Splenogonadal fusion: aiding detection and avoiding radical orchidectomy

Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.

Splenogonadal fusion: aiding detection and avoiding radical orchidectomy

Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.

Penile lymphoedema: approach to investigation and management

BACKGROUND

Penile lymphoedema (with and without cellulitis) is a rare, often chronic, clinically heterogeneous entity with an uncertain pathogenesis and an important differential diagnosis. It creates significant physical and psychosexual morbidity, and presents considerable therapeutic challenges. The existing literature is limited.

AIM

To describe and share our updated cumulative experience of a cohort of patients with penile lymphoedema.

METHODS

This was a retrospective review of the case records of patients with chronic penile lymphoedema seen in two dedicated male genital dermatology clinics between January 2011 and July 2016.

RESULTS

In total, 41 cases were identified. Over a third had Crohn disease (CD) (which was occult in one-third of these), and over a third had serological evidence of streptococcal infection. All patients responded to systemic antibiotics and specialized urological surgery circumcision and excision).

CONCLUSIONS

Penile lymphoedema should be investigated to exclude underlying pathology especially CD and streptococcal infection. Treatment with antibiotics should be considered early and long term to try to preserve the foreskin: most patients are uncircumcised. Some patients may benefit from a course or courses of oral steroids. The development of gross dysfunction of the prepuce usually dictates circumcision and excision of lymphoedematous tissue once the situation is medically stabilized.

Mumps Orchitis

Although the incidence of mumps orchitis has dramatically declined since the introduction of the childhood vaccination programme, a sharp increase in reported cases of both mumps and mumps orchitis has been seen recently in the UK. There are great concerns about mumps outbreaks and the associated risk of infertility; it remains an important clinical condition. Immunization is the best policy to avoid this viral disease.

Clinical parameters in male genital lichen sclerosus: a case series of 329 patients

BACKGROUND

  The dermatological aspects of male genital lichen sclerosus (MGLSc) have not received much prominence in the literature. Sexual morbidity appears under-appreciated, the role of histology is unclear, the relative places of topical medical treatment and circumcision are not established, the prognosis for sexual function, urinary function and penis cancer is uncertain and the pathogenesis has not been specifically studied although autoimmunity (as in women) and HPV infection have been mooted.

OBJECTIVE

  To illuminate the above by analysing the clinical parameters of a large series of patients with MGLSc.

METHODS

  A total of 329 patients with a clinical diagnosis of MGLSc were identified retrospectively from a dermatology-centred multidisciplinary setting. Their clinical and histopathological features and outcomes have been abstracted from the records and analysed by simple descriptive statistics.

RESULTS

  The collation and analysis of clinical data derived from the largest series of men with MGLSc ever studied from a dermatological perspective has been achieved. These data allow the conclusions below to be drawn.

CONCLUSIONS

  MGLSc is unequivocally a disease of the uncircumcised male; the adult peak is late in the fourth decade; dyspareunia is a common presenting complaint; non-specific histology requires careful interpretation; most men are either cured by topical treatment with ultrapotent steroid (50-60%) or by circumcision (>75%); effective and definitive management appears to abrogate the risk of developing penile squamous cell carcinoma; urinary contact is implicated in the pathogenesis of MGLSc; HPV infection and autoimmunity seem unimportant.

Ureteric colic: new trends in diagnosis and treatment

The diagnostic approach to ureteric colic has changed due to the introduction of new radiological imaging such as non-contrast CT. The role of intravenous urography, which is regarded as the gold standard for the diagnosis of ureteric colic, is being challenged by CT, which has become the first-line investigation in a number of centres. The management of ureteric colic has also changed. The role of medical treatment has expanded beyond symptomatic control to attempt to target some of the factors in stone retention and thereby improve the likelihood of spontaneous stone expulsion.

Mumps orchitis

Although the incidence of mumps orchitis has dramatically declined since the introduction of the childhood vaccination programme, a sharp increase in reported cases of both mumps and mumps orchitis has been seen recently in the UK. There are great concerns about mumps outbreaks and the associated risk of infertility; it remains an important clinical condition. Immunization is the best policy to avoid this viral disease.

Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases

BACKGROUND

Penile intraepithelial neoplasia (PIN) is the term used to describe erythroplasia of Queyrat (EQ), Bowen's disease (BD) and bowenoid papulosis (BP). These conditions are distinct clinical entities and have different epidemiological and aetiological associations and prognostic implications.

OBJECTIVES

To describe the presentation and treatment of patients with PIN.

METHODS

Thirty-five patients presenting with PIN over a 7-year period are described.

RESULTS

Our observations include: (i) patients with BP are younger than those with EQ or BD and sometimes have a history of immunosuppression; (ii) patients with BP usually have a history or clinical evidence of previous genital human papillomavirus infection; (iii) patients with EQ often have a concurrent penile dermatosis (lichen sclerosus or lichen planus); (iv) patients with PIN are usually uncircumcised; and (v) response to treatment of BP depends on the integrity of the immune system.

CONCLUSIONS

We recommend vigorous treatment of all patients with PIN, including circumcision. Smoking should be actively discouraged. Patients should have life-long follow-up and partners of patients with BP should be screened for other forms of intraepithelial neoplasia (cervical and anal).

Circumcision and genital dermatoses

CONTEXT

It is well recognized that the presence of a foreskin predisposes to penile carcinoma and sexually transmitted infections. We have investigated the relationship between the presence or absence of the foreskin and penile dermatoses.

OBJECTIVE

To determine whether there is an association between circumcision and penile dermatoses.

DESIGN

A retrospective case control study of patients attending the department of dermatology with genital skin conditions.

SUBJECTS

The study population consisted of 357 male patients referred for diagnosis and management of genital skin disease. The control population consisted of 305 male patients without genital skin disease attending the general dermatology clinics over a 4-month period.

MAIN OUTCOME MEASURES

The relationship between circumcision and the presence or absence of skin disease involving the penis was investigated. The rate of circumcision in the general male dermatology population was determined.

RESULTS

The most common diagnoses were psoriasis (n = 94), penile infections (n = 58), lichen sclerosus (n = 52), lichen planus (n = 39), seborrheic dermatitis (n = 29), and Zoon balanitis (n = 27). Less common diagnoses included squamous cell carcinoma (n = 4), bowenoid papulosis (n = 3), and Bowen disease (n = 3). The age-adjusted odds ratio for all penile skin diseases associated with presence of the foreskin was 3.24 (95% confidence interval, 2.26-4.64). All patients with Zoon balanitis, bowenoid papulosis, and nonspecific balanoposthitis were uncircumcised. Lichen sclerosus was diagnosed in only 1 circumcised patient. Most patients with psoriasis, lichen planus, and seborrheic eczema (72%, 69%, and 72%, respectively) were uncircumcised at presentation. The majority of men with penile infections (84%) were uncircumcised.

CONCLUSIONS

Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a köebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses.

Dermatomyositis in association with transitional cell carcinoma of the bladder

We report a case of dermatomyositis occurring in association with transitional cell carcinoma of the bladder. The case illustrates the importance of a thorough search for neoplasms in elderly patients with dermatomyositis and is a reminder that bladder cancer may be a rare cause of dermatomyositis. The case also shows that successful treatment of an underlying tumour may lead to resolution of paraneoplastic dermatomyositis, and relapse of cutaneous and muscle symptoms and signs may indicate recurrence of tumour.

Transurethral microwave therapy: patient selection and outcome

Forty-one patients with benign prostatic disease awaiting transurethral resection of the prostate were offered transurethral microwave therapy as an alternative. Pre-operative assessment consisted of symptom scores, prostate-specific antigen levels, flow rates and urinary tract ultrasound with residual urine estimation. Patients were reassessed 6 weeks, 3 months and 6 months after microwave treatment. Twenty-three patients had a successful outcome and 18 an unsuccessful outcome to treatment. Fifteen of the 18 with an unsuccessful outcome could have been predicted by the presence of one or more of the following pretreatment features: glands over 50 g (10 patients), the presence of a median lobe (5 patients), high residual urine (6 patients), a history of recurrent urinary infection (2 patients) and coexisting neurological disorders such as parkinsonism (1 patient) and CVA (1 patient). Three failures had none of these criteria present and could not have been predicted from their pretreatment assessment. Transurethral microwave therapy produces subjective and objective improvements in appropriately selected patients. Patients with large glands or decompensated bladders fail to benefit and should continue to be treated by conventional surgery.

Shifts of dependency in the resolution of folie à deux

We have presented a case of folie à deux in which the wife was the primary (dominant) partner and the husband the secondary (submissive) partner. The husband's symptoms seemed to have resolved as his dependency shifted from his wife back to his mother. Treatment is recommended by deliberately shifting dependencies only when there is advantage in doing so. For most patients, the aim should be independence.