Common Urological Skin Conditions

In the age of artificial intelligence and the internet, patients will likely come to their provider with a preconceived idea of what their lesions, rashes, discoloration, ulcers, irritation, or changes in skin texture mean. Providers should be prepared to not only confirm or deny their patients’ assumptions but also explain what the patient is experiencing and help provide next steps. This article intends to parse through the various skin conditions patients could present with.

Initial Evaluation

Providers should be aware of the various ways an alarming dermatologic condition can present itself. A thorough examination and history should be taken, including where on the body the issue is located and what the problem looks like, how it has changed over time, if there is any pain or other associated symptoms, and the patient’s sexual history. Providers should also ask about any new products being used and whether there is presentation elsewhere on the body.

Benign Conditions and Normal Variants

Genital warts may be a common cause for concern in patients presenting with genital dermatologic conditions. As a potential sign of human papillomavirus (HPV), it is important to patients that this is ruled out. However, several benign and noninfectious conditions could be mistaken for genital warts:

• Pearly papules are characterized by rows of small, flesh-colored, dome-shaped papules.
• Fordyce spots can appear as small, yellow-tinged papules that look a bit like pimples and do not cause any symptoms.
• Angiokeratomas are dark red or purple vascular papules resulting from vascular ectasia. They may be prone to bleeding with trauma or may be asymptomatic.
• Epidermoid cysts are slow-growing, skin-colored cysts filled with keratin.

Other conditions include hyperpigmentation, skin tags, vitiligo, and moles.

Most of these require no treatment. However, vitiligo and skin tags may be bothersome to patients and should be treated to improve quality of life at the patient’s request. For moles and hyperpigmentation, it may be beneficial to perform a biopsy to rule out cancer.

Inflammatory Conditions

Inflammation may be mistaken for sexually transmitted infections (STIs) and can cause pain or discomfort. Therefore, it is imperative that accurate examination and history-taking occur.

• It is not uncommon for psoriasis to affect the genitals, but it may lack the scaliness that is seen elsewhere on the body. It may be itchy, painful, moist, and peeling. If the patient has a history of psoriasis, then this may be more likely.
• Balanitis is an acute inflammatory condition of the glans penis and is more common in uncircumcised men and those who are prone to fungal infections. Balanitis commonly affects those with poor hygiene and can present with a white, curdy substance.
• Contact dermatitis and urticaria can look red, raised, and can be itchy. It is important to ask about any soaps, lubricants, or other products used in the genital area. Providers should request that patients switch products to a hypoallergenic or fragrance-free option. Contact dermatitis and urticaria may also be the result of friction.
• Fixed drug eruption is a rash that appears in the same spot at every occurrence with repeated drug use. This rash can look deep red to purple and can present with burning pain. Providers should consider any new oral medications that may have caused the breakout.
• Lichen sclerosis (LS) is a chronic skin disease that causes scarring and inflammation. It can lead to physical changes of the genitalia, including ulceration, phimosis, and scar tissue affecting urinary and sexual function. LS may also present as white plaques.

Other conditions may include seborrheic dermatitis and hidradenitis suppurativa.

Infectious Conditions

• HPV can present as genital warts or dysplasia, and the majority look like pink to gray-white cauliflower-like lesions. Atypical lesions, including those that are pigmented, indurated, ulcerated, bleeding, or unresponsive to standard therapy, may warrant biopsy.
• Herpes simplex virus (HSV) classically presents with grouped vesicles that progress to painful erosions or ulcers, although presentation can vary. When lesions are present, diagnosis should be confirmed with nucleic acid amplification testing (NAAT), such as PCR. Treatment of HSV should be recommended on a case-by-case basis, and patients should be made aware that treatment does not necessarily prevent spread.
• Molluscum contagiosum is characterized by small, typically umbilicated papules that can resemble warts or benign lesions. These are spread through skin-to-skin contact and caused by poxviruses.

Other conditions may include syphilis, infectious balanitis, scabies, and crab lice.

Don't Miss: Premalignant and Malignant Lesions

When treating patients with dermatologic conditions, be sure to watch out for red flags associated with malignancy. These can include:

• Persistent or nonhealing lesions
• Ulceration
• Unexplained bleeding
• New or changing pigmentation
• Growth or progressive change
• Failure to respond to appropriate treatment

An uncertain or suspicious lesion may require biopsy and dermatology or urology referral.

Key Takeaways

• Benign and inflammatory conditions can mimic STIs
• A patient’s history, how the lesions look, and location can help narrow down the diagnosis.
• Persistent, atypical, changing, and treatment-resistant lesions could be a sign of malignancy. It is important to perform a biopsy or refer the patient to a dermatologist or urologist if this is evident.

Resources

Fistarol, S. K., & Itin, P. H. (2013, February). Diagnosis and treatment of lichen sclerosus: an update. American Journal of Clinical Dermatology; PubMed Central. https://doi.org/10.1007/s40257-012-0006-4

Gabrielson, A. T., Le, T. V., Fontenot, C., Usta, M., & Hellstrom, W. J. G. (2019). Male Genital Dermatology: A Primer for the Sexual Medicine Physician. Sexual Medicine Reviews, 7(1), 71–83. https://doi.org/10.1016/j.sxmr.2018.09.004