Ano-genital Lumps
Overview
Ano-genital lumps (papules/nodules/vesicles)
Possible causes
- STIs: human papillomavirus (HPV), Molluscum contagiosum virus, herpes simplex virus (HSV), syphilis (may cause lymphadenopathy)
- Other conditions: folliculitis, impetigo, immunological conditions, normal anatomical variations.
Clinical presentation
| Symptoms | Comments/Consideration |
|---|---|
| Vesicles |
Herpes simplex viruses (HSV) 1 and 2 are the most common causes, generally evident by clusters of small painful vesicles. Other causes include bullous impetigo (S. aureas) and immunobullous diseases such as pemphigus. |
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Papules/Nodules
|
Genital warts caused by human papillomavirus (HPV) can vary greatly in size, number and appearance. Molluscum contagiosum causes regular pale dome shaped lesions with a central punctum. Syphilis can cause painless irregular nodules with a wart-like appearance in moist anatomical sites. Syphilis lesions can be painful if super-infected by other microbes. Bacterial folliculitis is common in hair bearing areas, which can sometimes be difficult to distinguish from Molluscum contagiosum. Care must be taken to avoid misdiagnosis of normal vestibular papillae, scrotal sebaceous glands and pearly penile papules as warts. These conditions are usually notable for the regularity and consistency in their appearance and distribution of lesions. |
Diagnosis
| Infection | Site/Specimen | Test |
|---|---|---|
| Genital warts (human papillomavirus (HPV)) |
Diagnosis is usually based on visual appearance. If there are atypical lesions (e.g. variable pigmentation, raised plaque-like lesions or cervical warts, consider histology biopsy to exclude cancer). HPV DNA testing is not used to diagnose genital warts. |
|
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Molluscum contagiosum |
Clinical diagnosis
|
|
| Herpes | Swab of base of ulcer or de-roofed vesicle | NAAT |
| Syphilis | Swab of base of ulcer Blood |
NAAT Serology. If clinical suspicion of syphilis, refer to the syphilis guideline. |
| Donovanosis | Dry swab or punch biopsy of lesions. | Histology has low to moderate sensitivity but highly specific; requires experienced histopathologist as classic Donovan bodies may be sparse. NAAT is highly sensitive and specific but NAAT only available in research laboratories. |
| Chancroid | If chancroid suspected, seek specialist advice. | |
| NAAT – Nucleic Acid Amplification Test | ||
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Management
| Principal Treatment Options | ||
|---|---|---|
| Infection | Recommended | Alternative |
| Genital warts (human papilloma virus (HPV)) |
Patient applied podophyllotoxin 0.15% cream or 0.5% paint topically applied, BD for 3 days, then 4 days off, repeated weekly for 4-6 cycles until resolution. Paint is more suited for use on external keratinised skin. Cream is best used in perianal area, introital area and under the foreskin. |
Clinician initiated Cryotherapy weekly.
|
| Herpes* |
Initial episode: Valaciclovir 500mg PO, BD for 5 - 10 days. Recurrence: Episodic therapy: Valaciclovir 500mg PO, BD for 3 days. Suppressive therapy: Valaciclovir 500mg PO, daily for 6 months. |
Initial episode: |
| Syphilis# | Benzathine penicillin 1.8g IMI, stat | Procaine penicillin 1.5g IMI, daily for 10 days |
| Donovanosis | Azithromycin 500mg PO, daily for 7 days. OR Azithromycin 1g PO, once weekly for at least 4 weeks, until complete resolution of lesions. |
Doxycycline 100mg PO, BD for a minimum of 4 weeks, until complete resolution of lesions. |
| Chancroid | Azithromycin 1g PO, stat. OR Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat. OR Ciprofloxacin 500mg PO, BD for 3 days. |
Alternative regimens are not recommended. |
| Molluscum contagiosum | De-roof lesions with needle and express contents. | Topical imiquimod may be useful, but the optimum treatment schedule has yet to be determined. |
Treatment advice
* Limited evidence comparing other antiviral agents (aciclovir and famciclovir) with valaciclovir indicate that they are therapeutically equivalent for treating herpes. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment. Initial episodes of herpes may require a longer duration of treatment.
# Seek specialist advice for all patients who are pregnant, hypersensitive to penicillin or who are HIV positive.
Other immediate management
- If a specific STI is considered likely, refer to the specific guideline for information on advice to patient of any requirement to abstain from sexual contact.
- When diagnosis is in doubt consider recommending abstinence until results of diagnostic tests are available, especially where significant behavioural risk factors are present.
- Contact tracing.
Contact Tracing
- Contact tracing is a high priority for syphilis, donovanosis and chancroid and should be performed in all patients with confirmed infection.
- If the contact of syphilis is confirmed (i.e. the named contact names the index case) then treatment should be offered even if the serology is negative.
- Contact tracing for herpes and genital warts is not recommended.
See Australasian Contract Tracing Manual for more information.
Follow up
If STI confirmed, follow up provides an opportunity to:
- Confirm patient adherence with treatment and assess for symptom resolution.
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
Consider alternative diagnoses, biopsy or referral for any lesions not responding as expected to treatment.
For test of cure (TOC) and retesting advice see:
Auditable outcomes
100% of patients complaining of a genital lump have a genital examination.
References
- Rane V, Read T. Penile appearance, lumps and bumps. Australian Family Physician. 2013;42(5):270-274.
- Syed TA, Lundin S, Ahmad M. Topical 0.3% and 0.5% podophyllotoxin cream for self-treatment of molluscum contagiosum in males. A placebo-controlled, double-blind study. Dermatology. 1994;189(1):65-68.