NON-VENEREAL LESIONS OF THE GENITO-ANAL AREA
Major. M.P.Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)
Ex. Hon. Sr. Venereologist, St. George’s Hospital, Bombay
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine and Surgery etc .
Volume LXXXVIII, Number-11 of November 1968
This article was solely contributed to Indian Medical Record
When a patient complains of a lesion of the genitor-anal area, a venereologist thinks at once of the possibility of a venereal disease, and tries to confirm or exclude it. Such a high index of suspicion is commendable; but not so praiseworthy is the procedure that is often followed by the generalist. He is often inclined to jump to the conclusion that it is either due or not due to venereal disease and that too without a careful physical examination, close interrogation, and laboratory aids and institutes treatment. Such a practice is beset with grave dangers and amounts to professional negligence. There are the great varieties of non-venereal or venereal lesions which occur in the genitor-anal region and pose a multitude of diagnostic problems. Hence such a distinction between venereal or non-venereal lesions becomes of great practical importance. So far little attention has been paid to these vast and varied diagnostic problems. Instances where a non-venereal lesion is diagnosed as venereal or vice versa are not lacking. Naturally, a discussion on the subject will help to differentiate the manifestations of the common venereal diseases from the great variety of non-venereal conditions of the genitor-anal region. As this group consists of numerous conditions of diverse origin, it is impossible to describe them in detail for want of space and time. Hence a brief mention of the lesions will be made, leaving aside the venereal diseases and lesions resulting from then and their various manifestations.
There is a large number of cases both of syphilis and gonorrhoea, which are either misdiagnosed or not diagnosed in time. These cases, the number of which is quite large, give rise to serious late complications besides the grave risks of spread of infections in the community. To get better of the serious threat to the public health, posed by the large reservoir of latent syphilis or gonorrhoea, it is essential to adopt mass serologic and careful physical and bacteriological examinations of the population groups to an ever increasing degree. For, this is the only way to liquidate the vast reservoir of venereal infections.
Mycotic or Fungal infections
Numerous fungi are pathogenic to man and the diseases they cause are known as mycosis or dermatomycosis. The genitor-anal region is a site of predilection for various lesions due to great variety of fungi. 1. Superficial or epidermal and mucosal infections and 2. Deep or cutaneous and subcutaneous infection.
Tinea cruris or eczema marginatum – Highly resistant fungus, epidermophyton flocculossum is the cause. It affects the internal surface of the upper parts of the thigh, pubic and gluteal regions. It has a tendency to peripheral expansion and central regression. It has a slightly elevated margin and the lesion is sharply demarcated. Itching is a prominent symptom.
Erythrasma – The causative fungus is microsporan minutissimum or nocardia minutissimum. It gives rise to chronic superficial infection limited to the upper and middle layers of the stratum corneum. It involves the inner and upper surface of the thighs, groins and the anogenital region. There is hardly any itching in the early stages. It begins as pin-head size spots of dark brown or red-brown colour and spreads slowly to form large patches. Eczema may supervene and mask the condition. Conjugal transmission of the infection is common.
Tinea versicolor or pityriasis versicolor – Malassezia furfur is the fungus responsible. It gives rise to yellowish patches (café au lait or islands in a sea) round or discoid, finely scaling, yellowish lesions and larger polycyclic patches. Pruritis is absent. The fungus gives a golden fluorescence under wood’s light.
Tinea circinata – It is due to trichophyton verrucosum. The infection spreads peripherally and heals centrally. A ring with a scaly vesicular border and a central zone of normal or discoloured skin are typical.
Favus or Tinea favosa – The causative fungus, Achorion Scholeinii affects the skin and the mucous membrane. It is contagious. The typical crusts or scutula of favus-yellowish-coloured masses with central depression, mousy odour and threads of mycelium or chains of spores in the specimen are characteristics.
Candidiasis or Moniliasis – Candida (monilia) albicans affects the mucosae and the skin in several ways causing intertriginous dermatitis, vulvo-vaginitis, balanitis and balano-posthitis. Pruritis vulvae may follow vulvo-vaginitis. A shiny flexural erythema with a heaping up of white sodden epidermis at the margin is typical. When the epidermal barrier is broken, cocci and Gram-negative bacilli gain access to the folds modify the picture.
Chromobalstomycosis or Verrucous dermatitis – It gives rise to warty lesions which become encrusted and eventually ulcerate. Lesions on the thighs and buttocks are met with. The scraping of verrucous lesion reveals the typical brown thick-walled round fungal cells.
Rhinosporidiasis – The causative organism, Rhinosporidium seeberi gives rise to chronic infection of the mucous membrane of the nose, penis, vagina and rectum. Local pruritis and mucoid discharge are first noticed. Its lesions may resemble venereal warts of the penis or vulva, vaginal granuloma may simulate condylomata and the rectal involvement may be confused with rectal polyps and piles. The biopsy material shows large number of typical sporangia containing innumerable small spores.
Blastomycosis – Blastomyces dermatitidis may involve the muco-cutaneous area of the anus and the rectum and give rise to verrucous granulomata having raised serpiginous borders. The yeast cells of the fungus and mycelium can be detected in the exudate.
Actinomycosis – dermal or abdominal may give rise to lesions in the vicinity to resemble dermal granuloma or chronic pyogenic infection. Because of the rare possibility of its existence, the condition is often overlooked or unrecognised. Examination of the exudate will show sulphur granules and Gram-positive branching filaments.
Sporotrichosis – It is due to the fungus, Sporotrichum schenckii which gives rise to chronic granuloma or an ulcer and involves draining lymphatics. The culture, biopsy and the pus are valuable in the diagnosis.
Coccidioidomycosis – It is due to a diphasic fungus, Coccidioides immitis which grows as mycelium or as rounded cells. Dermal or subcutaneous granuloma later giving rise to cold abscesses are common.
Histoplasmosis – It is due to the fungus, Histoplama capsulatum a diphasic organism which grows as mycelium or as yeasts. It gives rise granuloma and mucocutaneous ulcerations.
Non-venereal diseases due to filterable viruses
Common venereal warts or condyloma acuminatum – Its conjugal transmissibility is well known. Very often the earliest stages of warts are confused with the congenital anomalies of the glans penis such as the papillae corona glandis or papillae glans penis.
Molluscum contagiosum – Its contagious nature is established. Its appearance is characteristic. Discrete waxy papules with cornified centre, which may be umbilicated or projected as a plug. On squeezing it firmly waxy-looking or cheesy material is expressed containing ‘molluscum corpuscles’.
Herpetic eruptions – Herpes simplex, Herpes zoster, herpes genitalis and herpes menstrualis are met with in the area.
Vaccinia or accidental vaccinatum of the genitalia and eczema vaccinatum of the scrotum and the penis.
Small-pox or variola, Chicken-pox or varicella , may give rise to eruptions on the area.
Primary lesion of lymphogranuloma venerium
Behcet’s triple syndrome – A complex of oral, genital and occular lesion.
Pyogenic lesions of the genito-anal region
Impetigo contagiosa – It is due to a coccal infection of the epidermis, sometimes involving the ostia of the pilosa-baceous follicles (follicular impetigo) or of the sweat ducts (infected miliaria rubra, Bockhart’s impetigo).
Pyoderma – It is common complication of the parasitic infestations of the skin such as scabies or pediculosis pubis.
Ecthyma – The coccal infection, originating from the surface and affecting the dermis, leading to necrosis, ulceration and scarring. Undernourished people are prone to the lesions.
Follicullitis – either due to coccogenic or Mycotic infection. Discrete follicular papules and pustules are present. Numerous hair follicles in the area are present. A superficial pustule is pierced by a hair.
Furunculosis or boils – It is a staphylococcal infection of a sebaceous gland, forms a perifollicular abscess with sloughing. Scar tissue replaces the hair papilla and the pilosebaceous follicle.
Carbuncle – With this, greater constitutional disturbances are noted.
Erysipelas or St.Anthony’s fire – It is due to streptococcal infection, gives rise to fever, rigor, local inflammation with redness, has a distinctly raised margin, and spreads peripherally. Vesicles or bullae filled with clear fluid at the spreading margin. It gives rise to excessive oedema and swelling of the prepuce, scrotum and labia.
Pyogenic granuloma – It develops usually in connection with staphylococcal infection of preceding traumatic lesion. It may present a pedunculus or mushroom-like tumor. Histological examination of the tissue is of great value. It does not heal with ordinary remedies. Excision or scraping will initiate healing.
Hidro-adenitis suppurativa – It is a pyogenic infection of the apocrine glands of the skin. Ano-genital area is a frequent site for lesions of this type. Frequent recurrences, scar tissue formation, linear bands of fibrous tissue, and sinus tracts may be seen in old and chronic lesions.
Animal Parasite Infestations of the Genital Area
Scabies – An intensely itchy disease of the skin due to Sarcopts scabiei. It has special sites of election, the typical burrow and the clinical picture. Its transmission may be familial or venereal.
Phthiriasis or Pediculosis Pubis – In this disease, itching is confined almost entirely to the hairy region of the genitalia. The glans penis is not affected as in scabies. Sexual relation is the most frequent method of transmission of the parasite. Inspection reveals the casual parasite and the ova attached to the hair.
Insect bite or sting – Ants or gnats – It gives rise to swelling, oedema and redness.
Cutaneous Tuberculosis in the area
Tubercular ulcer either acute or chronic
Lupus vulgaris – Vulva, scrotum and the penis may be affected. Nodules present the characteristic “apple jelly” appearance; scarring and contractures, elephantiasis, chronic and indolent course, young age.
Lupus verrucosus – The buttocks are the common site. It gives rise to violaceous warty excrescences with reddish surroundings.
Tuberculosis colliquativa (Scrotulodermia) – It is Tuberculosis of the skin secondary to the tuberculosis of the underlying lymph nodes. They may simulate lymphogranuloma venereum.
Papulo-necrotic tuberculides – Involvement of the glans penis is not uncommon. Depresses or pitted scars with a zone of pigmentation in adolescents or young adults are suggestive.
Tuberculosis cutis orificalis – It is a painful tuberculous ulceration in the perianal region in persons with intestinal tuberculosis. Sometime, genitalia may be affected as the result of urinary tract tuberculosis.
Neurodermatitis of the Genito-anal Region
Localised Neurodermatitis or Lichen Simplex Chronicus – This is a very itchy condition occurring in persons over 40 years in age. Localised patches of thickened skin, adherent scales, leathery texture, chronicity etc are predominant features. Sacral region and thighs are common sites.
Disseminated Neurodermatitis or Atopic dermatitis – In this condition, the eruption is widely spread and usually symmetrical. The skin becomes pigmented, thickened and lichenified.
Pruritus Ani – It is a symptom of diverse conditions. Proctitis with irritating discharge, diabetes, drug intolerance, lack of cleanliness, candida albicans, phthiriasis, threadworms, sensitization due to local application, warts, lichen planus, bacterial infection, emotional conditions etc.
Scrotal and perineal pruritis – The conditions which are likely to give rise to this complaint are hyperhidrosis, friction of clothing, sensitization of dyed material, psoriasis, lichen planus, lichen simplex, diet deficiency, or as a local manifestation of general disorder such as leukemia or Hodgkin’s disease, jaundice & gall stone.
Pruritus Vulvae – In this condition, dermatoses of the vulva, the genito-crural region and the medial and upper aspects of thighs may be affected. Vaginal discharge due to various causes, trichomoniasis (T.vaginalis), candidiasis, nutritional deficiencies, drug intolerance, glycosuria, psychological factors, psycho-sexual difficulties, contact sensitization, chemicals or contraceptives, lack of cleanliness, pediculosis pubis, psoriasis, seborrhea, lichen planus, atrophic senile changes, precancerous condition, lichen sclerosis atrophicus etc may be responsible.
Prurigo – A group of intensely itchy conditions with predominant physical signs of lichenification and excoriation. The folds of the genito-crural region, natal cleft etc are favourite sites. The skin may become thickened, fissured, sodden and whitened. Lichenified and excoriated papules are seen.
Secondary Disorders of the region
Hyperhidrosis – Excessive sweating in the ano-genital region often predisposes to dermatitis.
Hypohidrosis – Diminished sweating especially in xerodermia, senility and sclerodermia also lead to dermatitis.
Xerodermia and Ichthyosis – The skin is abnormally dry with diminished secretion of sebum and sweat. This leads to a thickening of the horny layer and the pilosebaceous follicular orifices (keratosis suprafollicularis).
Diseases due to Protozoal Infection
Cutaneous Leishmaniasis due to Leishmania tropica and Mucocutaneous Leishmaniasis due to Leishmania braziliensis – Lesions of the genitalia, the perianal region and the rectum are met with. Granuloma with secondary infection and ulceration may be present. The smears made from the lesion show parasites in the histiocytes and macrophages. Culture is positive.
Amoebiasis due to Entamoeba histolytica – Amoebic ulceration of the genitalia and vulva is at times met with.
Trichomoniasis due to Trichomonas vaginalis may give rise to urethritis, balanitis in the male and vaginitis with offensive and irritating discharge in the female. Vulvitis and intertrigo of the thighs, strawberry cervix are typical.
Diseases due to Metazoa
Schistosomiasis or Bilharziasis due to Schistosomia mansoni gives rise to intestinal lesions and perianal lesions.
Schistosomiasis haematobia or urinary Schistosomiasis due to S.haematobium – gives rise to genito-urinary lesions. In both types, dermatitis is met with.
Diseases due to Nematodes
Filariasis as the result infection with Wuchereria bancrofti. The microfilariae can be detected in the peripheral blood. Lymphangitis, lymphadenitis lymph scrotum, hydrocele, elephantiasis, ulceration, funiculitis, orchitis etc
Dracontiasis or Guinea worm infestation due to Dracunculus medinensis gives rise to erythema, pruritis, ulcer or cord-like mass below the skin.
Enterobiasis due to the infection with Enterobius vermicularis – This gives rise to vulvo-vaginitis, pruritus ani, and urethritis.
Diseases due to Arthropods
Myiasis – When the fly larvae invade tissue or mucous membrane or wounds.
Aphthosis of the Genitalia
Genital Aphthosis – Aphthous erosions of the vulva, vagina and the external urethral meatus is some times noticed.
Disorders of Metabolism
Diabetes Mellitus, Hypocalcaemiaand Hyperparathyroidism – In these conditions, the mucosae is often affected by fungal or bacterial infections.
Deficiency Diseases or nutritional deficiency
Vitamin A deficiency – follicular hyperkeratosis of the skin, urinary tract infection and hyperkeratosis of the hair follicles.
Riboflavin deficiency – Dermatitis of seborrhoeic type affecting the skin around the mouth, scrotum and vulva.
Nicotinamide deficiency – Burning while passing urine, pellagra dermatitis and seborrhoeic skin lesions.
Vitamin C deficiency – Hyperkeratosis of the hair follicles on the buttocks and thighs.
Drug Eruptions in the genital region
Localised and fixed drug eruptions of the genital region taken internally or applied externally – The penis, scrotum and vulva are the sites of predilection for fixed drug eruptions. It may involve mucous membrane of the vulva and the urethra. Antipyrin, phenolphthalein iodine, bromide, sulphanilamides, and antibiotics are known. Involvement of the genital region in anaphylactic reactions to sera is familiar.
Agranulocytosis following sulpha or antibiotic therapy, gives rise to ulcerative or gangrenous lesions of the rectum, vulva etc.
Pigmentary changes in the genital region
Physiological – as darkening of the genitalia in pregnancy
Congenital – The Mongolian spot or a blue black discolouration of the skin in the sacral are, mole.
Physical causes – Light, X-ray irradiation, heat friction, ultra-violet bath, solar irradiation, exposure to tar or creosote can increase pigment.
Certain dermatoses – Lichen planus, dermatitis herpetiformis, erythrodermia and urticaria pigmentosa are often followed by increase pigment.
Toxic preparations – arsenic and bismuth.
Endocrine metabolism or nutritional disorders – Addison’s disease, acromegaly, malaria, malignancy, diabetes, pellagra and acanthosis nigricans.
Albinism due to genetic defect , Vitiligo either primary or secondary – depigmentation of the genitalia is the commonest. It may be due to syphilis, leprosy, scleroderma, eczema, psoriasis, pityriasis versicolor, contact with rubber.
Tattooing – on the genital area, leucoderma penis or the glans penis.
Pigmentated Tumours – Mole, melanomata, basal cell epithelioma, leiomyomata, fibromata, neurofibromata, Darier’s disease, acanthosis nigricans, senile warts.
Intertrigo, toxic erythema, urticaria pigmentosa, erythema multiformi (lesions of the glans penis and the vulva), purpura, lupus erythematosus, drug eruptions.
Psoriasis – It is more often found than usually realised on the glans penis, labia majora and intergluteal cleft. Psoriasis punctata, psoriasis guttata, annularis and gyrate often involve scrotum, penis, genito-crural folds.
Pityriasis rubra pillaris
Lichen planus on the external genitalia and the medial aspects of the thighs.
Lichen sclerosis atrophicus
Lichen spinulosus or keratosis follicularis
Porokeratosis (Mibelli) annular type
Chronic bullous eruptions
Dermatitis herpetiformis involving buttocks, genitalia or vulva
Benign pemphigus of the mucous membrane on the glans penis, or the prepuce causing phimosis in the male and on the vulva or vagina causing narrowing (kraurosis) in the female.
Other Dermatoses involving genito-anal region
Eczematous dermatitis, seborrhoeic dermatitis, Sulzberger–Garbe syndrome, Haily Haily disease, Xanthomatosis, Scleroderma, Fox-Fordyce disease, Leukaemic disease, Pseudolues Papulosa Lipschutz, cutaneous horn, etc. Keratosis pillaris.
Basal cell papilloma – senile or seborrhoeic warts
Squamous cell papilloma – condylomata acuminate
Epidermal cyst – on the scrotum
Sebaceous cyst on the scrotum
Basal cell epithelioma
Squamous cell epithelioma
Bowen’s disease – precancerous condition of the vulva
Queyrat’s erythroplasia – precancerous condition of the glans penis or the vulva. It gives a clear-cut, shiny pink infiltrated elevated patch.
Diseases of the Connective Tissue in the Ano-genital Region
Systemic Lupus Erythematosus
Progressive Systemic Scleroderma
Sjogren’s syndrome – dryness of the mouth, eyes and nose
Affections of the Lymphatics of the ano-genital area
Elephantiasis or Lymphoedema
Malignant lymphoma or Hodgkin’s disease
Primary malignant carcinoma of the lymph gland
Lymphadenitis due to acute infectious diseases such as scarlet fever, infectious mononucleosis.
Filariasis or tropical elephantiasis
Actinomycosis in the groin
Bilharziasis or Schistosomiasis
Prurigo Hebrae giving rise to bilateral bubo
Sarcoidosis or Lymphogranulomatosis benigna in which the testis & the skin may be involved
Lymphoblastoma, Follicular lymphoma
Progressive sclerotic atrophic processes of the penis and vulva
Balanitis xerotica obliteransand Kraurosis glandis et preputii are closely related. A faulty operation for phimosis and chronic inflammation of the glans penis and the prepuce can lead to progressive sclerotic atrophic process. It gives rise to sclerosis, atrophy, adhesions and constrictor of the external urinary meatus.
Lichen sclerosis et atrophicans
Leucoplakia (Leucokeratosis) penis may be preceded by chronic inflammation and calls for vigilance. Biopsy is necessary to exclude malignancy.
Leucoplakia vulvae after the menopause or the removal of ovaries in the young female.
Neoplasms of the External Genitalia
The Non-Venereal ulceration of the genitalia
Apart from ulcerative lesions due to venereal diseases, there are innumerable causes of ulceration of the genito-anal region. Some non-venereal ulcers may closely simulate a venereal ulcer. Pyogenic infections may at times mask an underlying venereal infection. It is quite common for pyogenic infection either to associate with or follow a venereal ulcer. It is therefore of prime importance to have a recourse to laboratory tests at the earliest stages to determine the precise etiology of the lesion. Mechanical, thermal, chemical and physical trauma may give rise to an ulcer in the region.
Coccal infection, cutaneous tuberculosis, infected scabies, pediculosis pubic, herpes, leprosy, fungus infections such as anthrax or Moniliasis, muco-cutaneous Leishmaniasis, cutaneous Amoebiasis, Schistosomiasis, Filariasis, cutaneous diphtheria or pseudo diphtheritic ulcer, Vincent’s ulceration, gangrene or phagedene, Dracontiasis, Enterobiasis, Myiasis, Aphthosis, acute infectious diseases such as small-pox, chicken-pox, typhoid, skin conditions such as erythema multiformi, erythema nodosum, lupus erythematosus, erythema intertrigo, pemphigus dermatitis herpetiformis, eczema lichen planus, psoriasis, lichen nitidus, exfoliative dermatitis, acanthosis nigricans, Darier’s disease or keratosis follicularis, Porokeratosis (Mibelli), elephantiasis, leukaemia, agranulocytosis, epithelioma, ulcus artifecta (self limited), primary lesion of lymphogranuloma venereum, granuloma inguinale, ulcus vulvae acutum (Lipschutz), infected warts or granuloma, etc. All these conditions may lead to ulceration in the region.
Diffuse Irritative Inflammation of the glans penis and the prepuce or the vulva
Non-venereal diseases of the accessory sexual glands
Cowperitis, Bartholinitis, Skeneitis, cervicitis, prostatitis, orchitis epididymitis
Orchitis – traumatic, filarial, acute infectious fever, fungus infection. Torsion of the cord or testis, cryptochism, leprosy tumour or secondaries.
Epididymitis – Tuberculosis, filariasis, retention syndrome, Neoplastic, mumps, secondary metastasis, infection, eosinophilia, etc.
Lesions due to vascular diseases
Thrombosis of the dorsal vein of the penis
Aneurism of the femoral artery simulating a bubo.
Non-venereal diseases of the corpora cavernosa
Traumatic or non-venereal bacterial cavernositis
Malignant neoplasm or secondary deposits
Induratio penis plastica
Fibrosis leading to bending
Non-gonococcal (Non-specific) Urethritis
Urethritis Bacterial – It may be due to B.coli, diphtheroid, staphylococci, streptococci, micrococcus, influenza, L.organism, spirochetes mycoplasma, mimmae, la priturelle, sarcine urethritis etc. It is characterised by an acute onset, short incubation period, less discharge and less complications.
Urethritis Non-gonorrhoeica Chronica – (Waelsch Urethritis) – It is virus induced urethritis. It is characterised by a long incubation period, slight subjective symptoms, marked chronicity, and resistant to usual methods of therapy. Urethroscopy reveal typical infiltration of the urethral mucosa. Inclusion bodies are detected on microscopic examination. Tric agent urethritis Mimea and Mycoplasma urethritis.
Urethritis caused byProtozoa
Urethritis Mycotica – Candida albicans or monilia
Urethritis due to general diseases
Urethritis as a symptom of skin diseases – Local itchy dermatoses may cause reflex urethritis, erythema exudativeem multiforme, pemphigus, lichen planus etc.
Urethritis in association with acute rheumatism , mumps, scarlet fever, exanthemata, typhoid, dysentery or influenza
Urethritis in Reiter’s syndrome
Urethritis in chronic infectious diseases
Urethritis due to Bilharziasis
Urethritis due to intra-urethral chancre or chancroid or secondary syphilitic lesions of the urethral wall.
Urethritis associated with chronic infectious diseases –
Urethritis tuberculosa as the result of tuberculosis of the urinary tract.
Stricture of the urethra
Urethritis as the result of sinuses or fistulae opening in the urethra
Urethritis secondary to urinary tract infection or urinary calculus formation.
Urethritis associated with neoplasma of the urethral wall.
Intra urethral condylomata acuminata.
Urethritis traumatica – Instrumentation, catheterization or foreign body like calculi.
Urethritis Chemical – Use of strong antiseptic, Idiosyncrasy to contraceptives
Urethritis due to sexual or alcoholic excesses
Urethritis artifecta or factitious urethritis artificially induced or produced
Conditions simulating urethritis
Ingestion of certain foods
Accessory canal of the urethra
Stricture congenital or acquired
In children, thread worms and various organisms may produce urethritis and urethral discharges.
The most important points to remember for the correct diagnosis of the lesions in the genito-anal region are: –
If these principles are religiously followed, chances of misdiagnosis or wrong diagnosis will be considerably eliminated.