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.
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.

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.

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.
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

Specimen collection

Clinician collected | Self-collection

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. OR Patient applied imiquimod 5% cream topically, 3 times per week at bedtime (wash after 6-10 hours) until resolution (up to 16 weeks).	Clinician initiated Cryotherapy weekly. Excision under local anaesthetic e.g. localised pedunculated warts. Ablative therapy under general anaesthetic.
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: Aciclovir 400mg PO, TDS for 5 - 10 days. Recurrence: Episodic therapy: Famciclovir 1g PO, BD for 1 day. Suppressive therapy: Famciclovir 250mg PO, BD for 6 months.
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.

Last Updated: Wednesday, 11 July 2018