Clinical Focus
16 FEBRUARY 2024 ausdoc . com . au
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A patient presents with a two-month history of a single erythematous plaque on the glans penis .
Dr Ryan Holmes GP in Sydney , NSW .
GARY , a 68-year-old male , presents with a two-month history of a persistent red “ rash ” on his penis . There is no associated discomfort , itching or burning . He does not have any dysuria or lower urinary tract symptoms , and there is no urethral discharge . Gary denies the possibility of an STI . He is in a long-term monogamous heterosexual relationship . His medical history includes previous coronary artery stenting and asthma for which he regularly takes aspirin , olmesartan , rosuvastatin and inhaled budesonide – formoterol .
There is no past history of diabetes , malignancy or any dermatological conditions .
Gary is uncircumcised , and on examination , the area of concern appears to be a single erythematous patch / plaque on the glans penis ( pictured ). Gary confirms this is the lesion he is describing and that it has been stable in appearance over the two-month period . The plaque is slightly tender and well circumscribed . There is no urethral discharge , testicular tenderness , mass or inguinal lymphadenopathy . There are no other lesions on full skin examination .
Investigation
Urine dipstick is negative for blood , nitrites and leukocytes . A swab is collected from the base of the lesion , which shows mixed skin flora but no growth of pathogenic organisms , including HSV and syphilis . Syphilis serology is also negative .
Management
A provisional diagnosis of tinea cruris is made , and Gary is given general genital hygiene advice and prescribed a trial of hydrocortisone and clotrimazole cream for two weeks . He is asked to return if it has not resolved at this point .
He returns one month later and reports a slight but incomplete improvement in the lesion .
Given the lack of complete resolution , a punch biopsy is taken for histopathology . This shows an eroded mucosa with lymphocytic infiltration in the stroma , spongiosis and numerous sheets of plasma cells . In the clinical context , this is most in keeping with Zoon ’ s balanitis , also known as plasma cell balanitis .
Discussion
Zoon ’ s balanitis is an inflammatory condition of the glans penis that occurs almost exclusively in middle- to older-aged uncircumcised men .
It usually presents as a single shiny or glistening red – orange plaque . It is often asymptomatic but can present with slight irritation or itch .
The aetiology is thought to be a combination of inadequate hygiene and prepuce dysfunction , resulting in retention of urine and / or smegma under the foreskin that leads to chronic irritation of the mucosa of the glans