A 76-year-old male presents with a three to four week history of a painless penile ulceration on his foreskin. There is no associated, palpable groin lymphadenopathy. The patient has a history of prostate cancer, and he has not been sexually active over the last six months.
a. Keratoacanthoma
b. Primary syphilis
c. Penile cancer
d. Penile ulcer (infections)
A penile ulcer is an open sore on the scrotum, shaft, or glans of the penis. Occasionally, an ulcer can also occur on the urethra. Penile ulcers can present as a singular occurrence or as a rash of several ulcers at once. The sores are typically accompanied by redness, itching, and inflammation. The presence of a penile ulcer can result in burning or pain during urination.
Treatment is dependent on the etiology of the ulcer. The cause of penile ulcers is often bacteria or viruses that are linked to sexually transmitted diseases, such as chancroid, syphilis, mononucleosis, or herpes. Those with HIV may notice that the HIV exacerbates other viruses in the body, such as herpes. When this happens, constant ulcers may result for long periods of time. A single, round, and painless ulcer of the penis or scrotum may indicate primary syphilis. The ulcer of primary syphilis typically self-resolves a few weeks after it appears. However, the disease persists in the bloodstream and may be passed on to a sexual partner.
A painless, irregular, nonhealing genital ulcer might be penile cancer, which most often appears on the foreskin or glans. Squamous cell carcinoma, the most common type of penile cancer, occurs more frequently in uncircumcised men.
Small, dome-shaped bumps with a central depression on the penis, scrotum, inner thighs, or pubis may be molluscum contagiosum. This is a harmless and common viral disease. It is most commonly spread through sexual contact. The infection is often self-limited.
A cluster of small blisters that evolve into painful ulcers is indicative of herpes simplex. Herpes is the most common cause of genital ulceration.
An itchy, red rash with swelling of the glans may be balanitis, and penile ulcers can also occur secondary to balanitis. Acute balanitis can be an early indication of diabetes.
Chancroid, granuloma inguinale, and lymphogranuloma venereum are tropical diseases that cause a single, painless, foul-smelling ulcer. These diagnoses must be confirmed by laboratory tests. They should be suspected in men with a history of sexual contact in tropical areas.
Finally, penile ulceration presenting in elderly patients most commonly will have either a neoplastic or infective etiology. Biopsy is required to exclude a malignancy. A serology test for syphilis and fungal, viral, and bacterial cultures should be performed.
Biopsy did not show any evidence of malignancy. Viral and bacterial cultures are negative (the patient was using local fusidic acid ointment and mupirocin ointment before he visited the clinic). Tests for syphilis and HIV were both negative. The ulcers healed spontaneously.
