Normal Variations – Do Not Adjust Your Set!
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“Oh my God ! Look at those lumpy bits. I’m gonna die, I’ve got genital warts or maybe it’s syphilis ! Why did I take that risk ? How can I possibly go to the clinic ? My life is ruined”. Eventually, six months later, the above distraught individual finally plucks up courage to go to the GU Clinic, only to be told those lumps are completely normal, they have always been there – you have just never looked that hard before.
The above story is not fantasy. It happens everyday in GU Clinics up and down the country. First of all, if people are worried, they should have no hesitation in going to a GU Clinic that are staffed by kind sympathetic people who have seen it all before. In the meantime, this section deals with common, normal lumps and bumps that can often be mistaken for something more serious by people who have never seen them before. Let’s face it, how can mere mortals be expected to know these subtle variations, they haven’t examined thousands of genitals, whereas, we have — we get paid for it ! Let’s do the men’s bits first, as believe it or not, they are usually the most neurotic and anxious in this area.
Many young people only see their own genitalia. It is therefore almost impossible for young men and women to know if recent changes, new developments, colour variation and lumpy bumpy bits are, in fact, a normal variant or something they should rush to their clinic with. Indeed, in a few cases, even experienced doctors and nurses can be uncertain whether pearly penile papules or vestibular papillae are really that or early genital warts. It is, however, a satisfying consultation to be able to totally reassure some patients that the ‘lesions’ they are looking at are just a normal variation or else a harmless anomaly of no significance. It is even more reassuring if they can be shown a picture, from an atlas such as this, that is identical to their condition.
Pearly penile papules
Most penises have some and some penises have a lot (Fig.1). These seem to develop more prominently during teenage years and can be alarming to young men. They are completely normal glands. They will never go away and they should not be treated, even if some patients think they look ugly and are demanding something must be done.
These are normal glands that are scattered on either side of the frenulum. Often there are just three or four lined up symmetrically. However, more often there is a scattering of glands that can look suspiciously like genital warts to the inexperienced eye (Fig.2). In darker coloured skin they can be even more dramatic (Fig.3). The glands are usually small and smooth in comparison to warts which have a rough surface. When both are present as in Figure 4, it is very important to point these out to the patient because during home treatment some patients will treat these glands thinking they are warts. The glands, of course, will not respond to the home therapy (podopyhllotoxin or imiquimod) and the patient will become disillusioned with the treatment.
These glands are scattered in clusters along the reflex prepuce, the shaft of the penis and in the vestibular area of the vulva. In some patients, these patches of glands can be extensive and can be quite dramatic, especially when the skin is stretched (Fig.5). Figure 6 shows penile skin with many of these small glands and there is a wart for comparison. In some patients there can be just one or two patches, as in Figure 7 or they can be more confluent, as in Figure 8.
These small frond like glands (Fig.9) can be quite confusing if they are extensive. In some patients it may be almost impossible to tell whether they are early genital warts or vestibular papillae (Fig.10). Unlike warts, vestibular papillae are usually located in a symmetrical fashion. However, if uncertain, it’s best just wait a month or two and review.
It is surprising that in this day and age some young men have never been told to pull back the foreskin and wash out the debris that accumulates underneath and, on occasions, young men can present with an apparent inability to retract the foreskin and pain and discomfort in the penis. However, on gentle but full retraction of the foreskin, for the first time ever, there can be some alarming concretions and debris uncovered ! (Fig.11). This young man just needed to go home and wash this in warm soapy water three times a day for two weeks, and on his return the skin was in pristine condition.
These are very common in the genital area. They can be alarming. They can grow quite fast, and many patients want surgical excision of these for cosmetic reasons. In some cases, however, they can be relatively discreet, painless and even unnoticed, as in Figure 12. When they are on the scrotum they can be very prominent and most men want something done (Fig.13a, 13b.). These, however, are quite harmless, can be left alone, other than for cosmetic reasons.
This is a cordlike swelling that develops behind the coronal sulcus. It is a lymph channel that has become solidified. The cordlike swelling can be smooth (Fig.14) or develop knobbly lumps and cause concern over cancer (Fig.15). This can happen spontaneously or it can happen after vigorous sex or masturbation. It can be painful, so anti inflammatory medication may be necessary i.e. Ibuprofen 400mg three times daily with food. The cordlike swelling gradually disappears and is of no consequence. Patients must be reassured that it is not a clot.
Various degrees of hypospaedius are commonly seen. If it is severe and the urethral opening is significantly distant from the anatomical meatus, surgery may be required, particularly if the young man is disturbed by the appearance.
Occasional cysts may appear in infancy or later in life and only need intervention if the patient wants it. In Figs 16, 17, this para meatal congenital cyst grew larger with time and eventually was surgically removed at 31 years of age.
Fear and embarrassment over perceived genital anomalies is relatively common. Reassurance, delivered with authority and confidence and occasionally backed up by images such as these, is curative.
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