Sexually transmitted penile infections

Sexually transmitted penile infections 

Updated: 04/15/2021

© Jun Wang, MD, PhD

Syphilitic chancre
  • Caused by Treponema pallidum
  • Presentation of primary syphilis
  • Usually solitary
  • Painless hard chancre
  • Commonly at inner foreskin, coronal sulcus, penile shaft and penile base
  • Pathological features
Same for syphilitic chancre at any location
Sheets of plasma cells
Spirochetes identified by silver stain (Warthin-Starry’s statin)
  • Laboratory test 
    • Screening tests: 
      • Detect anti-cardiolipin antibodies in patient with syphilis
      • Rapid plasma regain (RPR) 
      • Venereal Disease Research Laboratory (VDRL)
      • Toluidine Red Unheated Serum Test (TRUST)
    • Confirmatory tests 
      • May be used as initial tests due to automation 
      • Fluorescent treponemal antibody-absorption (FTA-ABS) 
      • Microhemagglutination test for antibodies to T. pallidum (MHA-TP)
      • T. pallidum particle agglutination assay (TPPA)
      • T. pallidum enzyme immunoassay (TP-EIA)
      • Chemiluminescence immunoassay (CIA)
  • Treatment: Penicillin
Chancroid
  • Etiology: Gram-negative rod Haemophilus ducreyi
  • Painful genital ulcer and inguinal adenopathy
  • Mainly in developing countries, particularly Africa, Asia and Latin America
  • Cofactor for HIV transmission
  • Zonation of ulcer
Upper layer: Ulcer base with fibrin, neutrophils and necrosis
Middle layer: Granulation tissue, palisading vessels and thrombosis
Deep layer: Marked lymphoplasmacytic infiltrate
  • Microbiology: Chains of Gram negative rods
  • Evaluation of other causes of genital ulcer, such as syphilus, Herpes
  • Diagnosis: Confirmed by culture or PCR to identify H. ducreyi
  • Treatment: Antibiotics (Azithromycin, Ceftriaxone, or erythromycin)
Herpes
  • Most common cause of genital ulceration
  • Usually caused by DNA viruses herpes simplex virus 2 (HSV2) and less commonly HSV1
  • Spreads by direct contact with lesions
  • May spreads by asymptomatic shedding when no lesion is apparent
  • More common in genital area and mouth
  • Clusters of small papules and macules, followed by vesicles that rupture and cause painful ulcers
  • Pathological features
Multinucleation, molding, margining of chromatin, same as skin herpes 
Background of acute inflammation
  • Treatment: Antiviral drugs
Granuloma inguinale
  • Caused by Klebsiella granulomatis, a gram negative rod
  • More common in African American, lower social-economic status
  • Endemic in tropical and subtropical climates such as Papua New Guinea, parts of South Africa, parts of India, Indonesia and Australian aborigines
  • More common in foreskin, glans, penile shaft or scrotum
  • Four cutaneous presentations
    • Nodular: Initially a small pruritic erythematous nodule at infection site that ulcerates; may have satellite lesions
    • Ulcerovegetative: Painless beefy red ulcer with distinct raised border
    • Cicatricial: Cicatricial plaques
    • Hypertrophic/verrucous: vegetating mass similar to wart
  • Pathological features
Large mononuclear cells with Donovan bodies (large intracytoplasmic encapsulated bipolar bodies)
Background plasma cell and neutrophil infiltrate
  • Diagnosis: Histology or cytology (crush) prep of tissue from ulcer edge to identify Donovan bodies
  • Treatment: Antibiotics (erythromycin, tetracyclin, ampicillin etc)
Lymphogranuloma venereum
  • Caused by Chlamydia trachomatis
  • Incidence highest in the tropics and subtropics
  • Causes either inguinal, rectal or rarely pharyngeal syndrome
  • Incubation period: 3-12 days
  • Initial lesion: Painless ulcer at inoculation site appears and rapidly disappears
  • Inguinal syndrome: Enlarged superficial and deep inguinal lymph nodes (groove sign) with suppurative granulomatous changes, with focal necrosis (stellate abscesses)
  • Diagnosis: Clinical presentations with molecular tests (Nucleic Acid Amplification Testing), serology
  • Treatment: Tetracycline (except during pregnancy) or erythromycin
Condyloma acuminatum
  • Human papillomavirus-related
  • Transmitted through skin contact during sex
  • Most commonly affects young males in teens and 20’s
  • Many HPV infections don’t lead to condyloma
  • Rarely transform into malignancy
  • Pathologic features
Papillary warty growth 
Koilocytes
  • Treatment: Cryotherapy, laser, curettage, excision, etc

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