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Intraurethral condylomas acuminata in previous hypospadias repair
INTRAURETHRAL PREVIOUS MELCHIORE LEONARD MONEER
CONDYLOMAS
HYPOSPADIAS L. BUSCEMI,
M. SILBER,
ACUMINATA
IN
REPAIR
M.D.
M.D.
K. HANNA, M.D.
From the Division of Urology, Department of Surgery, Long Island Jewish-Hillside Medical Center, Queens Hospital Center Affiliation, Jamaica, New York
ABSTRACT-Zn recent years, the number of reported cases of venereal warts has increased more than fivefold, and various methods of treating these lesions have been described. We herein report reDair. a rare case of condvlomas acuminata in a hupowadias
Condylomas acuminata (venereal warts) is the most frequently occurring benign tumor of the penis.’ In 1966, the Center for Disease Control reported 169,000 documented cases of venereal warts; in 1981 this figure rose to 946,000.2 We believe the following is the only case of condylomas acuminata in a hypospadias repair reported in recent years.
multiple papillary lesions involving much of the skin urethra and extending to the bulbous urethra, which was involved to a lesser extent. At this time these warts were endoscopically debulked using biopsy forceps. The bladder was free of involvement. Pathologic examination of the urethral biopsy fragments confirmed the diagnosis of condylomas acuminata (Fig. 2). Five per cent
Case Report A twenty-one-year-old homosexual Hispanic male complained of dysuria and bouts of urethral irritation with gross hematuria following sexual intercourse. Eleven years ago the patient underwent repair of a penile hypospadias. There is also a history of gonorrhea treated with penicillin and condylomas acuminata of the external penis treated with podophyllin. The meatus was adequate in caliber and was located at the most distal portion of the glans (Fig. 1). The skin urethroplasty was approximately 3 cm in length. No lesions were visible on the external surface of the penis, but multiple warts were noted in the perianal region. Results of intravenous urogram were normal. A voiding cystourethrogram demonstrated inadequate evacuation of the bladder with multiple filling defects (Fig. 1). Cystoscopy disclosed
398
FIGURE 1. Pretreatment voiding cystouTethTogram demonstrating multiple filling defects.
UROLOGY
/ OCTOBER1985
/ VOLUMEXXVI,NUMBER4
FIGURE
2.
tram&ear
Histopathologic examination shows inand cytoplasmic inclusion bodies.
5-fluorouracil (S-FU) cream was instilled intraurethrally by the patient after each void for five weeks. Repeat urethroscopy and urethrogram revealed that the urethra was free of visible disease (Fig. 3). The patient was referred to the Proctology Clinic for treatment of anal warts. Comment Venereal warts usually are found at the base of the glans and overlying prepuce. Like most other warts, they appear to be caused by the papovavirus. Histologically they consist of multiple villi originating from a definite pedicle with intranuclear and cytoplasmic inclusion bodies (Fig. 2). Though most are thought to be transmitted through an infected sexual partner, many are transmitted without venereal contact. In the dermis, there is a slight to moderate lymphocytic infiltrate. Malignant transformation of these warts, although rare, has been reported.3 An average of 5 per cent of reported cases of venereal warts involve the urethra,4 and 80 per cent of these lesions will be within the distal 3 cm.5 Several cases of venereal warts invading the bladder also have been reported.4%5 Various methods of treating condylomas have been reported;0.7 the most popular is excision and fulguration.4,8 Kaplan6 reported treatment of these warts with podophyllin. Rosenberg and Al-Askari’ reported 2 cases of intraurethral condylomas acuminata. They recommend intraurethral instillation of thiotepa once a week for seven to ten weeks to avoid stricture formation that may develop if treated with electric fulguration or podophyllin. The administration of an autogenous vaccine has been reported to activate the defense mechanism of the host against condylomas.s Gigax and Robinson9 recommended weekly in-
UROLOGY
I/ OCTOBER
1985
I VOLUME
XXVI. NUMBER
FIGURE 3. Post-treatment voiding cystourethrogram demonstrates urethra is free of disease.
traurethral instillation of 10 cc of 0.5% colchitine. DeBenedictis, Marmar, and Prais9 reported a case that necessitated the entire anterior urethra be opened and treated. After being completely clear of condylomas for ten months, the urethra was closed. Bissada, Redman, and Suliemanl” recommended the use of 5% 5-fluorouracil for twenty minutes twice a week for five weeks. Fuselier et al.” reported the destruction of meatal condylomas with carbon dioxide laser. Selected patients needed a urethral meatotomy for better exposure. This report demonstrates how condylomas acuminata in our patient were diagnosed and successfully treated without disruption of the previous hypospadias repair. 530 First Avenue New York, New York 10016 (DR. HANNA) References 1. Netter F, and Vest S: Diseases of the Penis and Urethra, The Ciba Collection of Medical Illustrations 2: 42 (1965). 2. American Medical News, National Section 26: 25, 36, July 1, 1983. 3. Kovi J, Tillman MA, and Lee SM: Malignant transformation of condyloma acuminatum, Am J Clin Path01 61: 702 (1974). 4. Kleiman H, and Lancaster Y: Condylomata acuminata of the bladder, J Urol 88: 52 (1962). 5. DeBenedictis T, Marmar J, and Praiss D: Intraurethral condylomas acuminata, management and review of literature, ibid 118: 767 (1977). 6. Kaplan IW: Condylomata acuminata, New Orleans Med Surg J 94: 388 (1942). 7. Rosenberg JW, and Al-Askari S: Management of intraurethral condylomas acuminata, J Urol 110: 686 (1973). 8. Ablin RJ, and Curtis WW: Condylomata acuminata: treatment by autogenous vaccine, Ill Med J 147: 343 (1975). 9. Gigax JH, and Robinson JR: The successful treatment of intraurethral condylomas acuminata with colchicine, J Urol 105: 809 (1971). 10. Bissada NK, Redman JF, and Sulieman JS: Condylomas of male urethra, successful management with 5-fluorouracil, Urology 3: 499 (1974). 11, Fuselier HA Jr, et al: Treatment of condylomata acuminata with carbon dioxide laser, Urology 15: 265 (1980).
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399
CONDYLOMAS
HYPOSPADIAS L. BUSCEMI,
M. SILBER,
ACUMINATA
IN
REPAIR
M.D.
M.D.
K. HANNA, M.D.
From the Division of Urology, Department of Surgery, Long Island Jewish-Hillside Medical Center, Queens Hospital Center Affiliation, Jamaica, New York
ABSTRACT-Zn recent years, the number of reported cases of venereal warts has increased more than fivefold, and various methods of treating these lesions have been described. We herein report reDair. a rare case of condvlomas acuminata in a hupowadias
Condylomas acuminata (venereal warts) is the most frequently occurring benign tumor of the penis.’ In 1966, the Center for Disease Control reported 169,000 documented cases of venereal warts; in 1981 this figure rose to 946,000.2 We believe the following is the only case of condylomas acuminata in a hypospadias repair reported in recent years.
multiple papillary lesions involving much of the skin urethra and extending to the bulbous urethra, which was involved to a lesser extent. At this time these warts were endoscopically debulked using biopsy forceps. The bladder was free of involvement. Pathologic examination of the urethral biopsy fragments confirmed the diagnosis of condylomas acuminata (Fig. 2). Five per cent
Case Report A twenty-one-year-old homosexual Hispanic male complained of dysuria and bouts of urethral irritation with gross hematuria following sexual intercourse. Eleven years ago the patient underwent repair of a penile hypospadias. There is also a history of gonorrhea treated with penicillin and condylomas acuminata of the external penis treated with podophyllin. The meatus was adequate in caliber and was located at the most distal portion of the glans (Fig. 1). The skin urethroplasty was approximately 3 cm in length. No lesions were visible on the external surface of the penis, but multiple warts were noted in the perianal region. Results of intravenous urogram were normal. A voiding cystourethrogram demonstrated inadequate evacuation of the bladder with multiple filling defects (Fig. 1). Cystoscopy disclosed
398
FIGURE 1. Pretreatment voiding cystouTethTogram demonstrating multiple filling defects.
UROLOGY
/ OCTOBER1985
/ VOLUMEXXVI,NUMBER4
FIGURE
2.
tram&ear
Histopathologic examination shows inand cytoplasmic inclusion bodies.
5-fluorouracil (S-FU) cream was instilled intraurethrally by the patient after each void for five weeks. Repeat urethroscopy and urethrogram revealed that the urethra was free of visible disease (Fig. 3). The patient was referred to the Proctology Clinic for treatment of anal warts. Comment Venereal warts usually are found at the base of the glans and overlying prepuce. Like most other warts, they appear to be caused by the papovavirus. Histologically they consist of multiple villi originating from a definite pedicle with intranuclear and cytoplasmic inclusion bodies (Fig. 2). Though most are thought to be transmitted through an infected sexual partner, many are transmitted without venereal contact. In the dermis, there is a slight to moderate lymphocytic infiltrate. Malignant transformation of these warts, although rare, has been reported.3 An average of 5 per cent of reported cases of venereal warts involve the urethra,4 and 80 per cent of these lesions will be within the distal 3 cm.5 Several cases of venereal warts invading the bladder also have been reported.4%5 Various methods of treating condylomas have been reported;0.7 the most popular is excision and fulguration.4,8 Kaplan6 reported treatment of these warts with podophyllin. Rosenberg and Al-Askari’ reported 2 cases of intraurethral condylomas acuminata. They recommend intraurethral instillation of thiotepa once a week for seven to ten weeks to avoid stricture formation that may develop if treated with electric fulguration or podophyllin. The administration of an autogenous vaccine has been reported to activate the defense mechanism of the host against condylomas.s Gigax and Robinson9 recommended weekly in-
UROLOGY
I/ OCTOBER
1985
I VOLUME
XXVI. NUMBER
FIGURE 3. Post-treatment voiding cystourethrogram demonstrates urethra is free of disease.
traurethral instillation of 10 cc of 0.5% colchitine. DeBenedictis, Marmar, and Prais9 reported a case that necessitated the entire anterior urethra be opened and treated. After being completely clear of condylomas for ten months, the urethra was closed. Bissada, Redman, and Suliemanl” recommended the use of 5% 5-fluorouracil for twenty minutes twice a week for five weeks. Fuselier et al.” reported the destruction of meatal condylomas with carbon dioxide laser. Selected patients needed a urethral meatotomy for better exposure. This report demonstrates how condylomas acuminata in our patient were diagnosed and successfully treated without disruption of the previous hypospadias repair. 530 First Avenue New York, New York 10016 (DR. HANNA) References 1. Netter F, and Vest S: Diseases of the Penis and Urethra, The Ciba Collection of Medical Illustrations 2: 42 (1965). 2. American Medical News, National Section 26: 25, 36, July 1, 1983. 3. Kovi J, Tillman MA, and Lee SM: Malignant transformation of condyloma acuminatum, Am J Clin Path01 61: 702 (1974). 4. Kleiman H, and Lancaster Y: Condylomata acuminata of the bladder, J Urol 88: 52 (1962). 5. DeBenedictis T, Marmar J, and Praiss D: Intraurethral condylomas acuminata, management and review of literature, ibid 118: 767 (1977). 6. Kaplan IW: Condylomata acuminata, New Orleans Med Surg J 94: 388 (1942). 7. Rosenberg JW, and Al-Askari S: Management of intraurethral condylomas acuminata, J Urol 110: 686 (1973). 8. Ablin RJ, and Curtis WW: Condylomata acuminata: treatment by autogenous vaccine, Ill Med J 147: 343 (1975). 9. Gigax JH, and Robinson JR: The successful treatment of intraurethral condylomas acuminata with colchicine, J Urol 105: 809 (1971). 10. Bissada NK, Redman JF, and Sulieman JS: Condylomas of male urethra, successful management with 5-fluorouracil, Urology 3: 499 (1974). 11, Fuselier HA Jr, et al: Treatment of condylomata acuminata with carbon dioxide laser, Urology 15: 265 (1980).
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