Noninfectious Penile Lesions

 

Am Fam Physician. 2018 Jan 15;97(2):102-110.

Author disclosure: No relevant financial affiliations.

Noninfectious penile lesions are classified by clinical presentation as papulosquamous (e.g., psoriasis), inflammatory (e.g., lichen sclerosus, lichen nitidus, lichen planus), vascular (e.g., angiokeratomas), or neoplastic (e.g., carcinoma in situ, invasive squamous cell carcinoma). Psoriasis presents as red or salmon-colored plaques with overlying silvery scales, often with extragenital cutaneous lesions. Lichen sclerosus presents as a phimotic, hypopigmented prepuce or glans penis with a cellophane-like texture. Lichen nitidus usually produces asymptomatic pinhead-sized, hypopigmented papules. The lesions of lichen planus are pruritic, violaceous, polygonal papules that are typically systemic. Angiokeratomas are typically asymptomatic, well-circumscribed, red or blue papules, often with annular or figurate configurations. Carcinoma in situ should be suspected if there are velvety red or keratotic plaques on the glans penis or prepuce, whereas invasive squamous cell carcinoma presents as a painless lump, ulcer, or fungating mass. Some benign lesions, such as psoriasis and lichen planus, may mimic carcinoma in situ or invasive squamous cell carcinoma. Biopsy is indicated if the diagnosis is in doubt or neoplasm cannot be excluded. The management of benign noninfectious penile lesions usually involves observation, topical corticosteroids, or topical calcineurin inhibitors. Neoplastic lesions generally warrant organ-sparing surgery.

Diagnosis and management of cutaneous penile lesions can be challenging because of lack of physician familiarity and patient embarrassment. Even though noninfectious lesions are common, penile lesions are often attributed to infectious causes, especially in younger patients.1 The key to efficient diagnosis is a genitourinary examination that defines the predominant characteristic of the lesions2,3  (Table 13). Noninfectious penile lesions are classified by clinical presentation as papulosquamous (e.g., psoriasis), inflammatory (e.g., lichen sclerosus, lichen nitidus, lichen planus), vascular (e.g., angiokeratomas), or neoplastic (e.g., carcinoma in situ, invasive squamous cell carcinoma). Lesions localized to the penis usually involve different diagnostic and treatment considerations than those with extragenital findings. Biopsy is typically reserved for an unclear diagnosis, or if neoplasm cannot be excluded. Management options for noninfectious penile lesions are summarized in Table 2.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Topical corticosteroids are first-line therapy for psoriasis and lichen sclerosus.

A

4, 8, 11, 14, 15, 29, 34, 35

Psoriasis: consistent findings from multiple observational studies Lichen sclerosus: meta-analysis, consensus guidelines

Observation is sufficient for lichen nitidus and angiokeratomas because most cases are asymptomatic.

C

38, 41, 52, 54, 55

Observational studies

Topical corticosteroids are first-line therapy for lichen planus.

C

1, 44, 46

Observational studies

Circumcision is first-line therapy for isolated preputial carcinoma in situ.

C

70, 71

Observational studies and guidelines

Biopsy should be performed on any lesion for which penile carcinoma in situ or penile cancer cannot be excluded.

C

66

Expert opinion

Circumcision is the first-line therapy for isolated preputial invasive squamous cell carcinoma.

C

66, 78, 79

Observational studies and guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Topical corticosteroids are first-line therapy for psoriasis and lichen sclerosus.

A

4, 8, 11, 14, 15, 29, 34, 35

Psoriasis: consistent findings from multiple observational studies Lichen sclerosus: meta-analysis, consensus guidelines

Observation is sufficient for lichen nitidus and angiokeratomas because most cases are asymptomatic.

C

38, 41, 52, 54, 55

Observational studies

Topical corticosteroids are first-line therapy for lichen planus.

C

1, 44, 46

Observational studies

Circumcision is first-line therapy for isolated preputial carcinoma in situ.

C

70, 71

Observational studies and guidelines

Biopsy should be performed on any lesion for which penile carcinoma in situ or penile cancer cannot be excluded.

C

66

Expert opinion

Circumcision is the first-line therapy for isolated preputial invasive squamous cell carcinoma.

C

66, 78, 79

Observational studies and guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT

The Authors

show all author info

JOEL M. H. TEICHMAN, MD, is a professor in the Department of Urologic Sciences at the University of British Columbia, Vancouver, British Columbia, Canada....

MILES MANNAS, MD, is a second-year resident in the Department of Urologic Sciences at the University of British Columbia.

DIRK M. ELSTON, MD, is a professor in the Department of Dermatology and Dermatologic Surgery at the Medical University of South Carolina, Charleston.

Address correspondence to Joel M. H. Teichman, MD, University of British Columbia, St. Paul's Hospital, Burrard Bldg. C307, Vancouver, BC, Canada V6Z1Y6. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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