Flat condylomata of the penis presenting as patchy balanoposthitis

Detection of human papillomavirus in vulval carcinoma using semi-nested PCR and restriction enzyme typing: a rapid and sensitive technique

Aims-To develop a highly sensitive technique for the reliable detection and typing of human papillomavirus (HPV) DNA in clinical tissue.Methods-A two step, semi-nested PCR was used with primers spanning the L1 region of the HPV genome and capable of detecting HPV DNA of all known HPV types. The clinical samples were typed by digestion of the 412 base pair PCR product with Rsa I, generating unique fragments for each HPV type. Thirteen samples were screened by this method, including nine vulval carcinoma samples and four wart samples from the penis and vulva.Results-Experiments using DNA extracted from HPV DNA positive cell lines-that is, CaSki (HPV type 16) and HeLa (HPV type 18) established that the technique could detect as few as 50 HPV copies and that the predicted Rsa I fragments from HPV types 16 and 18 were generated. The predicted 412 base pair fragment was observed for all 13 clinical samples subjected to semi-nested PCR. Rsa I digestion of the product of the second round of PCR permitted the positive identification of the HPV type in most cases.Conclusions-This technique provides an effective and rapid means of detecting HPV DNA, in most cases providing the HPV type. High risk HPV types were always detected in the nine vulval carcinoma samples analysed. The amount of tissue available from the biopsy specimens was small, confirming the sensitivity of the method.

Balanitis and balanoposthitis: a review

OBJECTIVES

To give an overview of the literature on balanitis, with a special emphasis on infective causes.

METHOD

A data search was performed using the OVID CD plus Medline 1967-1995, using balanitis and balanoposthitis as textword search strategy. Specific subjects such as anaerobic infection, Zoon's balanitis were sought separately and subgroups combined. Original articles and abstracts were referenced to illustrate each condition. These were mainly English language articles, but included appropriate non-English language papers.

CONCLUSIONS

Balanitis is a common condition among genitourinary medicine clinic attendees, the cause often remaining undiagnosed. Many cases are caused by infection, with candida being the most frequently diagnosed. However, gardnerella and anaerobic infections are common, and there are a wide variety of other rarer infective causes. In addition irritant balanitis is probably a contributing factor in many cases. Balanitis which persists and in which the cause remains unclear warrants biopsy.

Papillomavirus-associated balanoposthitis

OBJECTIVE

To assess whether there might be an association between genital papillomavirus infection (GPVI) and balanoposthitis.

DESIGN

Retrospective HPV DNA examination of biopsy specimens from 23 men suffering from balanoposthitis and exhibiting acetowhite lesions that were penoscopically and histologically concurrent with HPV infection.

SETTING

The STD clinics at Karolinska Hospital and South Hospital, Stockholm, Sweden.

PARTICIPANTS

Randomly selected men attending with long-lasting and/or recurrent penile symptoms and exhibiting a clinical picture of balanoposthitis, who revealed a penoscopical and histopathological picture of epidermal lesions that were concordant with accepted criteria for typical or conspicuous GPVI. Asymptomatic controls were selected retrospectively on the basis of identical penoscopy and histology criteria.

RESULTS

A history of previous condylomata was obtained in eight (35%) of 23 men. At penoscopic evaluation tiny condylomatous lesions were observed in five (22%) patients. The in situ hybridisation (ISH) assay using specific probes for the HPV types 6/11, 16/18, 31/33 and 42 was positive in 13/23 (56%) of the patient samples, but in only 26% of the 19 control samples. In patient biopsies the oncogenic HPV types 16/18 and/or 31/33 were found in 7/13 samples, whereas HPV 6/11 and/or 42 were present in another six cases. PCR performed on the ten ISH negative patient biopsies, were negative in all cases.

CONCLUSION

Symptoms included redness, itching, burning, tenderness, dyspareunia, fissuring and in two cases penile oedema and inguinal adenopathy. All patients fulfilled penoscopical and histopathological criteria for HPV infection. We demonstrate some tentative evidence that HPV might be associated with long-lasting balanoposthitis, although our data still are circumstantial for a causative association. The results also elucidate the diversity in clinical presentation of GPVI.

The prevalence of "high-risk" HPV types in penile condyloma-like lesions: correlation between HPV type and morphology

OBJECTIVE

To evaluate the prevalence of "high-risk" human papilloma virus (HPV) types in penile condyloma-like lesions and to correlate HPV types with clinical and histological features.

DESIGN

The study included 94 male patients with signs of penile HPV infection. From acuminate, papular and macular lesions, specimens were collected for HPV DNA hybridisation, using the dot blot and Southern blot techniques. Biopsy specimens from 51 cases were examined by light microscopy for signs of koilocytosis and dysplasia.

SETTING

The STD outpatient clinic of the Department of Dermatovenereology of Sahlgrenska Hospital, Göteborg, Sweden.

RESULTS

In 79 (90%) of 88 patients HPV DNA was detected by dot blot. Of 51 cases examined by histology 88% disclosed an evident koilocytosis. "High-risk" HPV types (16, 18, 31, 33, 35) were demonstrated in 8% of acuminate, 24% of papular and 56% of macular lesions. In 29% of 51 lesions examined histologically moderate to severe dysplasia was observed. There was a significant correlation between "high-risk" HPV types and dysplasia.

CONCLUSION

"High-risk" HPV types are prevalent in papular and especially macular penile condyloma-like lesions. The histological finding of koilocytosis concomitant with dysplasia strongly indicates infection with a "high-risk" HPV type. Although the risk of penile cancer is low, it is from an epidemiological point of view important to diagnose these lesions. Until simple tests for HPV typing are available, biopsy for light microscopy (histology) should be obtained liberally from papular and macular condyloma-like lesions. In atypical cases of balanoposthitis HPV aetiology should also be considered.

Lichen sclerosus and acute urinary obstruction

A case of acute urinary obstruction due to early lichen sclerosus disease is described. In this case both histological corroboration and efficacy of potent topical steroid have been beneficial.

The acetic acid test in evaluation of subclinical genital papillomavirus infection: a comparative study on penoscopy, histopathology, virology and scanning electron microscopy findings

OBJECTIVES

To evaluate colposcopic criteria in acetowhite lesions of the penis ("penoscopy") for the diagnosis of subclinical genitoanal papillomavirus infection (GPVI) compared with histopathological criteria of HPV involvement and to various hybridisation assays for HPV DNA detection, and to depict typical lesions by scanning electron microscopy.

DESIGN

The study included 101 randomly selected male partners of females with known GPVI, or with penile symptoms such as itching, burning and dyspareunia who did not exhibit overt genital warts but appeared to be afflicted with acetowhite penile lesions after topical application of 5% acqueous acetic acid. Lesions were judged by penoscopy as either typical, conspicuous or nontypical for underlying HPV infection. Biopsy specimens from 91 men were examined by light microscopy and by either Southern blot (SB), polymerase chain reaction (PCR) and/or in situ hybridisation (ISH) assays for the presence of HPV DNA of the HPV types 6, 11, 16, 18, 31, 33 and 42 (Group A). From another ten men lesions clinically typical for GPVI were also examined topographically by scanning electronic microscopy (Group B).

SETTING

The STD out-patient clinic of the Department of Dermatovenereology of Karolinska Hospital, Stockholm, Sweden.

RESULTS

Group A Seventy eight (86%) of the biopsied lesions met the penoscopy criteria of being either typical of or conspicuous for GVPI. The agreement between penoscopy and histopathology was fairly good, as HPV diagnosis was made by both methods in 56 (62%) of the cases. The reliability of applying strict colposcopic hallmarks was further substantiated by the finding that 55 (60%) of the biopsy specimens taken from penoscopically typical/conspicuous lesions contained HPV DNA. However, there are diagnostic pitfalls for the acetic acid test. Coexistence of an eczematoid reaction with changes indicative of HPV influence was detected in six (7%) of the cases, while an inflammatory response only occurred in 17 (19%) of the specimens. Additional histopathological diagnoses (normal epithelium, lichen sclerosus et atrophicus, balanitis circinata parakeratotica, verruca plana) were established in another eight (9%) of the cases. Among the HPV DNA positive cases, all of the HPV types tested for were detected with the exception of HPV 18. A severe penile intraepithelial neoplasia (PIN III) was revealed in five (5%) of biopsies; HPV 16 was present in two and HPV 42 in one of these biopsy specimens.

GROUP B

Scanning electron microscopy depiction harmonised with the penoscopy findings showing that subclinical GPVI characteristically exhibits a well demarcated, slightly elevated border and that the central area of lesions often displays a "groove" in which the epithelium appears to be thin with protrusions from beneath that probably represent capillaries.

CONCLUSION

Use of the acetic acid test for evaluation of GPVI should be combined with a colposcopic evaluation based on strict topographic hallmarks, followed by a directed biopsy for light microscopic evaluation. We found that the positive predictive value of colposcopy was as high when correlated with histopathological findings (72%) as when virological methods were used, whether HPV DNA hybridisation testing was performed with the well established SB and ISH assays (45%), or by applying the newly introduced and highly sensitive PCR assay as well (71%). False positivity from the acetic acid test occurs and is mainly due to inflammatory conditions but also to the presence of other conditions. Epithelial fissures are evidently associated with some subclinical GPVI lesions and may potentially represent loci minores for infectious stimuli and perhaps facilitate the transmission of some blood-borne STDs. We prose that the term "papillomavirus balanoposthitis" should be used for penile HPV infection associated with inflammatory responses. Our study indicates that PIN III frequently occurs in a subclinical form and may be associated with not only previously identified "high-risk" HPV types such as type 16, but also with the HPV type 42 that has not previously been considered as oncogenic.