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28th May 2008, 03:17 PM
Facts about Peyronies disease
The Basic Facts
Men with Peyronies disease generally seek medical attention for pain or bending of the penis during erection, which results from inflammation and scarring in a particular part of the male anatomy known as the tunica albuginea.
This condition is most commonly acquired at about age 55. A man can be born with curvature of the penis, though this is not Peyronies disease.
Severity varies - only a minority of the men afflicted with this problem are unable to engage sexually. Through an effect on the erection mechanism it can reduce rigidity (hardness), but it rarely causes impotence.
It is somewhat uncommon, affecting somewhere between one and three men in a hundred.
In addition to producing curvature, Peyronies disease may change the shape of the erection in other ways: indentation, diameter reduction, or loss of length.
Peyronies disease can have a strong psychological impact. Some cases are mild, healing without treatment within a year of onset. Most cases produce at least some degree of persistant curvature. A noticeable lump, or plaque within the penis is commonly detected. Contrary to prevalent anxieties, it is noncancerous, and unrelated to cholesterol – containing arterial plaque.
Peyronies disease can run in families, though most cases do not appear to be hereditary.
This condition is not associated with serious internal disorders. 10 –20% of men develop scarring of either the hands (Dupuytren’s contractures) or of the feet.
The goal of therapy is to maintain sexual function. In some cases, education about the disease and reassurance is all that is required. Rarely, when long-term deformity prevents intercourse, surgery is recommended.
Can Peyronie’s disease cause impotence?
Impotence, defined as the inability to maintain a hard enough erection to have intercourse, is uncommon in Peyronie’s disease. Yet it frequently affects the erection mechanism in a less serious way. Scientific studies have shown that at some point in time, up to 40% of men with Peyronie’s disease have experienced some degree of erectile dysfunction. Usually, this consists of a reduction in maximum hardness. It is usually a temporary effect, and rarely causes enough softening to preclude normal intercourse. When associated with severe bending however, it can be a problem. Persistant difficulty with erectile rigidity can usually be treated medically
The cause for the erectile dysfunction of Peyronie’s disease is "venous leakage." In other words, the blood that should normally be trapped within the taut confines of the tunica albuginea is leaking slowly out. By locally hardening the tunica, plaques may prevent the exit veins from pinching off in the normal fashion.
Damaging effects of mechanical stress
When fully expanded, the rigid corpora cavernosa forms something like an inflatable I beam. Mechanical forces on this structure will create a unique region of tissue stress at the top of the "I". The majority of the tunica albuginea compresses with stretch during erection, but the topmost strip is subject to an opposite, delaminating force.
Fibrin deposition, the first step in the wound healing process and the precursor to Peyronie’s plaque, usually develops in this area. The mid- topof the penis is the area most commonly involved by Peyronie’s disease.
If Peyronie’s plaque forms in the hoop (circumfrential) direction, it causes indentation or segmental loss of penile diameter. These so-called hourglass areas have a profound effect on over all penile rigidity. The resistance to bending of an inflatable tube is related to its cross sectional area. Because of this, indented areas make the erect penis easier to bend, even at high internal fluid pressures.
Peyronie's Disease - Background and Description
Peyronie's Disease was first described in 1743 by a French surgeon, Francois de la Peyronie and was written about as early as 1687. The disease is oftentimes associated with impotence.
The most common symptom of Peyronie's Disease is a curvature, lump or hard area observed in the penis. Painful erections and penile pain are also symptoms of this condition. . The lumps or hard areas, also referred to as plaque or scar tissue form between the tunica and the outer layers of skin. The plaque or scarring also reduces the elasticity to the affected area, it will not stretch as the surrounding, unaffected tissues. The erect penis bends in the direction of the scar or plaque formation as a result of this, often with associated pain.
Recent studies in Europe report three percent of men have Peyronie's Disease. Statistics gathered show the average age of the patient to be 55, although patients as young as 16 and as old as 83 have been treated. About 30 percent of the patients with Peyronie's Disease also develop fibrosis in other tissues of the body, such as the hands and feet. This group of patients with involvement in more than one body part may have been born with a genetic predisposition to the disease. This genetic predisposition can occur in women as well.
Many physicians believe that the plaque associated with Peyronie's Disease develops as a result of trauma to the penis that causes localized bleeding inside the penis. Repeated trauma to the damaged area may prevent normal healing, or very slowl healing. As the plaque that forms hardens, it becomes fibrotic and sometimes allows for calcium deposits.
Common dermatoses of the male genitalia
Recognition of differences in genital rashes and lesions is essential and attainable - Barry D. Goldman, MD
VOL 108 / NO 4 / SEPTEMBER 15, 2000 / POSTGRADUATE MEDICINE
CME learning objectives
1. To recognize the appearance of common dermatoses of the male genitalia
2. To distinguish which dermatoses are accompanied by lesions elsewhere on the body
3. To identify topical treatment of common dermatoses of the male genitalia
4. The author discloses no financial interests in this article.
Preview: Dermatoses of the male genitalia can be confusing to identify and difficult to diagnose and treat. Rashes and lesions that occur on other areas of the body can be hard to recognize when they appear on the genitalia. In this article, Dr Goldman reviews the common dermatoses, presents defining characteristics, and suggests treatment options.
Goldman BD. Common dermatoses of the male genitalia: recognition of differences in genital rashes and lesions is essential and attainable. Postgrad Med 2000;108(4):89-96
Male genital dermatology encompasses a wide variety of lesions and skin rashes. Some of these occur only on the genitalia, while others are typically found elsewhere on the body and may take on an atypical appearance on the genitalia. One reason for these different characteristics is that genitalia are covered by thin skin that is usually moist, so the dry scaliness associated with skin rashes on other parts of the body may not be present. In addition, genital skin may be more sensitive and reactive to cleansers and medications than skin elsewhere--a fact that emphasizes the need for thorough history taking.
After noticing skin changes of the genitalia, many patients express anxiety that they may have a sexually transmitted disease (STD). The clinician's challenge is to determine whether a genital skin eruption is a dermatologic problem limited to the genitalia or whether it is part of a widespread skin eruption that requires a comprehensive skin exam.
Psoriasis
Psoriasis is the most common inflammatory reaction that affects the male genitalia. It may appear in two forms: inverse psoriasis and penile psoriasis.
Patients may develop bright red, well-defined inguinal plaques known as inverse psoriasis. The psoriatic scale so apparent on other parts of the body is not seen here, nor is central clearing, which is often experienced in tinea. The plaque appears homogeneously erythematous. Occasionally, the entire scrotum, inguinal folds, and penis are involved, and similar lesions may affect the axilla or popliteal fossa. Unlike psoriasis elsewhere on the body, inverse psoriasis may be itchy. Often, patients have no history of psoriasis.
The disorder may also affect the penis, particularly the glans penis. Thin, pale erythematous plaques with slight scale are seen in discrete or continuous forms (figure 1: not shown). Penile psoriasis may be aggravated by trauma. As with psoriasis elsewhere, its plaques tend to be well defined. However, no vesicles or erosions are seen, and no itching or burning is present. In many patients, psoriatic lesions are limited to the genitalia and are not found on the rest of the body.
Both types of psoriasis respond well to low-potency corticosteroid creams. (Topical mid- and high-potency corticosteroids should not be used, to avoid atrophy of the surrounding skin.) It can be beneficial to compound hydrocortisone 2.5% cream and ketoconazole (Nizoral) cream, a response that leads many clinicians to believe that Candida infection helps precipitate psoriasis in susceptible individuals. Calcipotriene (Dovonex) cream, a vitamin D derivative used for psoriasis on other parts of the body, can be a nonsteroidal alternative treatment for psoriasis on the glans penis. A persistent penile plaque that does not respond to therapy should be reevaluated periodically to rule out squamous cell carcinoma in situ.
Dermatitis
Contact dermatitis of the genitalia can be divided into irritant and allergic forms. Theoretically, all persons are susceptible to irritant contact dermatitis. It may develop from chronic use of certain soaps, disinfectants, or antiseptic solutions. The latter often are used on the genitalia in an attempt to prevent STDs. Irritants such as fluorouracil (Efudex, Fluoroplex) cream used for actinic keratoses on the face may be inadvertently transferred from the hands to the genitalia. Patients typically complain of itching on the distal shaft of the penis. Clinically, they have ill-defined erythematous, scaly patches.
Patients with a history of atopic dermatitis are predisposed to develop irritant contact dermatitis of the scrotum. They generally present with erythema and mild lichenification. Direct contact with imiquimod (Aldara) cream used for genital warts on the penile shaft, for example, can cause erythema and erosion on the scrotum. Discontinuing the offending medication and treating with a low-potency corticosteroid cream for 5 to 7 days are all that is needed.
Allergic contact dermatitis is also common. The penis may become immensely swollen and have accompanying erythema and scaling (figure 2: not shown). Marked edema can occur because the skin covering the genitalia is thin and elastic.
The list of possible offending agents is long and includes many medications that can be transferred from other parts of the body to the genital area. Benzocaine cream, triple antibiotic ointment, and diphenhydramine hydrochloride (eg, Benadryl) cream are frequent offenders. Poison ivy and other rhus dermatitides also are commonly transferred by the hands to the genitalia.
Obtaining a history of topical products used by the patient is very important, because many products may be applied by patients who are concerned about hygiene or STDs. Men with latex allergy can experience erythema and scale along the entire penis because of latex condom use. Switching to a nonlatex condom is an option that can help control and prevent this allergic reaction.
Cases of severe contact dermatitis may require treatment with systemic corticosteroids as well as cool tap-water compresses. Mild cases can be treated with low-potency corticosteroid creams.
Dermatitis often becomes chronic, developing into lichen simplex chronicus, which is characterized by extensive lichenification and hypertrophy of the affected skin. The scrotum is particularly prone to lichen simplex chronicus. Patients complain of intense, unrelieved itching that is often related to heat and sweat. They typically present with lichenified erythematous plaques on the lateral or entire scrotum. Darker-skinned patients often exhibit hyperpigmented eruptions rather than erythematous ones, which may lead the clinician to underestimate the degree of inflammation.
In severe cases, low-potency topical corticosteroids prescribed for a maximum of 2 weeks can be helpful. Zinc oxide ointment is very soothing and helps absorb sweat. For particularly inflammatory eruptions, hydrocortisone 2.5% cream can be added to zinc oxide ointment. In most cases of chronic dermatitis, however, topical medications are soothing for only a few hours. Oral antihistamines may provide relief from scratching during sleep, primarily because of their sedative effect.
Feeling that cleanliness will aid the dermatitis problem, patients often wash the area vigorously with soap. Getting patients to avoid excessive washing is very important to long-term resolution, because soaps act as irritants on genital skin. (Water is adequate for cleansing.) In addition, breaking the itch-scratch-itch cycle is crucial, because lichenification results from prolonged scratching and rubbing.
Fixed drug eruptions
Patients with fixed drug eruptions of the genitalia usually present with a sudden onset of single or multiple well-defined circular plaques on the glans penis and distal shaft of the penis (figure 3: not shown). The eruption may be bullous, and its surface can become necrotic and painful--a sensation that has been compared to the pain of being branded with a hot iron.
Eruptions commonly are caused by medications, such as tetracyclines or laxatives containing phenolphthalein. In fact, more than 500 medications have been implicated. Some patients have been falsely labeled as having herpes simplex because of the intermittent nature of fixed drug eruptions. A careful drug history needs to be taken and should include medications used intermittently, such as antibiotics for chronic prostatitis and pain relievers (eg, acetaminophen). Multiple recurrences may result in postinflammatory hyperpigmentation.
Lichen planus and lichen nitidus
Lichen planus is an inflammatory disorder characterized by violaceous, flat-topped papules measuring 2 to 10 mm that may appear on any part of the body. Although the etiology is unknown, drugs and such infections as hepatitis C have been identified as precipitants.
Typically, the glans penis is involved as part of a systemic process. The surface of the lesions usually appears shiny, and no vesicles or crust is seen. However, annular lesions are sometimes covered with white scale known as Wickham's striae.
Diagnosis of lichen planus can be aided by an oral exam that reveals white streaks on buccal mucosa. Lesions are also commonly found on the wrists and ankles. Biopsy can help confirm the diagnosis.
Lichen nitidus is a similar inflammatory disorder of unknown etiology. Patients may present with monomorphic, flesh-colored papules measuring 1 to 2 mm along the shaft of penis (figure 5: not shown). Similar lesions may be present on the elbows and knees and around the umbilicus. The condition is often confused with condyloma and molluscum contagiosum. However, unlike molluscum, lichen nitidus does not involve umbilication, and lesions have a smooth surface.
Both lichen planus and lichen nitidus respond well to low-potency corticosteroid creams. These conditions tend to resolve spontaneously over 1 to 2 years.
Lichen sclerosus
Lichen sclerosus is a progressive sclerosing dermatosis of unknown origin. Typically, it causes atrophic white plaques on the glans or prepuce (figure 6: not shown). The eruption tends to fissure, and adhesion may develop. Skin biopsy is necessary to make the diagnosis. Lichen sclerosus of the glans penis (balanitis xerotica obliterans) may result in phimosis, which necessitates circumcision.
In the past, testosterone creams were used for treatment. However, clinical studies have not validated their use. Recently, application of high-potency topical corticosteroids (eg, clobetasol propionate [Cormax, Embeline E, Temovate]) for short periods has resulted in complete remission. The development of squamous cell carcinoma has occasionally been reported. These patients need to be under the care of an expert in genital dermatology.
Vitiligo
Vitiligo can appear similar to lichen sclerosus: The patient presents with hypopigmented or depigmented areas on the genitalia (figure 7: not shown). However, unlike lichen sclerosus, no atrophy is present. The glans penis and shaft are commonly affected, but there are no symptoms. Diagnosis can be aided by the presence of depigmented areas elsewhere on the body, especially on the face and the dorsum of the hands. The appearance is chiefly a cosmetic concern, and reassurance is usually all that is needed. Treatment with low-potency corticosteroids is helpful in some cases.
Conclusion
Genital dermatology is a varied field characterized by a multiplicity of lesions and eruptions. Proper history taking is important, because many eruptions may acquire an atypical appearance due to the patient's prior use of medication. Moistness, heat, and sweat combine to aggravate common dermatoses that involve the genital area. When in doubt, physicians should consider a biopsy for a persistent eruption, which can confirm or dispel a diagnosis.
Blue Balls
What are blue balls?
Blue Balls is a real condition! The "correct" term for blue balls is epididymitis, which is an inflammation of the epididymis.
In simple terms blue balls occurs when the epididymis get blocked up with sperm that have left the testis but not the penis. The vas deferns are the conduit for the sperm from the testis to the urethra. When they get blocked you get pain. Why blue balls and not "swollen balls," well maybe the connotation is that you balls have the "blues", or maybe its because with all that swelling some of the blood flow is restricted enough to cause some blueing of the area because of pooling blood.
Genital Problems in Men
SYMPTOMS DIAGNOSIS SELF-CARE
1. Do you have any swelling or tenderness in the scrotum? Go to Question 9.*
2. Do you have a discharge, either yellowish or greenish, from the tip of the penis? Your symptoms may represent a SEXUALLY TRANSMITTED DISEASE or an infection of the mucous glands, URETHRITIS. See your doctor promptly.
3. Do you have a burning sensation or pain with urination? These may be symptoms of a bladder infection, CYSTITIS, or an infection of the mucous glands, URETHRITIS. See your doctor.
4. Do you have a sore or raw area on the penis? Sores may represent a simple YEAST INFECTION, HERPES or other infections, and even CANCER. See your doctor promptly.
5. Do you have a painless sore on the shaft or head of the penis? This mass may be from a GENITAL WART, SYPHILIS, or a form of CANCER. See your doctor promptly.
6. Is the entire tip of the penis tender or swollen? This may be from an INFECTION of the head of the penis, BALANITIS. See your doctor.
7. Do you have blood in your semen or pain with ejaculation? You may have an INFECTION of the prostate gland, PROSTATITIS, or an infection of the seminal vesicle. See your doctor. Heat and mild analgesics can bring comfort, as needed.
8. Do you have pain with sexual intercourse? A number of problems, such as ALLERGY to a contraceptive, ANXIETY, PROSTATITIS, or INFECTION or DRYNESS in the partner can cause pain for the male with sexual intercourse. Talk to your doctor about any pain you experience during sex.
*9. Is the tenderness intense, and has it occurred without any injury to the testicle? Your problem may be a severe form of infection, EPIDIDYMITIS, or a cutting off of the blood to the testicle, TESTICULAR TORSION. EMERGENCY
See your doctor or be seen in the emergency room right away.
10. Do you have mild tenderness around one testicle? Your symptoms may be from a less tender form of EPIDIDYMITIS. See your doctor.
11. Is there a hard, painless knot on one testicle? This type of painless knot could represent TESTICULAR CANCER, or a noncancerous SPERMATOCELE. See your doctor. Learn how to do a testicular self-examination.
12. Is there a soft swelling in the scrotum on one or both sides? A worm-like swelling is usually a VARICOCELE, and a soft, "water balloon" swelling is usually a HYDROCELE. Small CYSTS can occur in the epididymis. If these swellings have not been previously diagnosed, see your doctor for an exam and instructions. These problems are all benign, but could require surgery.
13. Is there a soft swelling above the testicle that gets worse with activity, lifting or coughing? This could be an INGUINAL HERNIA, a loop of the bowel that protrudes into the scrotum. See your doctor. Rarely, these loops can become twisted and need emergency repair. Wearing a truss or hernia belt can sometimes reduce the discomfort.
14. Is there tenderness with bowel movements, or is there pain behind the penis and scrotum? This may represent an INFECTION of the prostate gland, PROSTATITIS, or possibly a more serious problem. See your doctor.
For more information, please consult your doctor. If you think the problem is serious, call right away.
The Basic Facts
Men with Peyronies disease generally seek medical attention for pain or bending of the penis during erection, which results from inflammation and scarring in a particular part of the male anatomy known as the tunica albuginea.
This condition is most commonly acquired at about age 55. A man can be born with curvature of the penis, though this is not Peyronies disease.
Severity varies - only a minority of the men afflicted with this problem are unable to engage sexually. Through an effect on the erection mechanism it can reduce rigidity (hardness), but it rarely causes impotence.
It is somewhat uncommon, affecting somewhere between one and three men in a hundred.
In addition to producing curvature, Peyronies disease may change the shape of the erection in other ways: indentation, diameter reduction, or loss of length.
Peyronies disease can have a strong psychological impact. Some cases are mild, healing without treatment within a year of onset. Most cases produce at least some degree of persistant curvature. A noticeable lump, or plaque within the penis is commonly detected. Contrary to prevalent anxieties, it is noncancerous, and unrelated to cholesterol – containing arterial plaque.
Peyronies disease can run in families, though most cases do not appear to be hereditary.
This condition is not associated with serious internal disorders. 10 –20% of men develop scarring of either the hands (Dupuytren’s contractures) or of the feet.
The goal of therapy is to maintain sexual function. In some cases, education about the disease and reassurance is all that is required. Rarely, when long-term deformity prevents intercourse, surgery is recommended.
Can Peyronie’s disease cause impotence?
Impotence, defined as the inability to maintain a hard enough erection to have intercourse, is uncommon in Peyronie’s disease. Yet it frequently affects the erection mechanism in a less serious way. Scientific studies have shown that at some point in time, up to 40% of men with Peyronie’s disease have experienced some degree of erectile dysfunction. Usually, this consists of a reduction in maximum hardness. It is usually a temporary effect, and rarely causes enough softening to preclude normal intercourse. When associated with severe bending however, it can be a problem. Persistant difficulty with erectile rigidity can usually be treated medically
The cause for the erectile dysfunction of Peyronie’s disease is "venous leakage." In other words, the blood that should normally be trapped within the taut confines of the tunica albuginea is leaking slowly out. By locally hardening the tunica, plaques may prevent the exit veins from pinching off in the normal fashion.
Damaging effects of mechanical stress
When fully expanded, the rigid corpora cavernosa forms something like an inflatable I beam. Mechanical forces on this structure will create a unique region of tissue stress at the top of the "I". The majority of the tunica albuginea compresses with stretch during erection, but the topmost strip is subject to an opposite, delaminating force.
Fibrin deposition, the first step in the wound healing process and the precursor to Peyronie’s plaque, usually develops in this area. The mid- topof the penis is the area most commonly involved by Peyronie’s disease.
If Peyronie’s plaque forms in the hoop (circumfrential) direction, it causes indentation or segmental loss of penile diameter. These so-called hourglass areas have a profound effect on over all penile rigidity. The resistance to bending of an inflatable tube is related to its cross sectional area. Because of this, indented areas make the erect penis easier to bend, even at high internal fluid pressures.
Peyronie's Disease - Background and Description
Peyronie's Disease was first described in 1743 by a French surgeon, Francois de la Peyronie and was written about as early as 1687. The disease is oftentimes associated with impotence.
The most common symptom of Peyronie's Disease is a curvature, lump or hard area observed in the penis. Painful erections and penile pain are also symptoms of this condition. . The lumps or hard areas, also referred to as plaque or scar tissue form between the tunica and the outer layers of skin. The plaque or scarring also reduces the elasticity to the affected area, it will not stretch as the surrounding, unaffected tissues. The erect penis bends in the direction of the scar or plaque formation as a result of this, often with associated pain.
Recent studies in Europe report three percent of men have Peyronie's Disease. Statistics gathered show the average age of the patient to be 55, although patients as young as 16 and as old as 83 have been treated. About 30 percent of the patients with Peyronie's Disease also develop fibrosis in other tissues of the body, such as the hands and feet. This group of patients with involvement in more than one body part may have been born with a genetic predisposition to the disease. This genetic predisposition can occur in women as well.
Many physicians believe that the plaque associated with Peyronie's Disease develops as a result of trauma to the penis that causes localized bleeding inside the penis. Repeated trauma to the damaged area may prevent normal healing, or very slowl healing. As the plaque that forms hardens, it becomes fibrotic and sometimes allows for calcium deposits.
Common dermatoses of the male genitalia
Recognition of differences in genital rashes and lesions is essential and attainable - Barry D. Goldman, MD
VOL 108 / NO 4 / SEPTEMBER 15, 2000 / POSTGRADUATE MEDICINE
CME learning objectives
1. To recognize the appearance of common dermatoses of the male genitalia
2. To distinguish which dermatoses are accompanied by lesions elsewhere on the body
3. To identify topical treatment of common dermatoses of the male genitalia
4. The author discloses no financial interests in this article.
Preview: Dermatoses of the male genitalia can be confusing to identify and difficult to diagnose and treat. Rashes and lesions that occur on other areas of the body can be hard to recognize when they appear on the genitalia. In this article, Dr Goldman reviews the common dermatoses, presents defining characteristics, and suggests treatment options.
Goldman BD. Common dermatoses of the male genitalia: recognition of differences in genital rashes and lesions is essential and attainable. Postgrad Med 2000;108(4):89-96
Male genital dermatology encompasses a wide variety of lesions and skin rashes. Some of these occur only on the genitalia, while others are typically found elsewhere on the body and may take on an atypical appearance on the genitalia. One reason for these different characteristics is that genitalia are covered by thin skin that is usually moist, so the dry scaliness associated with skin rashes on other parts of the body may not be present. In addition, genital skin may be more sensitive and reactive to cleansers and medications than skin elsewhere--a fact that emphasizes the need for thorough history taking.
After noticing skin changes of the genitalia, many patients express anxiety that they may have a sexually transmitted disease (STD). The clinician's challenge is to determine whether a genital skin eruption is a dermatologic problem limited to the genitalia or whether it is part of a widespread skin eruption that requires a comprehensive skin exam.
Psoriasis
Psoriasis is the most common inflammatory reaction that affects the male genitalia. It may appear in two forms: inverse psoriasis and penile psoriasis.
Patients may develop bright red, well-defined inguinal plaques known as inverse psoriasis. The psoriatic scale so apparent on other parts of the body is not seen here, nor is central clearing, which is often experienced in tinea. The plaque appears homogeneously erythematous. Occasionally, the entire scrotum, inguinal folds, and penis are involved, and similar lesions may affect the axilla or popliteal fossa. Unlike psoriasis elsewhere on the body, inverse psoriasis may be itchy. Often, patients have no history of psoriasis.
The disorder may also affect the penis, particularly the glans penis. Thin, pale erythematous plaques with slight scale are seen in discrete or continuous forms (figure 1: not shown). Penile psoriasis may be aggravated by trauma. As with psoriasis elsewhere, its plaques tend to be well defined. However, no vesicles or erosions are seen, and no itching or burning is present. In many patients, psoriatic lesions are limited to the genitalia and are not found on the rest of the body.
Both types of psoriasis respond well to low-potency corticosteroid creams. (Topical mid- and high-potency corticosteroids should not be used, to avoid atrophy of the surrounding skin.) It can be beneficial to compound hydrocortisone 2.5% cream and ketoconazole (Nizoral) cream, a response that leads many clinicians to believe that Candida infection helps precipitate psoriasis in susceptible individuals. Calcipotriene (Dovonex) cream, a vitamin D derivative used for psoriasis on other parts of the body, can be a nonsteroidal alternative treatment for psoriasis on the glans penis. A persistent penile plaque that does not respond to therapy should be reevaluated periodically to rule out squamous cell carcinoma in situ.
Dermatitis
Contact dermatitis of the genitalia can be divided into irritant and allergic forms. Theoretically, all persons are susceptible to irritant contact dermatitis. It may develop from chronic use of certain soaps, disinfectants, or antiseptic solutions. The latter often are used on the genitalia in an attempt to prevent STDs. Irritants such as fluorouracil (Efudex, Fluoroplex) cream used for actinic keratoses on the face may be inadvertently transferred from the hands to the genitalia. Patients typically complain of itching on the distal shaft of the penis. Clinically, they have ill-defined erythematous, scaly patches.
Patients with a history of atopic dermatitis are predisposed to develop irritant contact dermatitis of the scrotum. They generally present with erythema and mild lichenification. Direct contact with imiquimod (Aldara) cream used for genital warts on the penile shaft, for example, can cause erythema and erosion on the scrotum. Discontinuing the offending medication and treating with a low-potency corticosteroid cream for 5 to 7 days are all that is needed.
Allergic contact dermatitis is also common. The penis may become immensely swollen and have accompanying erythema and scaling (figure 2: not shown). Marked edema can occur because the skin covering the genitalia is thin and elastic.
The list of possible offending agents is long and includes many medications that can be transferred from other parts of the body to the genital area. Benzocaine cream, triple antibiotic ointment, and diphenhydramine hydrochloride (eg, Benadryl) cream are frequent offenders. Poison ivy and other rhus dermatitides also are commonly transferred by the hands to the genitalia.
Obtaining a history of topical products used by the patient is very important, because many products may be applied by patients who are concerned about hygiene or STDs. Men with latex allergy can experience erythema and scale along the entire penis because of latex condom use. Switching to a nonlatex condom is an option that can help control and prevent this allergic reaction.
Cases of severe contact dermatitis may require treatment with systemic corticosteroids as well as cool tap-water compresses. Mild cases can be treated with low-potency corticosteroid creams.
Dermatitis often becomes chronic, developing into lichen simplex chronicus, which is characterized by extensive lichenification and hypertrophy of the affected skin. The scrotum is particularly prone to lichen simplex chronicus. Patients complain of intense, unrelieved itching that is often related to heat and sweat. They typically present with lichenified erythematous plaques on the lateral or entire scrotum. Darker-skinned patients often exhibit hyperpigmented eruptions rather than erythematous ones, which may lead the clinician to underestimate the degree of inflammation.
In severe cases, low-potency topical corticosteroids prescribed for a maximum of 2 weeks can be helpful. Zinc oxide ointment is very soothing and helps absorb sweat. For particularly inflammatory eruptions, hydrocortisone 2.5% cream can be added to zinc oxide ointment. In most cases of chronic dermatitis, however, topical medications are soothing for only a few hours. Oral antihistamines may provide relief from scratching during sleep, primarily because of their sedative effect.
Feeling that cleanliness will aid the dermatitis problem, patients often wash the area vigorously with soap. Getting patients to avoid excessive washing is very important to long-term resolution, because soaps act as irritants on genital skin. (Water is adequate for cleansing.) In addition, breaking the itch-scratch-itch cycle is crucial, because lichenification results from prolonged scratching and rubbing.
Fixed drug eruptions
Patients with fixed drug eruptions of the genitalia usually present with a sudden onset of single or multiple well-defined circular plaques on the glans penis and distal shaft of the penis (figure 3: not shown). The eruption may be bullous, and its surface can become necrotic and painful--a sensation that has been compared to the pain of being branded with a hot iron.
Eruptions commonly are caused by medications, such as tetracyclines or laxatives containing phenolphthalein. In fact, more than 500 medications have been implicated. Some patients have been falsely labeled as having herpes simplex because of the intermittent nature of fixed drug eruptions. A careful drug history needs to be taken and should include medications used intermittently, such as antibiotics for chronic prostatitis and pain relievers (eg, acetaminophen). Multiple recurrences may result in postinflammatory hyperpigmentation.
Lichen planus and lichen nitidus
Lichen planus is an inflammatory disorder characterized by violaceous, flat-topped papules measuring 2 to 10 mm that may appear on any part of the body. Although the etiology is unknown, drugs and such infections as hepatitis C have been identified as precipitants.
Typically, the glans penis is involved as part of a systemic process. The surface of the lesions usually appears shiny, and no vesicles or crust is seen. However, annular lesions are sometimes covered with white scale known as Wickham's striae.
Diagnosis of lichen planus can be aided by an oral exam that reveals white streaks on buccal mucosa. Lesions are also commonly found on the wrists and ankles. Biopsy can help confirm the diagnosis.
Lichen nitidus is a similar inflammatory disorder of unknown etiology. Patients may present with monomorphic, flesh-colored papules measuring 1 to 2 mm along the shaft of penis (figure 5: not shown). Similar lesions may be present on the elbows and knees and around the umbilicus. The condition is often confused with condyloma and molluscum contagiosum. However, unlike molluscum, lichen nitidus does not involve umbilication, and lesions have a smooth surface.
Both lichen planus and lichen nitidus respond well to low-potency corticosteroid creams. These conditions tend to resolve spontaneously over 1 to 2 years.
Lichen sclerosus
Lichen sclerosus is a progressive sclerosing dermatosis of unknown origin. Typically, it causes atrophic white plaques on the glans or prepuce (figure 6: not shown). The eruption tends to fissure, and adhesion may develop. Skin biopsy is necessary to make the diagnosis. Lichen sclerosus of the glans penis (balanitis xerotica obliterans) may result in phimosis, which necessitates circumcision.
In the past, testosterone creams were used for treatment. However, clinical studies have not validated their use. Recently, application of high-potency topical corticosteroids (eg, clobetasol propionate [Cormax, Embeline E, Temovate]) for short periods has resulted in complete remission. The development of squamous cell carcinoma has occasionally been reported. These patients need to be under the care of an expert in genital dermatology.
Vitiligo
Vitiligo can appear similar to lichen sclerosus: The patient presents with hypopigmented or depigmented areas on the genitalia (figure 7: not shown). However, unlike lichen sclerosus, no atrophy is present. The glans penis and shaft are commonly affected, but there are no symptoms. Diagnosis can be aided by the presence of depigmented areas elsewhere on the body, especially on the face and the dorsum of the hands. The appearance is chiefly a cosmetic concern, and reassurance is usually all that is needed. Treatment with low-potency corticosteroids is helpful in some cases.
Conclusion
Genital dermatology is a varied field characterized by a multiplicity of lesions and eruptions. Proper history taking is important, because many eruptions may acquire an atypical appearance due to the patient's prior use of medication. Moistness, heat, and sweat combine to aggravate common dermatoses that involve the genital area. When in doubt, physicians should consider a biopsy for a persistent eruption, which can confirm or dispel a diagnosis.
Blue Balls
What are blue balls?
Blue Balls is a real condition! The "correct" term for blue balls is epididymitis, which is an inflammation of the epididymis.
In simple terms blue balls occurs when the epididymis get blocked up with sperm that have left the testis but not the penis. The vas deferns are the conduit for the sperm from the testis to the urethra. When they get blocked you get pain. Why blue balls and not "swollen balls," well maybe the connotation is that you balls have the "blues", or maybe its because with all that swelling some of the blood flow is restricted enough to cause some blueing of the area because of pooling blood.
Genital Problems in Men
SYMPTOMS DIAGNOSIS SELF-CARE
1. Do you have any swelling or tenderness in the scrotum? Go to Question 9.*
2. Do you have a discharge, either yellowish or greenish, from the tip of the penis? Your symptoms may represent a SEXUALLY TRANSMITTED DISEASE or an infection of the mucous glands, URETHRITIS. See your doctor promptly.
3. Do you have a burning sensation or pain with urination? These may be symptoms of a bladder infection, CYSTITIS, or an infection of the mucous glands, URETHRITIS. See your doctor.
4. Do you have a sore or raw area on the penis? Sores may represent a simple YEAST INFECTION, HERPES or other infections, and even CANCER. See your doctor promptly.
5. Do you have a painless sore on the shaft or head of the penis? This mass may be from a GENITAL WART, SYPHILIS, or a form of CANCER. See your doctor promptly.
6. Is the entire tip of the penis tender or swollen? This may be from an INFECTION of the head of the penis, BALANITIS. See your doctor.
7. Do you have blood in your semen or pain with ejaculation? You may have an INFECTION of the prostate gland, PROSTATITIS, or an infection of the seminal vesicle. See your doctor. Heat and mild analgesics can bring comfort, as needed.
8. Do you have pain with sexual intercourse? A number of problems, such as ALLERGY to a contraceptive, ANXIETY, PROSTATITIS, or INFECTION or DRYNESS in the partner can cause pain for the male with sexual intercourse. Talk to your doctor about any pain you experience during sex.
*9. Is the tenderness intense, and has it occurred without any injury to the testicle? Your problem may be a severe form of infection, EPIDIDYMITIS, or a cutting off of the blood to the testicle, TESTICULAR TORSION. EMERGENCY
See your doctor or be seen in the emergency room right away.
10. Do you have mild tenderness around one testicle? Your symptoms may be from a less tender form of EPIDIDYMITIS. See your doctor.
11. Is there a hard, painless knot on one testicle? This type of painless knot could represent TESTICULAR CANCER, or a noncancerous SPERMATOCELE. See your doctor. Learn how to do a testicular self-examination.
12. Is there a soft swelling in the scrotum on one or both sides? A worm-like swelling is usually a VARICOCELE, and a soft, "water balloon" swelling is usually a HYDROCELE. Small CYSTS can occur in the epididymis. If these swellings have not been previously diagnosed, see your doctor for an exam and instructions. These problems are all benign, but could require surgery.
13. Is there a soft swelling above the testicle that gets worse with activity, lifting or coughing? This could be an INGUINAL HERNIA, a loop of the bowel that protrudes into the scrotum. See your doctor. Rarely, these loops can become twisted and need emergency repair. Wearing a truss or hernia belt can sometimes reduce the discomfort.
14. Is there tenderness with bowel movements, or is there pain behind the penis and scrotum? This may represent an INFECTION of the prostate gland, PROSTATITIS, or possibly a more serious problem. See your doctor.
For more information, please consult your doctor. If you think the problem is serious, call right away.