Genital conditions - an overview

Patient Information Leaflet
Link: Vulval care

https://www.pcds.org.uk/patient-info-leaflets/vulval-care

This chapter signposts to the many and varied skin conditions that can affect the genitalia and is set out as follows:

This chapter is categorised as follows:

• Inflammatory conditions (usually erythematous or pink) 
• White areas of discolouration 
• Ulcers and blisters
• Infection
• Genital oedema 
• Skin lesions 

Inflammatory conditions (usually erythematous or pink) 

• Balanitis - inflammation of the head of the penis, many causes

• Lichen sclerosus - can cause erythema, which can be glistening (previously referred to as Zoon's balanitis)

• Psoriasis - can be itchy. Erythema often well-demarcated, sometimes scaly

• Eczema - both atopic and contact allergic dermatitis. Itch and poorly-defined erythema 

• Lichen simplex - very itchy. Skin often very thickened. Usually localised

• The Red Scrotum syndrome - itching or burning sensation and hyperalgesia. Persistent erythema that always involves the anterior half of the scrotum, and may extend to its posterior part

• Angioedema - very marked swelling lasting 1-3 days

• Recurrent cellulitis can occasionally affect the genitalia, especially the scrotum - fever, erythema, oedema and tenderness 

White areas of discoloration

• Candida - itching and soreness. Erythema, satellite lesions, white patches 

• Vitiligo - asymptomatic. Hypopigmented macules with convex outlines, lesions often fuse together to form larger patches

• Lichen planus - a white lacy network. In men lesions sometimes annular and not always white

• Female lichen sclerosus or male lichen sclerosus - ivory-white, may have telangiectases and purpura. May cause atrophy and structural damage. Lesions occasionally ulcerate, which may suggest malignant transformation 

• Lichen nitidus - most commonly trunk, flexural aspects of upper extremities, dorsal aspects of hands, genitalia. Multiple and grouped lesions - 1-3 mm, flat-topped, shiny, skin-coloured or white papules

Ulcers and blisters

• Aphthous ulcers - women > men. Starts as a painful round yellowish macule with surrounding erythema. Lesions break down into a punched-out ulcer, covered with a loosely attached white, yellow or greyish membrane

• Behcet's syndrome - characterised by recurrent oral aphthous ulcers, genital ulcers, and uveitis

• Erosive lichen planus - mainly women. Labia minora and introitus. Can be very painful. The mucosa is bright red and raw. Scarring and atrophy in severe cases. Rare in men

• Lichen sclerosus - ivory-white, may have telangiectases and purpura. Can cause atrophy and structural damage. Can occasionally ulcerate, which may suggest malignant transformation

• Blistering conditions - several bullous disorders can affect anogenital skin causing painful blisters, erosions or ulcers eg mucous membrane pemphigoid, pemphigus vulgaris, paraneoplastic pemphigus, linear IgA disease

• Adverse cutaneous drug reactions eg fixed drug eruptions, and Nicorandil induced ulcers

• Some infections (see below)

• Malignancy (see below)

Infection

• Candida - itching and soreness. Erythema, satellite lesions, white patches

• Molluscum contagiosum - clusters of 2-5 mm shiny papules with an umbilicated centre

• Scabetic nodules - itchy papules and nodules most commonly seen in the groins and axillae, lesions on the shaft of the penis are pathognomonic. Nodules may persist for several weeks after the scabies has been eradicated

• Pubic lice - live on coarse hair, especially in the pubic and perianal areas. Lice are 'crab'-shaped, grey-brown in colour, 2 mm in length. Eggs are smaller than a pinhead

• Herpes simplex - systemic symptoms may precede the painful ulcers. Women - ulcers can affect external genitalia, vagina and cervix. Men - most commonly seen on the glans, prepuce and shaft of the penis

• Syphilis - a primary chancre is a solitary, small, firm, red, painless papule, which soon develops into an indurated ulcer. Condyloma lata are reddish-brown, moist, flat-topped papules

• Anogenital warts - skin-coloured, red or hyperpigmented. Variable shape - smooth and plaque-like, filiform, cauliflower, fungating, pearly

• Travel acquired / worldwide sexually transmitted infection

Genital oedema 

• Several conditions can result in genital oedema

Skin lesions 

Common benign lesions

• Pearly penile papules - skin-coloured to pink papules, occuring predominantly around the coronal margin of the glans penis

• Fordyce spots - penis, scrotum, labia. Yellow-white spots

• Angiokeratoma - red-purple papules that occasionally bleed

• Benign cysts eg Bartholin's cysts (small mucous-filled cysts that are found on either side of the vaginal opening) 

Melanocytic lesions

• Melanocytic lesions - most genital melanocytic lesions are benign and represent either mucosal melanocytic macules or common acquired melanocytic naevi. In contrast, genital melanoma is rare

Carcinoma in situ / squamous cell carcinoma

• Males
• Erythroplasia of Queyrat - single or multiple, non-tender, red, shiny patches or plaques of the ‘mucosal’ penis ie the glans and prepuce of the uncircumcised
• Bowen's disease of the penis - red or occasionally hyperpigmented scaly patches and plaques of the keratinised penis. Occasionally a warty or crusty appearance
• Bowenoid papulosis - multiple, smooth, brown, wart-like lesions
• Squamous cell carcinoma - a firm enlarging nodule, plaque, fungating lesion, or ulcer

• Females
• Vulval intraepithelial neoplasia (VIN) - is carcinoma in situ of the vulva. An irregular red, white or pigmented plaque
• Squamous cell carcinoma - a firm enlarging nodule, plaque, fungating lesion, or ulcer

Others

• Basal cell carcinoma - can affect any part of the body  

• Extramammary Paget's disease - well-defined, pink-red patch. Can have erosions, crusts and scale  

• Scrotal calcinosis - rare. Multiple benign white-yellow calcified nodules within the scrotal skin