Penile lumps and bumps

Distinguishing characteristics of a genital wart compared to a normal anatomical variant

Wart likely

Normal anatomical variant likely

History

Unvaccinated
Sexual contact with genital warts

Previous quadrivalent-HPV vaccination, especially if given before the commencement of sexual activity

Appearance

• Irregular
• Rough
• Asymmetrical
• Cauliflower or cobblestone appearance
• Evidence of keratinisation
  • whitening of lesion with dilute acetic acid
  • white frond tips

• Regular
• Smooth
• Symmetrical

Dermoscopy

Irregular projections with hairpin, comma-like and irregular vasculature surrounded by a whitish band

• Normal
• Delicate
• Central capillary dilation

Over time

New lesions appear, previous lesions increase in size

No or minimal change

Normal Variants

Pearly penile papules

• Pearly penile papules (PPPs) are tiny lumps seen in neat rows around the corona of the glans penis 
• They can occur as a single row, or in multiple orderly rings encircling the corona. PPPs are numerous, uniform, symmetrical and dome shaped, and vary from 1 to 3 mm in length. 
• PPPs occur in up to 20% of men and are frequently mistaken for warts, but bear no relationship to them.
• In difficult cases dermoscopy can be useful, as PPPs will have delicate, regular vessels that are distinct from genital warts. 
• Histologically, PPPs resemble angiokeratomas.

Fordyce spots

• Fordyce spots are visible sebaceous glands and occur along the shaft of the penis
• They often appear in adolescence. 
• Fordyce spots are more easily visible when the skin is stretched, and many patients may describe them as a lump that appears during an erection. 
• Spots may also appear on the scrotum. 
• Some patients may be able to express a thick, chalky discharge by squeezing the lump. 
• Fordyce spots may also appear in other areas such as at the vermillion border of the lips when, if seen, can help reassure the patient that they are a normal anatomical variant that does not require any treatment.

Tyson glands

• Tyson glands are ectopic sebaceous glands that appear in pairs as openings on either side of the frenulum 
• As they are normal structures, treatment is not required

Angiokeratomas

• Angiokeratomas can occur alone or in multiples and appear as deep-red or purple papules, usually over the scrotum. 
• They can also appear on the penis
• Angiokeratomas advance with age and represent a collection of enlarged capillaries.
• Treatment is only required if they bleed frequently.

Lymphocoeles 

• Lymphocoeles present as a palpable cord-like structure that can occur vertically or horizontally at the shaft of the penis
• They are associated with friction and increased sexual activity. 
• Lymphocoeles are probably due to sclerosing lymphangitis, an inflammatory process caused by a thrombosed vessel.7 Sclerosing lymphangitis can also occur in the presence of some sexually transmissible infections (STIs) such as Neisseria gonorrhoea or syphilis, and appropriate STI screening may be necessary. 
• The thrombosed vessel will usually spontaneously recanalise and therefore the condition itself requires no treatment.

Skin tags

• Also known as acrochordons, skin tags are common in the skin creases of the groin in middle aged men. 
• They typically have the size and shape of a grain of rice. 
• They are often also present in the axillae and on the lateral skin of the neck. Skin tags have a fibrovascular centre and normal overlying epidermis.
• Penile lumps that may require treatment

Penile lumps that may require treatment Warts

Warts

• Penile warts(Condylomata acuminata) are irregular, rough lesions that can occur anywhere along the penile shaft, glans and prepuce
• A smooth-looking wart may be difficult to distinguish from an acrochordon (skin tag) or other normal structure, but using a bright light and magnification will reveal fine dots or a cobblestone pattern. 
• Warts are most commonly due to strains 6 and 11 of HPV.
• There are a number of options for treatment including cryotherapy, podophyllotoxin and imiquimod. 
• All of these therapeutic options typically require multiple treatments over a number of weeks. 
• As the natural history of HPV in immunocompetent hosts is spontaneous recovery over 12–24 months, patients may also opt to have no treatment

Molluscum contagiosum

• Molluscum contagiosum appear as small papules with a central depression or umbilication. 
• They are caused by a member of the poxvirus family, molluscum contagiosum virus (MCV). 
• Molluscum contagiosum are commonly acquired by children from non-sexual skin contact, often during bathing or swimming with other infected children. 
• In adults however, sexually transmitted molluscum may be seen on or near the genitals
• The virus has a self limiting course over a period of months, but treatment with cryotherapy is often recommended to prevent the spread of MCV to others

Folliculitis

• Folliculitis is an inflammation of the hair follicles, frequently seen at the base of the penis
• Folliculitis presents as a pustule around the hair follicle, which is frequently itchy and sometimes painful. 
• Patients are often concerned that genital herpes simplex virus (HSV) is the cause, but the association with a hair follicle and the quality of the pain helps distinguish folliculitis from HSV. 
• If a lesion is aspirated, thick purulent material (which may be blood stained), is often seen, whereas, vesicles due to HSV express a clear or straw coloured fluid. 
• Herpes simplex virus may also be associated with a prodrome of malaise, fatigue and paraesthesia of the affected area. 
• Molluscum contagiosum lesions is another casue occasionally confused with folliculitis, but there is sometimes a red halo. 
• Folliculitis is often successfully managed with topical treatments and genital hygiene measures, but may need appropriate antimicrobial therapy if there is a surrounding cellulitis or a large number of lesions.

Primary syphilis

• An early syphilis chancre may present as a non-ulcerated, button shaped lump on the penile skin. Chancres are often indurated and there is usually some sign of epidermal breakdown or inguinal lymphadenopathy. 
• Syphilis serology may be negative for the first few days of a chancre and should be repeated 2–4 weeks later if syphilis is suspected. 
• In very early syphilis, treponemal polymerase chain reaction (PCR), using a dry cotton swab vigorously rubbed on the lesion at the time of the initial consultation, may be more likely to yield a positive result. 

Scabies

• Genital scabies presents as intensely itchy, pink nodules 
• Patients usually have some sign of scabies elsewhere, such as the wrists, fingers and lower abdominal skin, which may include typical linear burrows

Subcutaneous lumps

• Lumps beneath the skin are uncommon on the penis and are more likely to represent pathology. 
• An important diagnosis to consider is Peyronie disease, which can present as a plaque attached to the tunica albuginea, usually in the proximal half of the penis. 
• The skin moves freely over this, and patients may have noticed curvature of the erect penis. 
• In some cultures there is a practice of inserting steel, plastic or glass beads under the penile skin. 
• A small lump near the hair bearing skin of the proximal penis may represent a healed furuncle.