Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases

A comprehensive review of current knowledge on penile squamous cell carcinoma

Neoplasm of the penis is relatively rare in most regions representing 0-2% of cancers worldwide. While the penis can be affected by sarcomas, basal cell carcinomas or even melanoma, Penile Squamous Cell Carcinoma (PSCC) represents approximately 95% of all penile neoplasms. Despite its rarity and most common presentation at later decades of life most individuals diagnosed with PSCC are faced with significant decrease in quality of life. The prevalence and incidence vary among different regions and populations, but a common trend is for diagnosis to occur late (stage 4). Underdeveloped countries are traditionally reported to have higher incidence rates; however, rates may vary significantly between urban and rural areas even in developed countries. Age adjusted rates are on the rise in some countries that used to have incidence rates of 1:100 000 or less. The list of associated risk factors is long and includes among others, lack of neonatal circumcision, poor genital hygiene, socioeconomic status, history of human papillomavirus (HPV) infection and penile intraepithelial neoplasia (PeIN). Many risk factors are widely debated among experts however HPV and PeIN are indisputable risk factors, and both also form part of the classification system for PSCC. Both conditions may have occurred in the past or be present at the time of diagnosis and identifying them plays a major role in management strategies. For such a rare condition PSCC can present in many different forms clinically making diagnosis no easy feat. Diagnosis of PSCC is done through clinical examination, including lymph node palpation, followed by a biopsy, which is essential for the classification. Lymph node involvement is a common finding at first presentation and investigation of spread to deep nodes is important and can be done with the aid of PET-CT. Treatment options for PSCC include surgery, chemotherapy, and radiation therapy. Surgical removal of the tumor is considered the most effective however can lead to severe decrease of quality of life. Chemotherapy is used in the case of fixed or bulky lymph nodes, where surgery is not indicated, and for distant metastasis. Radiation therapy is particularly effective in the case of HPV-positive PSCC.

Transcriptional analysis reveals distinct gene expression profiles of three bowenoid papulosis patients

Bowenoid papulosis (BP) is a benign and possibly carcinogenic disease associated with human papillomavirus (HPV) infection, which has been increasingly recognised and paid attention to in recent years, but the potential mechanisms still remain unclear. In our study, three patients who were diagnosed with BP were enrolled into our research. Skin biopsies were taken and were separated into two parts, one part was for HE staining and the others were for RNA-sequencing (RNA-seq). All the three patents were human papillomavirus (HPV) positive and HE staining revealed typical skin histopathological changes in BP, including dyskeratosis, hyperplasia and hypertrophy of the granular and spinous layers, atypical keratinocytes. RNA-seq analysis demonstrated that a total of 486 differentially expressed genes (DEGs) were detected between the skin tissues from BP and the controls, among which, 320 genes were significantly upregulated and 166 genes were dramatically downregulated. GO enrichment revealed that antigen binding, cell cycle, immune response and keratinisation to be the most notably altered pathways, whereas KEGG analysis indicated that cell cycle cytokine-cytokine receptor interaction, ECM receptor interaction and p53 signalling pathway to be the most significantly changed signalling pathways in BP. Furthermore, metabolism-associated enrichment analysis showed that cholesterol metabolism, metabolism of xenobiotics by cytochrome p450 and pyrimidine metabolism to be the most dramatically dysregulated metabolic pathways in BP as compared to normal controls. Our study revealed that inflammation, metabolism and cell proliferation signalling pathways might be the most important pathways for BP disease, targeted inhibiting of these signals might be a potential method for BP treatment.

The prevalence of human leucocyte antigen and human papillomavirus DNA in penile intraepithelial neoplasia in England 2011-2012

BACKGROUND

The pathogenesis of penile intraepithelial neoplasia (PeIN) is unclear but human papillomavirus (HPV) infection and polymorphisms in human leucocyte antigen (HLA).

OBJECTIVES

To examine the prevalence of HPV DNA and HLA in PeIN.

METHODS

Adult Caucasian men with a clinical and histological diagnosis of PeIN, that is, Bowenoid papulosis (BP), Bowen's disease of penis (BDP) and erythroplasia of Queyrat (EQ) were selected and phenotyped from the clinical records. DNA was extracted from blood and paraffin-embedded sections for HLA and HPV typing, respectively. Human leucocyte antigen allele frequencies were compared with those derived from the UK-based Caucasian population.

RESULTS

Seventy-two cases of PeIN (20 BP, 34 BDP and 18 EQ) were studied. Human papillomavirus DNA was identified in 65/72 (90.2%) PeIN; Alphapapillomavirus types were detected in 62/72 (85%) followed by Betapapillomavirus types in 9/72 (12.5%) and cutaneous types in 7/72 (9.7%); HPV16 was the most prevalent genotype at 35/72 (48.6%) followed by HPV33 at 7/72 (9.7%); multiple infections were seen in 18/72 (25%) PeIN. HLA-C*15 (Bonferroni corrected p = 0.049) confers susceptibility to PeIN, whereas HLA-DQA1*01 (corrected p = 0.02) protects against PeIN. HPV16-associated PeIN cases showed no statistically significant association with HLA genotype after multiple corrections.

CONCLUSION

Human papillomavirus is involved in the pathogenesis of PeIN. Immunogenotype may play a role in the pathogenesis of PeIN.

Photodynamic therapy combined with circumcision for the treatment of penile intraepithelial neoplasia

Penile intraepithelial neoplasia(PIN) is a premalignant lesion that can effect any part of the penile surface. Approximately 10-30 % of PIN patients are at risk of progression to squamous cell carcinoma (SCC), with metastatic potential of 3%-5% .. The use of photodynamic therapy (PDT) for PIN is currently controversial. Here, we performed circumcision in combination with PDT and successfully cured 3 cases of PIN. We considered that circumcision is very important before PDT. We recommend the treatment of circumcision combined with PDT to treat patients with PIN, especially for those who have failed previous treatment, or with an excessively long foreskin.

Penile squamous cell carcinoma and lichen planus

Background

Penile squamous cell carcinoma (PSSC) has some non-PHV associated precursos and lichen planus is not considered one of them.

Case presentation

A 78-year-old patient sought the urologist due to a history of erythema on glans for 12 months and growing mass for 6 months treated with different topical medications. Partial penectomy was performed with finding of squamous cell carcinoma usual / keratinizing type with invasion of glans (pT2) and presence of extensive differentiated PeIN in adjacent areas. Adjacent to PeIN areas, there was an inflammatory reaction typical of lichen planus. This lichenoid reaction was present in the periphery of the large mass and also in a separate hyperkeratotic plaque at the glans. No features of HPV infections or balanitis xerotica obliterans were detected on histologic analysis.

Conclusion

We report a case with rapid evolution (6 months) between inflammatory signs of penile disease to mass forming lesion. This report call attention to this potential association – describing the association with invasive squamous carcinoma. Treatment-resistant longstanding cases of lichen planus should be biopsied. Prospective studies of patients with penile lichen planus are warranted to evaluate the magnitude of the risk of progression to penile carcinoma.

Organ-sparing procedures in GU cancer: part 2-organ-sparing procedures in testicular and penile tumors

PURPOSE

Organ-sparing surgery (OSS) is recommended in selected patients with testicular tumors and penile cancer (PC). The functional and psychological impacts of organ excision for these genital tumors are profound. In this review, we summarize the indications, techniques and outcomes of OSS for these two tumors.

METHODS

PubMed^® was searched for relevant articles up to December 2018. For Testicular sparing surgery (TSS) search, keywords used were; testicular tumors alone and in combination with "testicular sparing surgery", "partial orchiectomy" and outcomes. For penile conserving surgery (PCS), keywords used were: penile cancer alone and in combination with "penile conserving surgery", "partial penectomy" and outcomes. Because of the low quality of available evidence, a narrative rather that systematic review has been performed.

RESULTS

Indications of TSS are tumors ≤ 2 cm in solitary testis or bilateral tumors and no rete testis invasion. Prerequisites include normal testosterone and luteinizing hormone levels and patient compliance with follow-up. Indications for PCS are distal penile lesions with clinical stage ≤ T1. Adequate penile stump (3 cm) is required after surgery to maintain forward urine stream. Frozen section helps to reduce the risk of recurrence. Local recurrence after PCS is not associated with reduced survival and can be managed with another PCS in selected patients. The reported oncological and functional outcomes following TSS and PCS are adequate.

CONCLUSIONS

In properly selected patient OSS in testicular and penile tumors has a comparable oncological outcome to total organ excision with added advantages of preserving organ function and psychological well-being.

Human oncoviruses: Mucocutaneous manifestations, pathogenesis, therapeutics, and prevention: Papillomaviruses and Merkel cell polyomavirus

In 1964, the first human oncovirus, Epstein-Barr virus, was identified in Burkitt lymphoma cells. Since then, 6 other human oncoviruses have been identified: human papillomavirus, Merkel cell polyomavirus, hepatitis B and C viruses, human T-cell lymphotropic virus-1, and human herpesvirus-8. These viruses are causally linked to 12% of all cancers, many of which have mucocutaneous manifestations. In addition, oncoviruses are associated with multiple benign mucocutaneous diseases. Research regarding the pathogenic mechanisms of oncoviruses and virus-specific treatment and prevention is rapidly evolving. Preventative vaccines for human papillomavirus and hepatitis B virus are already available. This review discusses the mucocutaneous manifestations, pathogenesis, diagnosis, treatment, and prevention of oncovirus-related diseases. The first article in this continuing medical education series focuses on diseases associated with human papillomavirus and Merkel cell polyomavirus, while the second article in the series focuses on diseases associated with hepatitis B and C viruses, human T-cell lymphotropic virus-1, human herpesvirus-8, and Epstein-Barr virus.

Primary penile cancer organ sparing treatment

INTRODUCTION

Surgical treatment of penile cancer is usually associated with mutilation; alterations in self-esteem and body image; affecting sexual and urinary functions; and declined health-related quality of life. Recently, organ sparing treatment has appeared and led to limiting these complications.

MATERIAL AND METHODS

An extensive review of the literature concerning penile-preserving strategies was conducted. The focus was put on indications, general principles of management, surgical options and reconstructive techniques, the most common complications, as well as functional and oncological outcomes.

RESULTS

Analyzed methods, e.g.: topical chemotherapy, laser ablation therapy, radiotherapy, Moh's microscopic surgery, circumcision, wide local excision, glans resurfacing and glansectomy are indicated in low-stage tumors (Tis, Ta-T2). After glansectomy, reconstruction is also possible.

CONCLUSIONS

Organ sparing techniques may achieve good anatomical, functional, and psychological outcomes without compromising local cancer control, which depends on early diagnosis and treatment. Penile sparing strategies are acceptable treatment approaches in selected patients with low-stage penile cancer after establishing disease-risk and should be considered in this population.

Does Routine Pathology Analysis of Adult Circumcision Tissue Identify Penile Cancer?

OBJECTIVE

To assess the utility of foreskin pathology analysis, we evaluated the outcomes and the costs of this practice in patients for whom penile cancer was not suspected. Adult circumcision specimens are routinely sent for pathologic analysis even when penile cancer is not suspected, increasing costs with little benefit.

MATERIALS AND METHODS

All adult patients who underwent circumcision between January 2000 and August 2013 at a single institution were evaluated by retrospective chart review. Cases of suspected penile cancer (n = 6) were excluded. We identified cases where foreskin specimens were sent for pathologic analysis and reviewed pathology reports. Our Department of Pathology estimated the cost for evaluation of specimens at $311 per case.

RESULTS

A total of 147 circumcisions were performed in patients with no suspicious findings. Pathologic analysis was obtained in 69% (101 of 147) of the cases. Inflammation (58%) was the most common finding. One unsuspected instance of squamous cell carcinoma (Tis) was identified in a patient with human immunodeficiency virus (1 of 147 = 0.7%). The overall cost of pathologic analysis in this study was $31,411.

CONCLUSION

In individuals without predisposing immunodeficiency and where cancer was not suspected, we found that pathologic analysis of circumcision specimens identified no additional malignancies. Our data suggest that in this normal risk population, pathologic analysis may not be required. Additionally, forgoing pathology on foreskin specimens in lower risk cases may reduce costs to the health care system.

2013 European guideline for the management of balanoposthitis

Balanoposthitis can be caused by a disparate range of conditions affecting the penile skin. This guideline concentrates on a selected group of conditions and offers recommendations on the diagnostic tests and treatment regimens needed for the effective management of balanoposthitis.

Anogenital malignancies and premalignancies: facts and controversies

Anogenital malignancies and premalignancies are an important personal/public health problem due to their effects on individuals' physical, mental, and sexual health. Also, due to their etiological association with human papillomavirus (HPV) infection, anogenital malignancies and premalignancies constitute an immense public health burden. In addition to HPV infection, immunosuppression, HIV infection, chronic dermatoses, such as lichen sclerosis, previous radiotherapy and chemotherapy treatments, and smoking, are the other important etiopathologic factors in the development of anogenital malignancies and premalignancies. The incidence of anal squamous cell carcinoma (SCC) has increased considerably in the past decade, mainly due to the growing number of cases in high-risk groups, such as men who have sex with men, immunosuppressed individuals, and patients with HIV infection. Also, an increase in vulvar intraepithelial neoplasia (VIN) and VIN-related invasive vulvar cancer has been noted in women younger than age 50 years due to its association with HPV infections over the past decade. SCC of the scrotum seems to be the first cancer linked to occupational exposure. Bowen's disease, Bowenoid papulosis, and erythroplasia of Queyrat are the most widely seen premalignancies of anogenital region and are all forms of squamous intraepithelial neoplasia. Histopathologically, these conditions share identical histologic features of SCC in situ, but their clinical features differ. Early diagnosis is vital to improve prognosis, especially in anogenital malignancies. Also, if a delay occurs in diagnosis, treatment options used will be associated with significant negative effects on the patient's psychological well-being and quality of life; hence, management of anogenital malignancies and premalignancies should be organized in a multidisciplinary fashion.

Penile intraepithelial neoplasia: important lessons from a case series

Summary

Seven men presenting to our genitourinary (GU) medicine clinic over a period of 22 months had a histopathological diagnosis of penile intraepithelial neoplasia (PIN). Median duration of symptoms was eight months (range 2–216 months). Macroscopic appearances were different in all cases. All histology was reviewed locally and at a tertiary centre. Six of seven had severe dysplasia (PIN III). Interestingly, only one individual was HIV-positive and one, who was immunocompetent, had multifocal disease. These cases highlight the importance of a full anogenital examination and early biopsy in patients presenting with atypical or persistent penile lesions.

Detection of human papillomavirus type 16 in Bowen's carcinoma of the toe

BACKGROUND

Human papillomavirus (HPV) is known to cause cervical cancer. Because it has been detected in lesions of Bowenoid papulosis, Bowen's disease, and Bowen's carcinoma, HPV infection has been implicated in the pathogenesis of these diseases.

METHODS

A 44-year-old man was diagnosed clinicopathologically with Bowen's carcinoma of the right great toe. He developed multiple organ metastases and died. We examined HPV DNA in skin biopsy specimens from the primary and skin metastatic lesions by polymerase chain reaction (PCR) and in situ hybridization (ISH). The PCR assay was carried out using primer sets specifically designed for detecting the E6 and E7 genes of the HPV types associated with malignancy. Purified and cloned PCR products were subjected to DNA sequence analysis. The ISH studies used INFORM(®) HPV III probes.

RESULTS

We found HPV DNA in specimens from both the primary and the skin metastatic lesions. DNA sequencing detected HPV type 16. We compared the base sequences of viral DNA from the primary and metastatic lesions. Point mutations of the base sequences of the E6 and E7 genes were observed in viral DNA from metastases but not in that from primary lesions. The E6 gene had mutated from G to A in the 383rd base sequence, causing a Glu-to-Lys amino acid change. Results of ISH showed punctuate signals in the nuclei of tumor cells.

CONCLUSIONS

We suspect an association between HPV 16 infection and the development of this malignant occurrence.

Male genital premalignant dermatoses

The spectrum of conditions affecting the penile skin is varied and ranges from simple, benign dermatoses to premalignant and malignant conditions. Recently, improved understanding of the aetiology and natural history of these conditions has shaped new treatment paradigms and a functional knowledge of dermatology, urology and genitourinary medicine is required to successfully diagnose and treat these men. In this article, we explore the common precancerous states that can lead to penile carcinoma and review the recent advances with regards to the molecular basis for these dermatoses and the treatments that may be most effective for these men.

Do not forget to examine the genitals: a case of anal cancer and anogenital intraepithelial neoplasia in an immunocompetent man

A 46-year-old Caucasian heterosexual male was referred to a dedicated AIN clinic from colorectal multidisciplinary meeting (MDM) with AIN 3 following complete resection of anal squamous cell carcinoma (SCC). On further questioning, he revealed that he also had a lesion on his penis. Histology of the penile lesion demonstrated full thickness penile intraepithelial neoplasia (PIN 3). This case illustrates the importance of thorough genital examination in patients found to have one genital pathology.

Treatment of carcinoma in situ of the glans penis with topical chemotherapy agents

BACKGROUND

The use of topical agents in the treatment of carcinoma in situ (CIS) of the penis has been well described in the literature. Previous studies have been limited by small sample size and imprecise end points.

OBJECTIVE

Establish the response rate of 5-fluorouracil (5-FU) and imiquimod (IQ) in the treatment of penile CIS in a large contemporary series in a supranetwork centre.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of all primary and recurrent cases of penile CIS treated with 5-FU and IQ identified from a prospective database over a 10-yr period. Therapy was standardised in all cases with application to the lesion for 12h every 48 h for 28 d.

INTERVENTION

5-FU was the first-line therapy, and IQ was the second-line topical agent.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary end point was defined as complete response (CR; i.e., resolution of lesion), partial response (PR; i.e., lesion reduced in size and or visibility), or no response (NR; ie, no improvement in lesion size and or visibility). The secondary end points included local toxicity and adverse events. No statistical analysis or software was used.

RESULTS AND LIMITATIONS

A total of 86 patients were diagnosed with CIS of the penis over the 10-yr period. Forty-four (51%) received topical chemotherapy. The mean follow-up was 34 mo. CR to topical chemotherapy was seen in 25 (57%), PR was seen in 6 (13.6%), and NR was seen in the remaining 13 (29.5%) patients. Local toxicity was experienced by 10% of patients, and 12% had an adverse event following application of 5-FU. The retrospective design and short follow-up were the major limitations of this study.

CONCLUSIONS

Topical chemotherapy agents are moderately effective first-line therapy in the treatment of penile CIS. Toxicity and adverse events were few with our treatment protocol. The issues of long-term surveillance and assessment of partial responders remain a challenge. Topical chemotherapy should remain a first-line treatment option for penile CIS.

[Penile squamous cell carcinoma]

Penile squamous cell carcinoma (SCC) is uncommon in Europe, where it accounts for approximately 0.7% of all malignant tumors in men. The main risk factors are poor hygiene, lack of circumcision, human papillomavirus (HPV) infection, and certain chronic inflammatory skin diseases. HPV infection is detected in 70% to 100% of all penile in situ SCCs and in 30% to 50% of invasive forms of the disease, mainly basaloid and warty SCCs. In situ tumors can be treated conservatively, but close monitoring is essential as they become invasive in between 1% and 30% of cases. The treatment of choice for penile SCC is surgery. Inguinal lymph node irradiation is no longer recommended as a prophylactic measure, and it appears that selective lymph node biopsy might be useful for reducing the morbidity associated with prophylactic inguinal lymph node dissection. Survival is directly related to lymph node involvement. Improving our knowledge of underlying molecular changes and their associated genotypes will open up new therapeutic pathways.

Diagnosis and management of premalignant penile lesions

Diagnosing premalignant penile lesions from benign penile dermatoses presents a unique challenge. The rarity of these conditions and the low incidence of penile cancer mean that the majority of our knowledge is based on small, non-randomized, retrospective studies. The introduction of specialist penile cancer centres in the UK has resulted in the centralization of expertise and resources, and has furthered our understanding of the biological behaviour and management of this rare malignancy. We review the current trends in the approach to diagnosing and treating various premalignant penile conditions.

Male circumcision and penile cancer: a systematic review and meta-analysis

Objective

We systematically reviewed the evidence of an association between male circumcision and penile cancer.

Methods

Databases were searched using keywords and text terms for the epidemiology of penile cancer. Random effects meta-analyses were used to calculate summary odds ratios (ORs) and 95% confidence intervals (CI).

Results

We identified eight papers which evaluated the association of circumcision with penile cancer, of which seven were case–control studies. There was a strong protective effect of childhood/adolescent circumcision on invasive penile cancer (OR = 0.33; 95% CI 0.13–0.83; 3 studies). In two studies, the protective effect of childhood/adolescent circumcision on invasive cancer no longer persisted when analyses were restricted to boys with no history of phimosis.

In contrast, there was some evidence that circumcision in adulthood was associated with an increased risk of invasive penile cancer (summary OR = 2.71; 95% CI 0.93–7.94; 3 studies). There was little evidence for an association of penile intra-epithelial neoplasia and in situ penile cancer with circumcision performed at any age.

Conclusions

Men circumcised in childhood/adolescence are at substantially reduced risk of invasive penile cancer, and this effect could be mediated partly through an effect on phimosis. Expansion of circumcision services in sub-Saharan Africa as an HIV prevention strategy may additionally reduce penile cancer risk.

Electronic supplementary material

The online version of this article (doi:10.1007/s10552-011-9785-9) contains supplementary material, which is available to authorized users.

More than a decade on: review of the use of imiquimod in lower anogenital intraepithelial neoplasia

To assess the effectiveness of 5% imiquimod cream (IQ) in the treatment of vulvar, penile and anal intraepithelial neoplasias (VIN, PIN and AIN), we searched Medline, Embase, PubMed and Cochrane Library databases. With regard to VIN there were two randomized controlled trials (RCTs), eight uncontrolled/cohort studies, nine case reports and one review article. Use of IQ in PIN and AIN were only supported by cohort studies (two each for PIN and AIN) and case reports (15 for PIN and 3 for AIN). On pooled analysis of RCTs, uncontrolled and cohort studies, the mean complete response (CR) rate for VIN, PIN and AIN were 51%, 70% and 48%, respectively. The mean partial response (PR) rate for VIN, PIN and AIN were 25%, 30% and 34% respectively. The recurrence (RR) rate for VIN, PIN and AIN were 16%, 0% and 36%, respectively. The follow-up period for VIN, PIN and AIN ranged from 2 to 32 months, 10 to 12 months and 11 to 39 months, respectively. Although the results for PIN look the best, the strongest evidence regarding efficacy of IQ in anogenital intraepithelial neoplasia is for VIN supported by RCTs. Evidence for use of IQ in AIN was essentially limited to HIV-positive men who have sex with men. IQ was reasonably well tolerated with side-effects being managed with reduction in frequency of drug usage and/or rest periods. Based on these results, IQ seems to be a safe mode of treatment and is possibly an alternative to currently available methods of treatment. However, there are no comparative studies assessing its efficacy against traditional modes of treatment.

Human papillomavirus in the era of highly active antiretroviral therapy for human immunodeficiency virus: an immune reconstitution-associated disease?

Human immunodeficiency virus (HIV)-related cutaneous and anogenital disease in the highly active antiretroviral therapy (HAART) era presents challenging problems for dermatologists. Immune reconstitution-associated diseases (IRADs) are common and important consequences of HAART. Dermatologists should be aware of the cutaneous manifestations of IRAD. The prevalence of clinical human papillomavirus (HPV)-related disease is increased in HIV and does not appear to be diminished by HAART. Many patients on HAART are dogged by persistent cutaneous warts. Anogenital precancer is also common in HIV and may be burgeoning with HAART. Clinicians should be aware of the increased risk of cervical, penile and vulval/vaginal cancers in treated and untreated patients with HIV. The increase in HPV infection in HIV-infected individuals may be, at least partly, due to increased exposure to diverse HPV types, particularly high-risk types that might be able to persist for longer in anogenital regions. Alternatively, persistent/emergent HPV disease in HIV infection might represent persistent or modulated immunodysregulation after HAART and be viewed as a form of IRAD. The immunopathogenesis of HPV IRAD is fascinating and possibly determined by host genotype.

Distinctive features of foreskin condylomata acuminata associated with diabetes mellitus

The aim of this study was to test the hypothesis that particular clinical features of foreskin condylomata acuminata in Chinese male patients are associated with diabetes. A prospective study enrolled 126 men presenting with foreskin condylomata acuminata from 2001 to 2006. Mean age was 46 years (age range 25-74 years) and mean duration of disease was 4.8 months (range 1-18 months). Patients were divided into two groups according to clinical features. In group 1, 42 men had distinctive signs such as redundant prepuce, crown warts circling the entire preputial ring, maceration, fissures, phimosis and balanitis, and 37 of 42 (88%) patients were found to have concurrent type 2 diabetes, furthermore 32 of these 37 patients had an insidious onset and were previously undiagnosed. In group 2, 84 male patients did not have those distinctive clinical features and type 2 diabetes was found in only 10 cases (11.9%, p<0.0001, Fisher's exact test). These clinical features strongly suggest the presence of diabetes. Therapy should address diabetes and condylomata concurrently.

Male genital dermatoses in old age

This review aims to highlight the clinical features, diagnosis and treatment of the most common dermatoses of the male genitals in old age. Diseases of the male genitalia range from infectious problems to inflammatory and neoplastic dermatoses. These can affect sexual and urinary functions. The importance of the former in older men should not be underestimated. Pre-malignant and malignant penile lesions are discussed. Although rare, penis cancer is preventable and curable if diagnosed early.

Penile intraepithelial neoplasia is frequent in HIV-positive men with anal dysplasia

Anogenital human papillomavirus (HPV)-infection is common in HIV-infected men who have sex with men (HIV+MSM). These patients have a strongly increased risk of HPV-induced anal cancer and its precursor lesion, anal intraepithelial neoplasia (AIN), and a moderately increased risk for penile cancer. Only limited data exist on penile intraepithelial neoplasia (PIN) in HIV+MSM. We determined the prevalence and evaluated the virologic characteristics of PIN and AIN in 263 HIV+MSM. In case of histologically confirmed PIN (and AIN), HPV-typing, HPV-DNA load determination, and immunohistochemical staining for p16(INK4a) were performed. PIN was detected in 11 (4.2%) and AIN in 156 (59.3%) patients. Ten PIN patients also had AIN within the observation period. Four clinical types of PINs could be distinguished. High-risk-alpha-HPV-DNA was found in 10 PIN lesions, with HPV16 being the most frequent type. Infections with multiple HPV-types were common. All high-grade lesions had high-risk-HPV-DNA-loads > or = 1 HPV-copy/beta-globin-gene-copy. Cutaneous beta-HPVs were found in PIN and AIN, but beta-HPV-DNA loads were very low, irrespective of the histological grade. p16(INK4a) Expression was detectable in all PIN lesions and correlated both with the histological grade and with high-risk HPV-DNA loads. In view of the PIN prevalence found in our study, all HIV+MSM should be screened for PIN in addition to AIN screening.