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Monday, August 18, 2025

Penis lumps and spots


Introduction

The appearance of lumps, bumps, or spots on the penis is a common reason for medical consultation. These lesions can range from harmless physiological variants to sexually transmitted infections (STIs) and malignancies.

Because of the sensitive location, patients often experience significant anxiety. While many cases are benign (e.g., pearly penile papules, sebaceous cysts, Fordyce spots), it is important to differentiate these from infections such as genital warts, herpes, syphilis, or more serious conditions like penile cancer.

Normal Variants (Benign Conditions Often Mistaken for Disease)

  1. Pearly Penile Papules

    • Small, dome-shaped papules around the corona of the glans.

    • Symmetrical, non-painful, non-infectious.

    • No treatment required; reassurance is sufficient.

  2. Fordyce Spots

    • Ectopic sebaceous glands, presenting as small, pale or yellow spots.

    • Harmless, common in adults.

    • No treatment required.

  3. Sebaceous Cysts / Epidermoid Cysts

    • Blockage of sebaceous gland ducts causes cysts under the skin.

    • Painless, mobile lumps; may become infected.

    • Management: incision and drainage if infected, surgical excision if persistent.

  4. Angiokeratomas

    • Small, dark red-purple papules due to dilated blood vessels.

    • Benign but may bleed.

    • Treated by laser or electrocautery if symptomatic.

Infectious Causes of Lumps and Spots

1. Genital Warts (Condyloma Acuminata)

  • Cause: Human papillomavirus (HPV), most commonly types 6 and 11.

  • Appearance: Soft, flesh-colored or cauliflower-like growths on glans, shaft, or foreskin.

  • Symptoms: Usually painless, but can cause itching, discomfort, or bleeding.

  • Treatment:

    • Podophyllotoxin solution 0.5%: applied by patient twice daily for 3 days, then 4 days off; repeat up to 4 cycles.

    • Imiquimod 5% cream: applied 3 times per week at night, washed off after 6–10 hours; continue up to 16 weeks.

    • Trichloroacetic acid 80–90%: applied by clinician weekly until resolved.

    • Cryotherapy or surgical removal if resistant.

2. Genital Herpes (HSV-1, HSV-2)

  • Appearance: Clusters of painful vesicles or ulcers on glans, shaft, or foreskin.

  • Associated symptoms: Burning, tingling, fever, lymphadenopathy.

  • Treatment:

    • Acyclovir: 400 mg orally three times daily for 7–10 days (first episode).

    • For recurrences: acyclovir 400 mg orally three times daily for 5 days, or valacyclovir 500 mg twice daily for 3 days.

    • Suppressive therapy: acyclovir 400 mg twice daily long-term for frequent recurrences.

3. Syphilis (Treponema pallidum)

  • Primary stage: painless, firm ulcer (chancre) on penis.

  • Secondary stage: mucocutaneous rashes, condylomata lata.

  • Diagnosis: serology (VDRL, RPR, treponemal tests).

  • Treatment:

    • Benzathine benzylpenicillin: 2.4 million units intramuscularly as a single dose (early syphilis).

    • Late latent syphilis: same dose weekly for 3 weeks.

4. Molluscum Contagiosum

  • Cause: Poxvirus infection.

  • Appearance: Small, umbilicated, dome-shaped pearly nodules.

  • Treatment:

    • Usually self-limiting within 6–12 months.

    • Options: cryotherapy, curettage, podophyllotoxin cream.

5. Balanitis / Balanoposthitis

  • Appearance: Red, inflamed glans with possible pustules or spots.

  • Causes: Candida albicans, bacterial infections, poor hygiene, irritants.

  • Treatment:

    • Topical clotrimazole 1% cream: applied twice daily for 1–2 weeks (candida).

    • Oral fluconazole: 150 mg single dose for recurrent candida.

    • Topical mupirocin 2% cream for bacterial causes.

Non-Infectious Pathological Causes

1. Penile Cancer (Squamous Cell Carcinoma)

  • Appearance: Non-healing ulcer, lump, or wart-like growth on glans or foreskin.

  • Risk factors: HPV, poor hygiene, phimosis, smoking.

  • Diagnosis: Biopsy essential.

  • Management: Surgery (circumcision, partial/total penectomy), radiotherapy, chemotherapy.

2. Lichen Sclerosus (Balanitis Xerotica Obliterans)

  • Appearance: White patches, atrophic skin, scarring, possible meatal stenosis.

  • Treatment:

    • Topical clobetasol propionate 0.05% cream: applied once daily for 1–3 months.

    • Circumcision if severe or recurrent.

3. Psoriasis

  • Appearance: Red patches with silvery scales, may occur on glans.

  • Treatment:

    • Topical corticosteroids (hydrocortisone 1% cream) applied once or twice daily.

    • Calcineurin inhibitors (tacrolimus 0.1% ointment) for sensitive areas.

Diagnostic Approach

  1. History

  • Onset, duration, pain/itching.

  • Sexual history, condom use, multiple partners.

  • Past STIs.

  • Hygiene, circumcision status.

  1. Examination

  • Location, number, and type of lesions.

  • Lymph node examination.

  • Associated systemic symptoms.

  1. Investigations

  • STI screening: syphilis serology, HIV, HSV PCR.

  • Swabs for bacterial/fungal culture.

  • Biopsy if persistent or suspicious of malignancy.

  • Urinalysis if urethral involvement.

Treatment Summary (Generic Names and Doses)

  • Podophyllotoxin 0.5% solution: apply twice daily × 3 days, 4 days off, up to 4 cycles.

  • Imiquimod 5% cream: apply 3 nights/week × up to 16 weeks.

  • Acyclovir: 400 mg orally TDS × 7–10 days (first episode).

  • Valacyclovir: 500 mg orally BD × 3–5 days (recurrence).

  • Benzathine benzylpenicillin: 2.4 million units IM once (early syphilis).

  • Clotrimazole 1% cream: apply twice daily × 1–2 weeks.

  • Fluconazole: 150 mg orally single dose (candida).

  • Mupirocin 2% cream: apply 2–3 times/day × 5–7 days (bacterial balanitis).

  • Clobetasol propionate 0.05% cream: once daily × up to 3 months (lichen sclerosus).

  • Hydrocortisone 1% cream: once or twice daily (psoriasis/dermatitis).

  • Tacrolimus 0.1% ointment: once or twice daily (psoriasis/eczema, non-steroidal option).

Complications

  • Anxiety and distress: fear of cancer or STIs.

  • Sexual dysfunction: due to pain, embarrassment, or psychological stress.

  • Scarring and phimosis: in lichen sclerosus or recurrent balanitis.

  • Cancer progression: untreated HPV or chronic inflammatory conditions.

  • Transmission of infections: herpes, HPV, syphilis, molluscum.

Prognosis

  • Benign variants: excellent prognosis, reassurance sufficient.

  • Infectious causes: usually treatable, but herpes and HPV may recur.

  • Malignancy: prognosis depends on early detection and treatment stage.

  • Chronic inflammatory conditions: may require long-term monitoring.

Preventive Measures

  • Safe sexual practices (condoms, limiting partners).

  • HPV vaccination (e.g., Gardasil 9 protects against HPV 6, 11, 16, 18).

  • Good genital hygiene.

  • Early medical evaluation for any persistent penile lesion.

  • Regular self-examination.




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