- Email: [email protected]
Penile Paraffinoma
EUF-525; No. of Pages 5 E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Review – Reconstructive Urology
Penile Paraffinoma Alison Pauline Downey *, Nadir I. Osman, Altaf Mangera, Richard D. Inman, Sheilagh V. Reid, Christopher R. Chapple Royal Hallamshire Hospital, Sheffield, UK
Article info
Abstract
Article history: Accepted June 21, 2018
Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. Patient summary: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common. © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Associate Gratzke
Editor:
Keywords: Paraffinoma Penis Reconstruction
Christian
* Corresponding author. Department of Urology, Royal Hallamshire Hospital, 32 Nettleham Road, Sheffield S8 8SX, UK. E-mail address: [email protected] (A.P. Downey).
1.
Introduction
Penile paraffinoma (also known as a sclerosing lipogranuloma or oleoma) is a rare cause of penile mass and occurs following subcutaneous liquid paraffin injection [1]. The
practice of injecting substances into the genitals for cosmesis was first described in 1899 by Austrian surgeon Robert Gersuny [2]. Following encouraging initial results, its use was widened to include breast augmentation and facial lesions. However, subsequent reports of late complications due to lipogranuloma formation led to a rapid decline in its
https://doi.org/10.1016/j.euf.2018.06.013 2405-4569/© 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 2
E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
medical use [3]. Despite this, it is clear that there has been a persistent use of injection of paraffin and other straight saturated hydrocarbons (eg, Vaseline) for the purposes of penile enlargement. Indeed, we have observed an increasing number of cases presenting with penile paraffinoma and, with this analysis of the literature, aimed to review the evidence relating to the management of these patients (Figs. 1 and 2). 2.
Evidence acquisition
PubMed and Scopus databases were screened for papers including the search terms “penile paraffinoma” OR “sclerosing lipogranuloma of penis” OR “mineral oil penis” OR “penile granuloma” OR “penile oleoma”. In total, 36 papers, published in English between 1956 and 2017, were identified, which included 10 case series and 26 case reports [1–36]. 3.
Fig. 1 – Clinical appearance of penile paraffinoma.
Fig. 2 – Clinical appearance of penile paraffinoma.
Evidence synthesis
A total of 124 cases have been reported with a mean age of 36.3 yr (range 17–71 yr). The majority originated in Korea (31.7%), Bulgaria (19.8%), and Hungary (14.3%; Fig. 3). A variety of materials were injected, with the most common being liquid paraffin (80.2%). Silicone was used in 4%, Jamaica oil in 3.2%, mineral oil in 4.8%, baby oil in 2.4%, mechanical oil in 1.6%, and melted lipstick in 0.8%; 3.2% used an undetermined substance. The median interval between injection and presentation was 24 mo. Patients presented with a variety of symptoms including penile pain and swelling (30.2%), ulceration/fistulae (15.4%), and deformity (11.4%). Foreskin-related problems occurred in 8.7% (one nonreducible paraphimosis and 10 phimosis cases) and voiding dysfunction in 5.4%. Potentially life-threatening complications were gangrene and sepsis with palpable inguinal lymphadenopathy (4.7%), and there was one case of penile squamous cell carcinoma associated with paraffinoma 35 yr following injection of mineral oil (Table 1). Both ultrasound (USS; 14.8%) and magnetic resonance imaging (MRI; 14.3%) have been used in diagnosis and surgical planning. USS appearances of paraffinoma were described as hyperechoic lesions associated with acoustic shadowing and thickening of subcutaneous planes. MRI appearances were usually described as low signal on both T1- and T2-weighted images with minimal enhancement after gadolinium. In contrast, Ahmed et al [35] reported lesions that were of high signal on both T1and T2-weighted images in two patients who had been injected with silicone and baby oil, respectively; both patients had undergone relatively recent procedures (<3 mo). Management options were understandably diverse. Ten patients were managed conservatively, that is, observation and analgesia (8.7%). Of these, there was a need for antibiotic therapy in 11 (5.6%), and definitive treatment with excision and direct closure in three/split skin graft in two
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 E U RO P E A N U RO L O GY F O C U S X X X ( 2 018 ) X X X– X X X
3
-QTGC $WNICTKC *WPICT[ 7- /CNC[UKC 5KPICRQTG 75# 4QOCPKC 6WTMG[ 6JCKNCPF .CQU /[CPOCT 7MTCKPG 5NQXCMKC 4WUUKC ,CRCP )TGGEG /QNFQXC
Fig. 3 – Geographical distribution of reported cases.
Table 1 – Various symptoms presented by the patients. Clinical feature
No. of patients (%)
Pain/swelling Penile deformity Painful erections Skin ulcer/fistulae Erectile dysfunction Skin necrosis Inguinal lymph nodes Voiding dysfunction Paraphimosis Phimosis Sepsis/abscess/gangrene SCC Penile deformity
45 (30.2) 17 (11.4) 12 (8) 23 (15.4) 9 (6) 7 (4.7) 4 (2.7) 8 (5.4) 1 (0.7) 10 (6.7) 9 (6) 1 (0.7) 17 (11.4)
SCC = squamous cell carcinoma.
cases. Surgical intervention was necessary in the majority of patients (91.3%). Circumcision was performed for paraffinoma limited to the foreskin (five cases, 4%). Local excision of paraffinoma was performed in 106 patients (84.1%). Of these, 29 underwent primary closure, which was successful in 25. Two patients developed recurrent lesions requiring further repeat excision and closure, and the remaining two required split skin grafting following wound breakdown. Seventy patients underwent local excision followed by reconstruction with skin grafts or flaps (55.55%). Split skin grafts were used in eight patients (three from the thigh and five from unspecified sites), prepuce in five, and penile skin in two. Bipedicled scrotal skin flap reconstruction was performed in 55 patients. In 16 cases, the operative approach was not specified. Only three patients undergoing reconstruction required a second procedure, all of whom
had had a scrotal skin flap reconstruction, including Zplasty for skin tightness and further debridement of persistent lesions. Six patients had extensive debridement requiring scrotal embedment of the penis and proceeded to a delayed scrotal skin flap reconstruction 2–6 mo later. Histological findings were reported in 70 cases; the most consistent findings were giant cell infiltration and lipid vacuoles in keeping with lipogranuloma. The mean duration of follow-up was 15.8 mo. There were no documented cases of sexual dysfunction or voiding difficulties in patients who had undergone surgical treatment. 4.
Discussion
The geographic distribution of this practice is concentrated in southeast Asia and eastern Europe; however, the UK is seeing an increase in incidence. In our centre, we have had three patients (mean age 38 yr) of central European origin presenting with complications of penile paraffinoma over a 2-yr period, all of whom had undergone injection of paraffin. MRI findings of subcutaneous tissue inflammation not involving Buck’s fascia and lymph node inflammation in one patient are consistent with those described in the literature; histopathology from one patient showed vacuolation and histiocyte reaction (again in keeping with literature reports). All three patients presented with penile swelling, pain, and penile deformation. One patient had signs of sepsis with multifocal abscess, which grew Staphylococcus aureus cultures. All were treated with intravenous antibiotics and analgesia initially. One patient responded to conservative management, and was referred to the plastic team for excision and reconstruction. One
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 4
E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
patient required circumcision and excision of paraffinoma with direct closure, while the other required incision and drainage of a superficial abscess as an emergency. Both were then referred to plastic surgery for delayed debridement and reconstruction as needed, in line with literature reports. Most individuals either self-inject or receive injections administered by non-healthcare professionals with the aim of increasing penile girth; our patient population had had paraffin injected by a non-healthcare professional with the aim of penile enlargement. It is possible that patients presenting with symptoms represent the “tip of the iceberg”, with others either too embarrassed to seek treatment or not presenting due to language barriers (in immigrant populations). The most commonly injected substance is paraffin, and patients may present anywhere from days following injection to years later with an inflammatory tissue reaction of varying degrees of severity. Imaging is not a diagnostic necessity; however, in some cases it, by preoperatively assessing the extent of tissue involvement, can help plan definitive treatment. There is no evidence for superiority of MRI over USS; however, MRI images are more readily interpretable and provide more anatomical information to aid surgical planning. Conservative management is used only in more minor cases as the majority of patients present with a symptomatic problem. Definitive management is by surgical excision and reconstruction as required, with the involvement of plastic surgeons as necessary when complex reconstruction is required to optimise the functional and cosmetic outcome. Whilst circumcision may suffice usually extensive debridement of the penile skin and subcutaneous tissue is required, leaving large tissue defects. The reconstruction method is dependent on the extent of resection, aims to provide adequate skin cover, and includes the use of prepuce flaps, bipedicled scrotal flaps, or split skin grafts. Clearly, there is a need for targeted preventative measures through public health agencies in communities where the practice appears to be more prevalent.
consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
References [1] Alcalde-Alonso M, Velasco-Albendea FJ, Soto-Diaz A, et al. Paraffinoma of the penis and scrotum (sclerosing granuloma of the male genitalia). Indian J Dermatol Venerol Leprol 2017;83:75–7. [2] Singh M, Singh V, Moh CLC. Penile paraffinoma. Med J Malaysia 2015;70:361–2. [3] Cohen JL, Koeleian DM, Krull EA. Penile paraffinoma: self-injection with mineral oil. J Am Acad Dermatol 2002;47:S251–3. [4] Chon W, Koo JY, Park MJ, et al. Paraffin granuloma associated with buried glans penis-induced sexual and voiding dysfunction. World J Mens Health 2017;35:129–32. [5] Morales-Raya C, Calleja-Algarra A, Tous-Romero D, et al. Penile paraffinoma: should we perform ultrasound? Actas Dermosifiliogr 2017;108:478–80. [6] Tsili AC, Xiropotamou ON, Nomikos M, et al. Silicone-induced penile sclerosing lipogranuloma: magnetic resonance imaging finding. J Clin Imaging Sci 2016;6:3. [7] Cormio L, Di Fino G, Scavone C, et al. Magnetic resonance imaging of penile paraffinoma: case report. BMC Med Imaging 2014;14:39. [8] Francis J, Poh Choo Choo A, Wansaicheong Khin-Lin G. Ultrasound and MRI features of penile augmentation by Jamaica Oil injection. A case series. Med Ultrason 2014;16:372–6. [9] Majedah S, Hanafiah M, Awang MK. MRI findings of penile paraffinoma.
BMJ
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bcr-2014-205448. [10] Gomez-Armayones S, Penin RM, Marcoval J. Penile paraffinoma. Actas Dermosifiliogr 2014;105:957–9. [11] Kim SW, Yoon BI, Ha US, et al. Treatment of paraffin-induced lipogranuloma of the penis by bipedicled scrotal flap with Y-V incision. Ann Plast Surg 2014;73:692–5. [12] De Siati M, Selvaggio O, Di Fino G, et al. An unusual delayed presentation of paraffin self-injection for penile girth augmentation. BMC Urol 2013;13:66. [13] Shin YS, Zhao C, Park JK. New reconstructive surgery for penile paraffinoma to prevent necrosis of ventral penile skin. Urology 2013;81:437–41. [14] Sejben I, Racz A, Svebis M, et al. Petroleum jelly-induced penile paraffinoma with inguinal lymphadenitis mimicking incarcerated
Author contributions: Alison Pauline Downey had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
inguinal hernia. Can Urol Assoc J 2012;6:E137–9. [15] Bayraktar
N,
Basar
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2012;2012:202840.
Study concept and design: Downey, Osman, Reid.
[16] Onate Celdran J, Sanchez Rodriguez C, Tomas Ros M, et al. Penile
Acquisition of data: Downey.
paraffinoma after subcutaneous injection of paraffin: Treatment
Analysis and interpretation of data: Downey.
with a two step cutaneous plasty of the penile shaft with scrotal
Drafting of the manuscript: Downey, Osman.
skin. Arch Esp Urol 2012;65:575–8.
Critical revision of the manuscript for important intellectual content: Chapple.
[17] Bachmeyer C, Moguelet P, Gombeaud T, et al. Penile paraffinoma developing during treatment with pegylated interferon alfa-2a for
Statistical analysis: None.
chronic hepatitis C virus infection. Arch Dermatol 2011;147:1232–3.
Obtaining funding: None.
[18] Manny T, Pettus J, Hemal A, et al. Penile sclerosing lipogranulomas
Administrative, technical, or material support: None.
and disfigurement from use of 1Super Extenze among Laotian
Supervision: Mangera, Inman, Reid, Chapple.
immigrants. J Sex Med 2011;8:3505–10.
Other: None.
[19] Ponyai K, Marschalko M, Harsing J, et al. Paraffinoma. J Dtsch
Financial disclosures: Alison Pauline Downey certifies that all conflicts of
[20] Picozzi SC, Carmignani L. Paraffinoma of the penis. Int J Emerg Med
Dermatol Ges 2010;8:686–8. interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript
(eg,
employment/affiliation,
grants
or
funding,
2010;3:507–8. [21] Rosenberg E, Romanowsky I, Asali M, et al. Three cases of penile paraffinoma: a conservative approach. Urology 2007;70(372):e9–10.
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 E U RO P E A N U RO L O GY F O C U S X X X ( 2 018 ) X X X– X X X
[22] Eandi JA, Yao AP, Javidan J. Penile paraffinoma: the delayed presentation. Int Urol Nephrol 2007;39:553–5. [23] Akkus E, Iscimen A, Tasli L, et al. Paraffinoma and ulcer of the external genitalis after self-injection of Vaseline. J Sex Med 2006;3:170–2. [24] Choudhury N, Frame JD, Lewi HJ. Penile paraffinoma and a novel treatment. BJU Int 2003;92(Suppl 3):e14. [25] Santos P, Chaveiro A, Nunes G, et al. Penile paraffinoma. J Eur Acad Dermatol Venerol 2003;17:583–4. [26] May JA, Pickering PP. Paraffinoma of the penis. Calif Med 1956;85:42–4. [27] Foxton G, Vinciullo C, Tait CP, et al. Sclerosing lipogranuloma of the penis. Australas J Dermatol 2011;52(3):e12–4. [28] Bjurlin MA, Carlsen J, Grevious M, et al. Mineral oil-induced sclerosing lipogranuloma of the penis. J Clin Aesthet Dermatol 2010;3 (9):41–4. [29] Nyirady P, Kelemen Z, Kiss A, et al. Treatment and outcome of Vaseline-induced sclerosing lipogranuloma of the penis. Urology
5
[30] Inn FX, Imran FH, Ali MF, et al. Penile augmentation with resultant foreign material granuloma and sequalae. Malays J Med Sci 2012;19:81–3. [31] Karakan T, Ersoy E, Hascicek M, et al. Injection of Vaseline under penis skin for the purpose of penis augmentation. Case Rep Urol 2012;2012, 510612. [32] Pehlivanov G, Kavaklieva S, Kazandijeva J, et al. Foreign-body granuloma of the penis in sexually active individuals (penile paraffinoma). J Eur Acad Dermatol Venereol 2008;22:845–51. [33] Lee SW, Bang CY, Kim JH. Penoscrotal reconstruction using groin and bilateral superomedial thigh flaps: a case of penile vaselinoma causing Fournier’s gangrene. Yonsei Med J 2007;48:723–6. [34] Ciancio SJ, Coburn M. Penile salvage for squamous cell carcinoma associated with mineral oil injection. J Urol 2000;164:1650. [35] Ahmed U, Freeman A, Kirkham A, et al. Self injection of foreign materials into the penis. Ann R Coll Surg Engl 2017;99:e78–82. [36] Kalsi JS, Arya M, Peters J, et al. Grease-gun injury to the penis. J R Soc Med 2002;95:254.
2008;71:1132–7.
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Review – Reconstructive Urology
Penile Paraffinoma Alison Pauline Downey *, Nadir I. Osman, Altaf Mangera, Richard D. Inman, Sheilagh V. Reid, Christopher R. Chapple Royal Hallamshire Hospital, Sheffield, UK
Article info
Abstract
Article history: Accepted June 21, 2018
Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. Patient summary: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common. © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Associate Gratzke
Editor:
Keywords: Paraffinoma Penis Reconstruction
Christian
* Corresponding author. Department of Urology, Royal Hallamshire Hospital, 32 Nettleham Road, Sheffield S8 8SX, UK. E-mail address: [email protected] (A.P. Downey).
1.
Introduction
Penile paraffinoma (also known as a sclerosing lipogranuloma or oleoma) is a rare cause of penile mass and occurs following subcutaneous liquid paraffin injection [1]. The
practice of injecting substances into the genitals for cosmesis was first described in 1899 by Austrian surgeon Robert Gersuny [2]. Following encouraging initial results, its use was widened to include breast augmentation and facial lesions. However, subsequent reports of late complications due to lipogranuloma formation led to a rapid decline in its
https://doi.org/10.1016/j.euf.2018.06.013 2405-4569/© 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 2
E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
medical use [3]. Despite this, it is clear that there has been a persistent use of injection of paraffin and other straight saturated hydrocarbons (eg, Vaseline) for the purposes of penile enlargement. Indeed, we have observed an increasing number of cases presenting with penile paraffinoma and, with this analysis of the literature, aimed to review the evidence relating to the management of these patients (Figs. 1 and 2). 2.
Evidence acquisition
PubMed and Scopus databases were screened for papers including the search terms “penile paraffinoma” OR “sclerosing lipogranuloma of penis” OR “mineral oil penis” OR “penile granuloma” OR “penile oleoma”. In total, 36 papers, published in English between 1956 and 2017, were identified, which included 10 case series and 26 case reports [1–36]. 3.
Fig. 1 – Clinical appearance of penile paraffinoma.
Fig. 2 – Clinical appearance of penile paraffinoma.
Evidence synthesis
A total of 124 cases have been reported with a mean age of 36.3 yr (range 17–71 yr). The majority originated in Korea (31.7%), Bulgaria (19.8%), and Hungary (14.3%; Fig. 3). A variety of materials were injected, with the most common being liquid paraffin (80.2%). Silicone was used in 4%, Jamaica oil in 3.2%, mineral oil in 4.8%, baby oil in 2.4%, mechanical oil in 1.6%, and melted lipstick in 0.8%; 3.2% used an undetermined substance. The median interval between injection and presentation was 24 mo. Patients presented with a variety of symptoms including penile pain and swelling (30.2%), ulceration/fistulae (15.4%), and deformity (11.4%). Foreskin-related problems occurred in 8.7% (one nonreducible paraphimosis and 10 phimosis cases) and voiding dysfunction in 5.4%. Potentially life-threatening complications were gangrene and sepsis with palpable inguinal lymphadenopathy (4.7%), and there was one case of penile squamous cell carcinoma associated with paraffinoma 35 yr following injection of mineral oil (Table 1). Both ultrasound (USS; 14.8%) and magnetic resonance imaging (MRI; 14.3%) have been used in diagnosis and surgical planning. USS appearances of paraffinoma were described as hyperechoic lesions associated with acoustic shadowing and thickening of subcutaneous planes. MRI appearances were usually described as low signal on both T1- and T2-weighted images with minimal enhancement after gadolinium. In contrast, Ahmed et al [35] reported lesions that were of high signal on both T1and T2-weighted images in two patients who had been injected with silicone and baby oil, respectively; both patients had undergone relatively recent procedures (<3 mo). Management options were understandably diverse. Ten patients were managed conservatively, that is, observation and analgesia (8.7%). Of these, there was a need for antibiotic therapy in 11 (5.6%), and definitive treatment with excision and direct closure in three/split skin graft in two
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 E U RO P E A N U RO L O GY F O C U S X X X ( 2 018 ) X X X– X X X
3
-QTGC $WNICTKC *WPICT[ 7- /CNC[UKC 5KPICRQTG 75# 4QOCPKC 6WTMG[ 6JCKNCPF .CQU /[CPOCT 7MTCKPG 5NQXCMKC 4WUUKC ,CRCP )TGGEG /QNFQXC
Fig. 3 – Geographical distribution of reported cases.
Table 1 – Various symptoms presented by the patients. Clinical feature
No. of patients (%)
Pain/swelling Penile deformity Painful erections Skin ulcer/fistulae Erectile dysfunction Skin necrosis Inguinal lymph nodes Voiding dysfunction Paraphimosis Phimosis Sepsis/abscess/gangrene SCC Penile deformity
45 (30.2) 17 (11.4) 12 (8) 23 (15.4) 9 (6) 7 (4.7) 4 (2.7) 8 (5.4) 1 (0.7) 10 (6.7) 9 (6) 1 (0.7) 17 (11.4)
SCC = squamous cell carcinoma.
cases. Surgical intervention was necessary in the majority of patients (91.3%). Circumcision was performed for paraffinoma limited to the foreskin (five cases, 4%). Local excision of paraffinoma was performed in 106 patients (84.1%). Of these, 29 underwent primary closure, which was successful in 25. Two patients developed recurrent lesions requiring further repeat excision and closure, and the remaining two required split skin grafting following wound breakdown. Seventy patients underwent local excision followed by reconstruction with skin grafts or flaps (55.55%). Split skin grafts were used in eight patients (three from the thigh and five from unspecified sites), prepuce in five, and penile skin in two. Bipedicled scrotal skin flap reconstruction was performed in 55 patients. In 16 cases, the operative approach was not specified. Only three patients undergoing reconstruction required a second procedure, all of whom
had had a scrotal skin flap reconstruction, including Zplasty for skin tightness and further debridement of persistent lesions. Six patients had extensive debridement requiring scrotal embedment of the penis and proceeded to a delayed scrotal skin flap reconstruction 2–6 mo later. Histological findings were reported in 70 cases; the most consistent findings were giant cell infiltration and lipid vacuoles in keeping with lipogranuloma. The mean duration of follow-up was 15.8 mo. There were no documented cases of sexual dysfunction or voiding difficulties in patients who had undergone surgical treatment. 4.
Discussion
The geographic distribution of this practice is concentrated in southeast Asia and eastern Europe; however, the UK is seeing an increase in incidence. In our centre, we have had three patients (mean age 38 yr) of central European origin presenting with complications of penile paraffinoma over a 2-yr period, all of whom had undergone injection of paraffin. MRI findings of subcutaneous tissue inflammation not involving Buck’s fascia and lymph node inflammation in one patient are consistent with those described in the literature; histopathology from one patient showed vacuolation and histiocyte reaction (again in keeping with literature reports). All three patients presented with penile swelling, pain, and penile deformation. One patient had signs of sepsis with multifocal abscess, which grew Staphylococcus aureus cultures. All were treated with intravenous antibiotics and analgesia initially. One patient responded to conservative management, and was referred to the plastic team for excision and reconstruction. One
Please cite this article in press as: Downey AP, et al. Penile Paraffinoma. Eur Urol Focus (2018), https://doi.org/10.1016/j. euf.2018.06.013
EUF-525; No. of Pages 5 4
E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
patient required circumcision and excision of paraffinoma with direct closure, while the other required incision and drainage of a superficial abscess as an emergency. Both were then referred to plastic surgery for delayed debridement and reconstruction as needed, in line with literature reports. Most individuals either self-inject or receive injections administered by non-healthcare professionals with the aim of increasing penile girth; our patient population had had paraffin injected by a non-healthcare professional with the aim of penile enlargement. It is possible that patients presenting with symptoms represent the “tip of the iceberg”, with others either too embarrassed to seek treatment or not presenting due to language barriers (in immigrant populations). The most commonly injected substance is paraffin, and patients may present anywhere from days following injection to years later with an inflammatory tissue reaction of varying degrees of severity. Imaging is not a diagnostic necessity; however, in some cases it, by preoperatively assessing the extent of tissue involvement, can help plan definitive treatment. There is no evidence for superiority of MRI over USS; however, MRI images are more readily interpretable and provide more anatomical information to aid surgical planning. Conservative management is used only in more minor cases as the majority of patients present with a symptomatic problem. Definitive management is by surgical excision and reconstruction as required, with the involvement of plastic surgeons as necessary when complex reconstruction is required to optimise the functional and cosmetic outcome. Whilst circumcision may suffice usually extensive debridement of the penile skin and subcutaneous tissue is required, leaving large tissue defects. The reconstruction method is dependent on the extent of resection, aims to provide adequate skin cover, and includes the use of prepuce flaps, bipedicled scrotal flaps, or split skin grafts. Clearly, there is a need for targeted preventative measures through public health agencies in communities where the practice appears to be more prevalent.
consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
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