Alberto Rosenblatt

Local and systemic adverse effects of imiquimod therapy for external anogenital warts in men: report of three cases.

Imiquimod is a topical immune response modifier used to treat anogenital warts. Although considered a safe drug, mild to moderate local and systemic side-effects may occasionally occur. We report three cases of local and systemic adverse effects related to imiquimod, including one case that mimicked meningitis, which promptly resolved with drug cessation.

Human Papillomavirus History and Epidemiology

Human papillomavirus (HPV) infection is a significant source of morbidity and mortality among the young population and, together with HIV, is considered the most costly sexually transmitted disease (STD) in terms of estimated direct medical expenses (Chesson et al., 2004). According to a recent Centers for Disease Control and Prevention (CDC) analysis (Forhan et al., 2008), one in four American women between the ages of 14 and 19 (approximately 3.2 million young girls) is infected with at least one of the most common STDs (i.e., HPV, Chlamydia trachomatis, trichomoniasis, and herpes simplex virus type 2). While genital chlamydia is the most commonly reported condition in the United States (Satterwhite, 2008), HPV is by far the most prevalent (18.3% in the CDC study compared to 3.9% for chlamydia).

Sexually Transmitted Infections

Sexually transmitted infections (STIs) mainly manifest as genital ulcers, urethritis, or genital warts. STIs must always be correctly diagnosed and treated so as to prevent further transmission and reduce the risk of human immunodeficiency virus (HIV) acquisition. This Chapter discusses the genital manifestations and current management of STIs caused by the organisms involved in the conditions related above.

Systemic Disorders Affecting the Genital Skin

Several systemic diseases may become manifest in the genital region. A systematic approach to diagnosis, including careful review of the clinical history associated with a comprehensive knowledge of local and systemic signs and symptoms is paramount in order to properly manage these conditions. Furthermore, selecting the most adequate laboratory investigation to aid in the diagnosis, particularly in diseases with unusual etiology or presentation, is an important skill. In this Chapter, the systemic disorders that may affect the male genitalia are reviewed.

Premalignant Lesions of the Penis

Premalignant penile lesions are a known risk factor for the development of penile neoplasias, and they have been reported in nearly half of invasive tumors. Prompt recognition and treatment prior to malignant transformation may avoid the need for traumatic procedures, which is often required when invasive penile cancer is diagnosed. The current terminology and categorization of penile precursor lesions, including risk factors, management, and prevention is reviewed in this chapter.

Pigmentary Lesions/Pigmentary Skin Changes

Melanocytic lesions of the male genital area are rare, and they share similar histological features to those pigmented lesions from other body sites. However, benign pigmented mucocutaneous macules have been described under various terms, which may cause a certain degree of confusion for non-dermatologist practitioners interested in the subject. This Chapter reviews the pigmentary lesions and pigmentary skin changes that may affect the male external genitalia

Nonsquamous Malignant Neoplasms of the Penis and Scrotum

Malignant lesions other than SCC infrequently involve the male external genitalia and usually affect older individuals. In this Chapter, basal cell carcinoma, lymphoma, malignant melanoma and sarcomas are discussed.

Embryology and Functional Anatomy of the Male External Genitalia

Dermatoses of the male external genitalia may comprise either specific disorders of the genital region or local manifestations of systemic diseases. In addition, normal anatomical variations of the penis and scrotum are commonly observed, which may further confound the correct diagnosis of the innumerous conditions affecting the region. Therefore, understanding the basic notions of the male genital embryology and functional anatomy, as well as the correct sequence of history taking and physical examination are of utmost importance in order to better characterize the conditions involving this particular site. The embryology of the male external genitalia and its functional anatomy are discussed in this Chapter.

Nonsexually Transmitted Infections

Balanitis is defined as an inflammation of the glans penis and balanoposthitis occurs when the glans inflammation has extended to the prepuce. Balanitis and balanoposthitis can develop from several causes, and those related to infectious agents (particularly Candida) are commonly observed in medical practice. Bacterial flora from the skin of the perineum, penis, and urethra is mostly comprised of Gram-positive cocci and diphtheroids, and members of the genera Candida and Malassezia comprise the opportunistic yeast that inhabit human genital skin. Moreover, several specific pathogens (including bacteria, virus, yeast, and parasites) may colonize human genital skin and cause anogenital disease, with transmission occurring via sexual and nonsexual routes. In this Chapter, mostly nonsexually transmitted infections are discussed, although some organisms reviewed here may also be transmitted through sexual contact (e.g., tuberculosis, molluscum contagiosum, cutaneous and deep mycoses, pediculosis pubis, scabies, and genital amebiasis).

Human Papillomavirus and Cervical Intraepithelial Neoplasia

This chapter reviews gynecological diseases associated with human papillomavirus (HPV) infection, particularly the terminology and grading of premalignant cervical lesions as well as general guidelines for the treatment of these disorders. The aim is to provide updated information that will help urologists and medical practitioners understand the diagnosis (including the different grading systems currently in use) and management of cervical intraepithelial neoplasia in the female partner. A full discussion of gynecological malignancies is beyond the scope of this book, and the interested reader should refer to specific literature. Cervical cancer is the second most common cancer among women worldwide and one of the leading causes of women’s death in developing countries (Parkin et al., 2005). Nevertheless, cervical premalignant conditions (also known as cervical intraepithelial neoplasia (CIN)) evolve slowly and these precancerous lesions can be discovered and treated before progression to invasive cervical carcinoma (ICC) occurs. Furthermore, in countries where organized cervical cancer surveillance has been implemented with a routine Papanicolaou (Pap) smear screening program, the ICC incidence and mortality have seen a dramatic reduction.