BISWAMA Y RAY* From the Division of Urology, Department of Surgery, University of Illinois College of Medicine and West Side Veterans Administration Hospital, Chicago, Illinois
ABSTRACT
Two cases are described of condyloma acuminatum of the scrotum, without evidence of condyloma on other parts of the genitalia. The clinical presentation, treatment and prognosis are discussed. age of onset closely parallels that of gonorrhea; warts first appear at the genital sites most often injured during coitus and there is a high incidence of genital warts among the sexual contacts of the patients. 2 Genital warts are found mostly in young adults between the ages of 16 and 25 years old and more commonly in uncircumcised than in circumcised men. 2 There is no significant difference in the incidence of skin warts or other genital infections, such as syphilis, gonorrhea and nongonococcal urethritis in men with and without genital warts.2
Condyloma acuminatum of the genitalia in male subjects usually is confined to the penis (prepuce, frenulum, corona, glans or shaft); only rarely does it involve the scrotum. Two patients with condyloma acuminatum of the scrotum, without any evidence of condyloma on other parts of the genitalia or perianal area, form the basis of this report. CASE REPORTS
Case 1. P. J., VAWSH 355248141, a 43-year-old black man, had had several small wart-like growths on both sides of the scrotum for 8 years. The growths had increased gradually in size, extending towards the groin, and were associated with mild pain. History revealed a urethral stricture many years in duration requiring intermittent dilatation. Pertinent physical u,.,~''""•u were 11 by 5 1 and 5 2.5 by 1 cm. firm, nontender, cauliflower-like 6 ,owths, respectively, on the posterolateral surfaces of the right and left scrotum, extending towards the groin (fig. 1). The patient was circumcised, and the penis, testes and cord structures were normal. All laboratory studies, including serologic tests, were within normal limits. On March 31, 1975 wide excision of the scrotal lesions was performed. Histologic diagnosis was condyloma acuminatum. The patient was well without any evidence of recurrence 17 months postoperatively. Case 2. M. L., VAWSH 427567402, a 47-year-old black man, had had a small mass on the right scrotum for 1 year. The lesion had increased slightly in size and was associated with mild pain. A pertinent physical finding was a 0.5 0.5 cm. firm, non-tender, sessile mass on the right upper scrotum near the penoscrotal junction 2). The was uncircumcised, and the testes and cord structures were normal. All hff•·~·,---··" "'''-'-cue,", including tests, were within 24, 1976 "Nide excision of the
DISCUSSION
Condyloma acuminatum is caused an auto-inoculab.-ve and filterable virus. Recent electron microscopic studies have shown the presence of intranuclear virus particles in warts that morphologically resemble similar m human skin warts, verruca vulgaris. 1 These lesions usually are found in warm, moist areas of the particularly on mucous membranes or mucocutaneous junctions, such as on the penis, labia and around the anus. They may occur as sessile or papillary lesions that vary from minute lesions, 1 to several mm. in diameter, to large, cauliflower or raspberrylike masses several centimeters in diameter. Genital warts in many ways behave like a sexually transmitted disease. The Accepted for publication September 24, 1976. *Requests for reprints: Division of Urology, University of Illinois Hospital, P.O. Box 6998, Chicago, Illinois 60680.
Fm. l. Case 1. Bilateral condyloma acuminatum on scrotum
Tumors of the are and ccc:.d-;'i,~~-r,' o. 1s no rare occurrence of scrotal is evident of 191 men with warts when the frenupenis were involved in 52 per cent, 33 per cent, external urethral meatus in shaft in 18 per cent and scrotum in 2 per cent of cases. 2 In this same series, in those patients who had had genital warts for a month or the parts most often affected were, in decreasing order of frequency: prepuce (inner surface) and frenulum, corona and coronal sulcus, and the external urethral meatus. However, none was noted on the outer part of the prepuce, penile shaft or the scrotum, suggesting that scrotal involvement was owing to secondary spread. It is of interest that neither of our 2 patients had condyloma on other parts of the genitalia or perianal area. Genital warts have been classified into 3 clinical types: hyperplastic, sessile and verruca vulgaris, resembling common skin warts. 2 Usually, the fleshy hyperplastic wart is found most often on the glans penis, inner surface of the prepuce and external urethral meatus; the sessile and verruca vulgaris type of warts are found on the shaft of the penis 2 or 739
740
RAY
initially by excisional biopsy, which provides adequate tissue for histologic examination and avoids possible misinterpretation of histologic changes induced by chemotherapy if used previously. Opinions vary regarding the malignant potentiality of condyloma. A number ofreports indicate that malignant transformation of this lesion does occur occasionally. Several cases of squamous cell carcinoma, arising in penile and perianal condyloma, a case of basal cell carcinoma arising in a perianal condyloma and coexistence of scrotal condyloma and carcinoma have been reported. 8 ' tH 5 There is no doubt that condyloma acuminatum can be associated with carcinoma but definite evidence that they are precursors of carcinoma is lacking and their coexistence may be owing to common predisposing factors. Dr. Joseph H. Kiefer gave helpful suggestions and Dr. Thomas E. Baron provided technical assistance. REFERENCES 1. Oriel, J. D. and Almeida, J. D.: Demonstration of virus particles
FIG. 2. Case 2. Condyloma acuminatum of right side of scrotum
scrotum as observed by us. Giant condyloma (Buschke-Lowenstein tumor), more commonly seen on the penis, also is known to occur on the scrotum. 7 • 8 Spontaneous regression of genital warts has been observed occasionally. However, these lesions usually grow slowly and remain superficial sparing the underlying tissue and, thus, differ from the giant condyloma that consistently penetrate underlying tissue by compression and pursue a clinically malignant course. Generally, condyloma acuminatum responds readily to treatment, although recurrence is not uncommon. The treatment depends on their location, number, size and degree of growth. Small warts can be treated with topical application of podophyllin, phenol, trichloroacetic acid, 5-fluorouracil, thio-tepa, bleomycin or electrocoagulation, 9 • 10 For larger warts various combinations of topical chemotherapy, electrocautery and surgical excision are used. Lesions on redundant skin, such as scrotum or prepuce, are easily and definitively treated by wide excision or circumcision, respectively. Previous reports suggest that the verruca vulgaris type of genital warts responds poorly to podophyllin.2 Both of our patients had the verruca vulgaris type of condyloma acuminatum: extensive in 1 case and small in the other. No attempt was made to treat them with either topical chemotherapy or electrocautery and total excision was considered the treatment of choice. Atypical condyloma acuminatum should be treated
in human genital warts. Brit. J. Vener. Dis., 46: 37, 1970. 2. Oriel, J. D.: Natural history of genital warts. Brit. J. Vener. Dis., 47: 1, 1971. 3. Ray, B., Huvos, A. G. and Whitmore, W. F., Jr.: Unusual malignant tumors of the scrotum: review of 5 cases. J. Urol., 108: 760, 1972. 4. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J. Urol., 117: 741, 1977. 5. Ray, B. and Clark, S. S.: Hemangioma of scrotum. Urology, 8: 502, 1976. 6. Ray, B., Sharifi, R. and Clark, S.S.: Massive scrotal and occult prepucial metastases from carcinoma of the prostate. Brit. J. Urol., in press. 7. Hudson, H. C., Holcomb, F. L. and Gates, W.: Giant condyloma acuminatum of the penis: case reports and review. J. Urol., 110: 301, 1973. 8. Dawson, D. F., Duckworth, J. K., Bernhardt, H. and Young, J. M.: Giant condyloma and verrucous carcinoma of the genital area. Arch. Path., 79: 225, 1965. 9. Condylomata acuminata (leading article). Brit. Med. J., 2: 179, 1972. 10. Ichikawa, T., Nakano, I. and Hirokawa, I.: Bleomycin treatment of the tumors of penis and scrotum. J. Urol., 102: 699, 1969. 11. Rhatigan, R. M., Jimenez, S. and Chopskie, E. J.: Condyloma acuminatum and carcinoma of the penis. South. Med. J., 65: 423, 1972. 12. Friedberg, M. J. and Serlin, 0.: Condyloma acuminatum: its association with malignancy. Dis. Colon Rectum, 6: 352, 1963. 13. Siegel, A.: Malignant transformation of condyloma acuminatum. Review of the literature and report of a case. Amer. J. Surg., 103: 613, 1962. 14. Fitzgerald, D. M. and Hamit, H. F.: The variable significance of condyloma acuminata. Ann. Surg., 179: 328, 1974. 15. El-Domeiri, A. A. and Paglia, M.A.: Carcinoma of the scrotum, radical excision and repair using oi fascia: case report. J. Urol., 106: 575, 1971.
ABSTRACT
Two cases are described of condyloma acuminatum of the scrotum, without evidence of condyloma on other parts of the genitalia. The clinical presentation, treatment and prognosis are discussed. age of onset closely parallels that of gonorrhea; warts first appear at the genital sites most often injured during coitus and there is a high incidence of genital warts among the sexual contacts of the patients. 2 Genital warts are found mostly in young adults between the ages of 16 and 25 years old and more commonly in uncircumcised than in circumcised men. 2 There is no significant difference in the incidence of skin warts or other genital infections, such as syphilis, gonorrhea and nongonococcal urethritis in men with and without genital warts.2
Condyloma acuminatum of the genitalia in male subjects usually is confined to the penis (prepuce, frenulum, corona, glans or shaft); only rarely does it involve the scrotum. Two patients with condyloma acuminatum of the scrotum, without any evidence of condyloma on other parts of the genitalia or perianal area, form the basis of this report. CASE REPORTS
Case 1. P. J., VAWSH 355248141, a 43-year-old black man, had had several small wart-like growths on both sides of the scrotum for 8 years. The growths had increased gradually in size, extending towards the groin, and were associated with mild pain. History revealed a urethral stricture many years in duration requiring intermittent dilatation. Pertinent physical u,.,~''""•u were 11 by 5 1 and 5 2.5 by 1 cm. firm, nontender, cauliflower-like 6 ,owths, respectively, on the posterolateral surfaces of the right and left scrotum, extending towards the groin (fig. 1). The patient was circumcised, and the penis, testes and cord structures were normal. All laboratory studies, including serologic tests, were within normal limits. On March 31, 1975 wide excision of the scrotal lesions was performed. Histologic diagnosis was condyloma acuminatum. The patient was well without any evidence of recurrence 17 months postoperatively. Case 2. M. L., VAWSH 427567402, a 47-year-old black man, had had a small mass on the right scrotum for 1 year. The lesion had increased slightly in size and was associated with mild pain. A pertinent physical finding was a 0.5 0.5 cm. firm, non-tender, sessile mass on the right upper scrotum near the penoscrotal junction 2). The was uncircumcised, and the testes and cord structures were normal. All hff•·~·,---··" "'''-'-cue,", including tests, were within 24, 1976 "Nide excision of the
DISCUSSION
Condyloma acuminatum is caused an auto-inoculab.-ve and filterable virus. Recent electron microscopic studies have shown the presence of intranuclear virus particles in warts that morphologically resemble similar m human skin warts, verruca vulgaris. 1 These lesions usually are found in warm, moist areas of the particularly on mucous membranes or mucocutaneous junctions, such as on the penis, labia and around the anus. They may occur as sessile or papillary lesions that vary from minute lesions, 1 to several mm. in diameter, to large, cauliflower or raspberrylike masses several centimeters in diameter. Genital warts in many ways behave like a sexually transmitted disease. The Accepted for publication September 24, 1976. *Requests for reprints: Division of Urology, University of Illinois Hospital, P.O. Box 6998, Chicago, Illinois 60680.
Fm. l. Case 1. Bilateral condyloma acuminatum on scrotum
Tumors of the are and ccc:.d-;'i,~~-r,' o. 1s no rare occurrence of scrotal is evident of 191 men with warts when the frenupenis were involved in 52 per cent, 33 per cent, external urethral meatus in shaft in 18 per cent and scrotum in 2 per cent of cases. 2 In this same series, in those patients who had had genital warts for a month or the parts most often affected were, in decreasing order of frequency: prepuce (inner surface) and frenulum, corona and coronal sulcus, and the external urethral meatus. However, none was noted on the outer part of the prepuce, penile shaft or the scrotum, suggesting that scrotal involvement was owing to secondary spread. It is of interest that neither of our 2 patients had condyloma on other parts of the genitalia or perianal area. Genital warts have been classified into 3 clinical types: hyperplastic, sessile and verruca vulgaris, resembling common skin warts. 2 Usually, the fleshy hyperplastic wart is found most often on the glans penis, inner surface of the prepuce and external urethral meatus; the sessile and verruca vulgaris type of warts are found on the shaft of the penis 2 or 739
740
RAY
initially by excisional biopsy, which provides adequate tissue for histologic examination and avoids possible misinterpretation of histologic changes induced by chemotherapy if used previously. Opinions vary regarding the malignant potentiality of condyloma. A number ofreports indicate that malignant transformation of this lesion does occur occasionally. Several cases of squamous cell carcinoma, arising in penile and perianal condyloma, a case of basal cell carcinoma arising in a perianal condyloma and coexistence of scrotal condyloma and carcinoma have been reported. 8 ' tH 5 There is no doubt that condyloma acuminatum can be associated with carcinoma but definite evidence that they are precursors of carcinoma is lacking and their coexistence may be owing to common predisposing factors. Dr. Joseph H. Kiefer gave helpful suggestions and Dr. Thomas E. Baron provided technical assistance. REFERENCES 1. Oriel, J. D. and Almeida, J. D.: Demonstration of virus particles
FIG. 2. Case 2. Condyloma acuminatum of right side of scrotum
scrotum as observed by us. Giant condyloma (Buschke-Lowenstein tumor), more commonly seen on the penis, also is known to occur on the scrotum. 7 • 8 Spontaneous regression of genital warts has been observed occasionally. However, these lesions usually grow slowly and remain superficial sparing the underlying tissue and, thus, differ from the giant condyloma that consistently penetrate underlying tissue by compression and pursue a clinically malignant course. Generally, condyloma acuminatum responds readily to treatment, although recurrence is not uncommon. The treatment depends on their location, number, size and degree of growth. Small warts can be treated with topical application of podophyllin, phenol, trichloroacetic acid, 5-fluorouracil, thio-tepa, bleomycin or electrocoagulation, 9 • 10 For larger warts various combinations of topical chemotherapy, electrocautery and surgical excision are used. Lesions on redundant skin, such as scrotum or prepuce, are easily and definitively treated by wide excision or circumcision, respectively. Previous reports suggest that the verruca vulgaris type of genital warts responds poorly to podophyllin.2 Both of our patients had the verruca vulgaris type of condyloma acuminatum: extensive in 1 case and small in the other. No attempt was made to treat them with either topical chemotherapy or electrocautery and total excision was considered the treatment of choice. Atypical condyloma acuminatum should be treated
in human genital warts. Brit. J. Vener. Dis., 46: 37, 1970. 2. Oriel, J. D.: Natural history of genital warts. Brit. J. Vener. Dis., 47: 1, 1971. 3. Ray, B., Huvos, A. G. and Whitmore, W. F., Jr.: Unusual malignant tumors of the scrotum: review of 5 cases. J. Urol., 108: 760, 1972. 4. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J. Urol., 117: 741, 1977. 5. Ray, B. and Clark, S. S.: Hemangioma of scrotum. Urology, 8: 502, 1976. 6. Ray, B., Sharifi, R. and Clark, S.S.: Massive scrotal and occult prepucial metastases from carcinoma of the prostate. Brit. J. Urol., in press. 7. Hudson, H. C., Holcomb, F. L. and Gates, W.: Giant condyloma acuminatum of the penis: case reports and review. J. Urol., 110: 301, 1973. 8. Dawson, D. F., Duckworth, J. K., Bernhardt, H. and Young, J. M.: Giant condyloma and verrucous carcinoma of the genital area. Arch. Path., 79: 225, 1965. 9. Condylomata acuminata (leading article). Brit. Med. J., 2: 179, 1972. 10. Ichikawa, T., Nakano, I. and Hirokawa, I.: Bleomycin treatment of the tumors of penis and scrotum. J. Urol., 102: 699, 1969. 11. Rhatigan, R. M., Jimenez, S. and Chopskie, E. J.: Condyloma acuminatum and carcinoma of the penis. South. Med. J., 65: 423, 1972. 12. Friedberg, M. J. and Serlin, 0.: Condyloma acuminatum: its association with malignancy. Dis. Colon Rectum, 6: 352, 1963. 13. Siegel, A.: Malignant transformation of condyloma acuminatum. Review of the literature and report of a case. Amer. J. Surg., 103: 613, 1962. 14. Fitzgerald, D. M. and Hamit, H. F.: The variable significance of condyloma acuminata. Ann. Surg., 179: 328, 1974. 15. El-Domeiri, A. A. and Paglia, M.A.: Carcinoma of the scrotum, radical excision and repair using oi fascia: case report. J. Urol., 106: 575, 1971.
