are genital warts or condylomata acuminata ("pointed condylomata"). The term "venereal warts" is now outdated and should not be used. Genital warts are the second commonest STI in the UK and are caused by human papillomavirus (HPV), which is the commonest sexually transmitted viral infection in the UK. Studies using nucleic acid amplification tests (e.g. polymerase chain reaction) for detecting tiny amounts of HPV DNA suggest that many sexually active people carry low levels of HPV in the genital tract for variable periods of time but only a small number of infected individuals develop warts. The natural history and infectivity of this so-called "subclinical" HPV infection is unknown.

A prophylactic vaccine against HPV types 6,11,16 and 18 has recently been licensed in the USA and UK. This should provide protection against genital warts and many cases of cervical, vulval, anal and penile intraepithelial neoplasia and carcinoma.

18.1.1 Management of Genital Warts

Patients with genital warts should ideally be referred to GU medicine for assessment and initiation of treatment, irrespective of the age of the patient and the length of time the warts have been present. Genital warts are almost always sexually acquired (Figures 18.1-18.5), although lesions may have been present for many months or even years before the patient seeks a medical opinion. Very occasionally hand warts may be transferred to the genitalia and this should be considered if the lesions resemble planar warts rather than condylomata acuminata.

The incubation period between acquiring HPV infection and the appearance of warts may be many months or, very occasionally, even years, which can lead to some difficulty in determining exactly when and from whom the infection was caught.

Figure 18.1. Penile wart

Anal warts (Figure 18.6) are commonly seen in both women and heterosexual men, either with or without genital lesions, and these may extend into the anal canal. Anal warts are not indicative of anal intercourse; the method by which HPV is transferred to the anus of a heterosexual male is currently unknown HPV infection is sexually acquired and most patients should be checked for other STIs, in particular chlamydial infection.

Figure 18.2. Intra-meatal wart

Figure 18.3. Vulval warts

Figure 18.4. Keratinized vulval warts

Figure 18.5. Cervical warts

Remember that STIs are frequently carried without symptoms. Sexual partners should be carefully assessed, which for female partners should include vaginal and cervical examination, ideally with a colposcope.

Figure 18.6. Anal warts

18.1.2 Treatment

(1) Cryotherapy is an extremely effective and generally well- tolerated treatment that does not require a local anesthetic. This is a useful first-line treatment.

(2) Podophyllin is a time-honored treatment that requires application by medical staff twice or thrice weekly. The patient should wash off the paint after 4-6 hours as prolonged application can lead to burning and ulceration. Fresh, moist warts may respond well to this form of treatment. Once keratin has started to appear on the wart surface success is less likely. Anecdotal evidence suggests that a combination of cryotherapy and topical podophyllin is more effective than either therapy alone. Podophyllin is now uncommonly used as sole therapy.

(3) Podophyllotoxin is a pure preparation of one of the active ingredients of podophyllin and has the advantage of selfapplication either as a lotion or as a cream. It is quite expensive compared with podophyllin but is highly effective in patients with fresh lesions and is ideal for those who find it difficult to adhere to regular clinic or surgery attendance. Some women find it difficult to apply, particularly if lesions are small, and treatment of anal warts usually requires some assistance.

(4) Imiquimod is also a self-applied cream that works by stimulating the cell-mediated immune response against HPV in the infected epithelium. As with podophyllotoxin, some patients experience soreness at the site of application. Response to treatment is sometimes a little slow, perhaps taking 8-12 weeks to act in some patients, but initial studies have suggested a lower recurrence rate than with other forms of treatment.

(5) Trichloracetic acid acts as a caustic agent and can be useful for burning off small warts. To be used with care!

(6) Diathermy, scissor excision and laser ablation require a local anesthetic; prior application of prilocaine plus lignocaine cream makes this more tolerable. Very useful for persistent warts and should be considered earlier rather than later in the course of treatment.

Since warts may resolve without treatment a "wait and see" approach may be considered. Unfortunately warts may enlarge and spread making treatment at a later date more difficult. In addition, most patients dislike the physical appearance of genital warts and usually opt for treatment.

The method of treatment used should be guided by lesion type, site, size, number, and patient needs. Single or small numbers of warts are effectively treated with cryotherapy or removal under local anesthetic whereas numerous lesions may be better approached with a self-applied treatment such as imiquimod or podophyllotoxin. More detailed advice is probably better sought from a specialist text (see Further Reading).

18.1.3 Other Management Issues and Frequently Asked Questions

18.1.3.1 Recurrences

Genital warts have a tendency to recur, in some cases with alarming frequency. Such patients may require psychological support.

18.1.4 HPV Infection and Anogenital Cancer

There is now a good deal of evidence linking HPV infection with cervical, vulval, penile, and anal squamous cell carcinoma. Most studies have focused on cervical neoplasia and dysplasia (or CIN) and have shown certain HPV types to have a greater potential to induce dysplastic and neoplastic change. The commonest so-called "high risk" types are HPV-16 and 18. HPV-6 and 11 are found in genital warts and are considered "low-risk" HPV types. As mentioned earlier, many sexually active people harbor low levels of HPV in the genital tract, including the high-risk types 16 or 18. In most individuals this infection probably eventually clears, in others it may persist indefinitely but pose no problem. In a small number of individuals, HPV infection may induce cellular dysplastic change. Dysplasia may revert to normal over time or, again in a small number of individuals, progress to cancer. The chances of an individual infected with a "high-risk" HPV type developing a cervical cancer depends on several factors. These include the quantity of virus present, the genetically determined immunological host response to the virus, which will have some control over viral persistence, and other cofactors such as smoking, herpes simplex virus co-infection and possibly the presence of other genital infections (e.g. Chlamydia). Current UK guidelines do not advise more frequent cervical cytology in women with a history of genital warts or genital wart contact.

18.1.5 Condom Use

Most clinicians advise the use of condoms while warts are present and most patients feel comfortable with this. Although HPV remains in the epithelium after warts have cleared, the degree of infectivity of subclinically carried virus is currently unknown as is the protective effect of condoms for subclinical infection. It is therefore very difficult to accurately advise for how long condoms should be used after apparently successful treatment. There would appear to be less need to use condoms in long-term relationships as the exposed partner is likely to have already been infected with the virus.

18.1.6 Oral Sex

As warts can occasionally be passed to the mouth through oro-genital contact, it is usually recommended that couples refrain from oral sex whilst warts are present. However, depending upon the site and extent of lesions, with sufficient care it may be possible to avoid direct wart contact.

18.2 OTHER CAUSES OF GENITAL “LUMPS”

18.2.1 Hirsuties Papillaris Penis Or Pearly Penile Papules

"Hirsuties papillaris penis" or "penile pearly pink papules" is one of the commonest conditions to be mistaken for genital warts in men. The lesions appear as rows of small pink or white filiform papillae on the corona of the glans penis and by the frenulum (Figure 18.7). They first appear at puberty and are found to varying degrees in up to 40% of men. They are harmless but a frequent cause of anxiety; if you are unsure, ask GU medicine to assess. Tiny papules by the frenulum can be difficult to distinguish from warts and may require examination with the aid of a magnifying glass or colposcope.

Figure 18.7. Hirsuties papillaris penis (penile papules)

Figure 18.8. Vulval micropapillae

Penile papules can be removed by cryotherapy or laser ablation if causing sufficient cosmetic anxiety but reassurance is usually sufficient.

18.2.2 Vulval Micropapillae

Many women have small finger-like projections on the inner surface of the labia minora and around the introitus. These are benign micropapillae (Figure 18.8) and may be seen in conjunction with warts, which often makes clinical assessment difficult. Micropapillae are not related to HPV infection and therefore do not warrant treatment. Examination with some form of magnification, such as the colposcope, is often required to differentiate these lesions from genital warts.

18.2.3 Fordyce Spots

"Fordyce spots" (Figures 18. 9 and 18.10) are commonly seen in both men and women. They are a normal variant, thought to be ectopic sebaceous glands, which appear as tiny cream-colored spots just under the skin surface.

Figure 18.9. Vulval Fordyce spots 18.2.4 Pilo-Sebaceous Glands

These are commonly found along the penile shaft but in some men they can be particularly numerous and prominent, giving rise to concern. The patient should be reassured that these are normal skin glands and do not require treatment (Figure 18.11).

Figure 18.10. Penile Fordyce spots

Figure 18.11. Prominent pilo-sebaceous glands on the penile shaft 18.2.5 Seborrhoeic Keratoses

These more commonly appear with increasing age and may resemble warts. Removal by curettage, scissor or shave excision under local anaesthetic for histological examination is recommeded if there is diagnostic uncertainty. Cryotherapy is an alternative effective method of treatment (Figure 18.12).

Figure 18.12. Seborrhoeic keratoses

Figure 18.13. Molluscum contagiosum

18.2.6 Molluscum Contagiosum

Lesions are classically smooth and rounded with a central punctum although polypoid forms are occasionally seen (Figure 18.13). Treatment is with cryotherapy. Applying phenol with a sharpened orange stick tends to be less well tolerated. Recent reports have also shown promising results using imiquimod, podophyllotoxin and cidofovir.

18.2.7 Sebaceous Cysts

These present as round, creamy yellow, smooth swellings. Scrotal cysts may reach a centimeter in diameter and are often multiple (Figure 18.14).

18.2.8 Lichen Planus

Papular lesions of lichen planus may be mistaken for flat or papular warts. Diagnosis is aided by the violaceous color and the presence of fine white linear striae (Wickham's striae) and by the presence of the condition elsewhere on the body (see also page 90 figure 18.5).

18.2.9 Linchen Nitidus

An uncommon condition presenting as very tiny pink or brown, dome-shaped, shiny papules. They may be found in conjunction with lichen planus.

Figure 18.14. Scrotal sebaceous cysts

18.4.1 Psoriasis

Plaques of psoriasis may occasionally be misdiagnosed as flat warts. Genital lesions often lack the characteristic silvery scale leaving a red, slightly shiny surface (see also page 91 figure 16.6).

18.4.2 Condylomata Lata

A feature of secondary syphilis that presents as pink or grey, moist, slightly elevated lesions (Figure 18.15). There are often other signs of syphilis (e.g. generalized rash, oral lesions, lymphadenopathy) and syphilis serology (T pallidum antibody; VDRL (Venereal Diseases Research Laboratories) and TPHA (T. pallidum hemagglutination assay)) will be positive at this stage of the disease.

18.4.3 PIN and Squamous Cell Carcinoma

Penile intraepithelial neoplasia presents as a flat or papular, erythematous or whitish, warty looking lesion (Figure 18.16 and page 92 figure 16.9). The application of acetic acid (gauze swab soaked in 5% acetic acid and held against the lesion for 3-5 minutes) highlights the lesions, although examination with a colposcope may be needed to reveal the characteristic features of punctation. Biopsy is required to confirm the clinical diagnosis. PIN is a pre-malignant condition. Cancerous lesions usually feel hard or gritty, often bleed on contact, and may be ulcerated. Genital warts rarely undergo malignant change but any suspicious lesion requires biopsy.

Figure 18.15. Condylomata lata of secondary syphilis 18.4.4 Lymphocele

A common condition presenting as a smooth, firm, worm-like cord in or below the coronal sulcus just below the glans penis. There may be a history of recent strenuous sexual activity. There is no specific treatment and the condition resolves with time (Figure 18.17).

Figure 18.16. Penile intraepithelial neoplasia (PIN)

Figure 18.17. Penile lymphocoele

18.4.5 Peyronie’s Disease

A condition of unknown cause characterized by the development of fibrous plaques within the penis. Some patients give a history of penile trauma which is thought to allow bleeding into the tunica albuginea. This initiates an inflammatory reaction that leads to fibrin deposition and scar formation. The first sign noted by the patient is often a painless lump, sometimes associated with discomfort on erection. As the condition progresses, the penis may bend to one side on erection, occasionally making intercourse impossible. Some patients notice the penile bending before a lump is detected. There is usually spontaneous improvement with time (often months or years) and reassurance may be all that is required. Potassium para-aminobenzoate (POTABA) and vitamin E combined with colchicine and intralesional verapamil or triamcinolone injection have been tried, with variable success in the early acute phase of the disease. Surgery is best reserved for those patients with a penile deformity that interferes with intercourse.



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