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Postcoital appearance of a median raphe cyst
Volume 26 Number 1, Part 1 February 1992
Brief communications 273
History of previous skin cancers
Synchronous or asynchronous
Underlying
Yes Yes
S AS
Actinic damage Actinic damage
This report This report
ND
S
ND
Peled and Wexler 8
ND ND ND ND ND ND ND
S S AS S S AS S
Condylomata acuminata ND Necrobiosis lipoidica Human papillomavirus 16 Recessive dystrophic epidermolysis bullosa Necrobiosis lipoidica ND
Fiumara and Wagner 5 Ginzburg et al. 7 Beljaards et al. 2 Stone et al. 6 Callen and Hudson 4 Kossard et al. 3 Crivellato et al. 9
skin condition
u n d e r r e p o r t i n g of basal cell carcinomas with coronal axis s y m m e t r y as well as closer clinical attention to instances of squamous cell carcinoma that arise in u n d e r l y i n g conditions such as necrobiosis lipoidica a n d recessive dystrophic epidermolysis bullosa. REFERENCES
1. Goudie RB, Soukop M, Dagg JH, et al. Hypothesis: symmetrical cutaneous lymphoma. Lancet 1990;335:316-8. 2. Betjaards RC, Groen J, Starink TM. Bilateral squamous cell carcinomas arising in long-standing necroblosis lipoidlea. Dermatologica 1990;180:96-8. 3. Kos,sard S, Collins E, Wargon O, et al. Squamous carcinomas developingin bilateral lesions of necrobiosis lipoid[ca. Aust J Dermatol 1987;28:14-7. 4. Callen JP, Hudson CP. Bilateral ulcers in a patient with hereditary bullous dermatosis. Arch DermatoL 1987; 123:811-6.
Reference
5. Fiumara N J, Wagner RF. Perianal Bowen's disease associated with anorectal warts: a case report. Sex Transm Dis 1987;14:58-60. 6. Stone MS, Noonan CA, Tschen J. Bowen's disease of the feet: presence of human papillomavirus 16 DNA in tumor tissue. Arch Dermatol 1987;123:1517-20. 7. Ginzburg A, Ingber A, Bialowans M, et al. Ein ungewolnlicher fall: bilateraler, symmetriseher morbus Bowen. Z Hautkr 1985;60:1810,1815-6. 8. Peled IJ, Wexler MR. Symmetric basal-cell carcinoma of the auricles. J Dermatol Surg Oneol 1985;11:164. 9. CriveUato E, Trevisan G, Grandi G, et al. Bilateral follicular basal cell nevus with comedo-like lesions. Aeta Derm Venereol (Stockh) 1983;63:77-9. 10. Robinson JK. Risk of developing another basal cell carcinoma: a 5-year prospective study. Cancer 198 7;60:118-20. 11. Rowe DE, Carroll R J, Day CL. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28.
Postcoital appearance of a median raphe cyst Michael J. Sharkey, M D , William J. Grabski, M D , M a r t h a L. McCollough, M D , a n d Timothy G. Berger, M D San Antonio, Texas
From the Departmentof Dermatology,BrookeArmyMedicalCenter. The opinions expressedare thoseof the authors and are not to be construed as officialor as reflectingthe viewsof the Departmentof the Army or the Departmentof Defense. Reprint requests: Michael J. Sharkey,MD, Departmentof Dermatology, BrookeArmy Medical Center, San Antonio, TX 78234. 16/4/32847
W e observed the abrupt onset of a m e d i a n r a p h e cyst of the penile shaft apparently precipitated by local trauma. CASE R E P O R T A 26-year-old white man developed a painless lump on the shaft of his penis several hours after intense prolonged
274
Journal of the American Academy of Dermatology
Brief communications DISCUSSION
'
?
~ ['...
Fig. 1. Median raphe cyst developed acutely after sexual intercourse. Fig. 2. Multilobulated cyst lined by stratified columnar epithelium. sexual intercourse. It had reached its present size within 24 hours. He denied dysuria or a penile discharge. Physical examination revealed a soft, nontender, multilobulated, cystic mass 1 cm in diameter on the distal third of the ventral penile shaft (Fig. 1). The cyst was slightly mobile and had a translucent blue hue. The patient had no significant adenopathy and his sexually transmitted disease evaluation was negative (rapid plasma reagin, human immunodeficiency virus serology, Chlamydiaand Neisseria gonorrhoeae cultures of the urethra and the cystic fluid). An excisional biopsy specimen demonstrated a multilobulated cyst lined by stratified columnar epithelium (Fig. 2). Scattered intraepithelial muciearrnine-positive mucous cells were noted. Some areas demonstrated decapitation-type secretion; however, no myoepithelial cells or papillary projections were observed.
Mcdian raphe cysts (MRCs) have a characteristic appearance and location. Although they usually form along the median raphe of the ventral shaft of the penis, they may form anywhere along the raphe from the anus to the glans penis. These cysts are typically asymptomatic unless they are secondarily infected; Neisseria gonorrhea is the most common organism.t Surgical excision with primary closure is the treatment of choice and was performed on our patient without evidence of recurrence. Three theories to explain the origin of MRCs have been proposed. The first postulates these cysts are due to a defect in the embryologic closure of the median raphe. During the development of the external genitafia there is incomplete fusion of the urethral folds that leaves rests of urethral epithefium beneath the median raphe. These rests later give rise to the cysts. 2, 3 The second theory proposed by Cole and Helwig4 hypothesizes that the cysts that contain mucous cells (mucoid cysts) develop from ectopic pcriurethral glands of Littre. These glands normally secrete a mucoid fluid during sexual arousal. The third proposed by Paslin s states that an anomalous outgrowth and sequestration of columnar epithelium occurs from the urethra after normal closure of the median raphe. This in turn leads to formation of nonmucinous MRCs. We postulate that there was a potential cystic space along the median raphe of this patient and that trauma along with enhanced mucoid secretion from sexual activity precipitated the macroscopic development of a cyst. To our knowledge this is the first report of a noninfected median raphe cyst that developed acutely after sexual intercourse. REFERENCES
1. SowminiCN, VijayalakshmiK, CheUamuthiahC, et al. Infectionsof the medianrapheof the penis. Br 3"VenerealDis 1973;49:469-74. 2. Asarch RG, Gofitz LE, Sausker WF, et al. Median raphe cysts of the penis. Arch Dermatol 1979;115:1084-6. 3. Neff JH. Congenitalcanalsand cystsof the genito-perineal raphe. Am J Surg 1936;31:308-15. 4. ColeLA, HelwigEB. Mueoidcystsof the penileskin. J Urol 1976;115:397-400. 5. Paslin D. Urethroidcyst. Arch Dermatol 1983;119:89-90.
Brief communications 273
History of previous skin cancers
Synchronous or asynchronous
Underlying
Yes Yes
S AS
Actinic damage Actinic damage
This report This report
ND
S
ND
Peled and Wexler 8
ND ND ND ND ND ND ND
S S AS S S AS S
Condylomata acuminata ND Necrobiosis lipoidica Human papillomavirus 16 Recessive dystrophic epidermolysis bullosa Necrobiosis lipoidica ND
Fiumara and Wagner 5 Ginzburg et al. 7 Beljaards et al. 2 Stone et al. 6 Callen and Hudson 4 Kossard et al. 3 Crivellato et al. 9
skin condition
u n d e r r e p o r t i n g of basal cell carcinomas with coronal axis s y m m e t r y as well as closer clinical attention to instances of squamous cell carcinoma that arise in u n d e r l y i n g conditions such as necrobiosis lipoidica a n d recessive dystrophic epidermolysis bullosa. REFERENCES
1. Goudie RB, Soukop M, Dagg JH, et al. Hypothesis: symmetrical cutaneous lymphoma. Lancet 1990;335:316-8. 2. Betjaards RC, Groen J, Starink TM. Bilateral squamous cell carcinomas arising in long-standing necroblosis lipoidlea. Dermatologica 1990;180:96-8. 3. Kos,sard S, Collins E, Wargon O, et al. Squamous carcinomas developingin bilateral lesions of necrobiosis lipoid[ca. Aust J Dermatol 1987;28:14-7. 4. Callen JP, Hudson CP. Bilateral ulcers in a patient with hereditary bullous dermatosis. Arch DermatoL 1987; 123:811-6.
Reference
5. Fiumara N J, Wagner RF. Perianal Bowen's disease associated with anorectal warts: a case report. Sex Transm Dis 1987;14:58-60. 6. Stone MS, Noonan CA, Tschen J. Bowen's disease of the feet: presence of human papillomavirus 16 DNA in tumor tissue. Arch Dermatol 1987;123:1517-20. 7. Ginzburg A, Ingber A, Bialowans M, et al. Ein ungewolnlicher fall: bilateraler, symmetriseher morbus Bowen. Z Hautkr 1985;60:1810,1815-6. 8. Peled IJ, Wexler MR. Symmetric basal-cell carcinoma of the auricles. J Dermatol Surg Oneol 1985;11:164. 9. CriveUato E, Trevisan G, Grandi G, et al. Bilateral follicular basal cell nevus with comedo-like lesions. Aeta Derm Venereol (Stockh) 1983;63:77-9. 10. Robinson JK. Risk of developing another basal cell carcinoma: a 5-year prospective study. Cancer 198 7;60:118-20. 11. Rowe DE, Carroll R J, Day CL. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28.
Postcoital appearance of a median raphe cyst Michael J. Sharkey, M D , William J. Grabski, M D , M a r t h a L. McCollough, M D , a n d Timothy G. Berger, M D San Antonio, Texas
From the Departmentof Dermatology,BrookeArmyMedicalCenter. The opinions expressedare thoseof the authors and are not to be construed as officialor as reflectingthe viewsof the Departmentof the Army or the Departmentof Defense. Reprint requests: Michael J. Sharkey,MD, Departmentof Dermatology, BrookeArmy Medical Center, San Antonio, TX 78234. 16/4/32847
W e observed the abrupt onset of a m e d i a n r a p h e cyst of the penile shaft apparently precipitated by local trauma. CASE R E P O R T A 26-year-old white man developed a painless lump on the shaft of his penis several hours after intense prolonged
274
Journal of the American Academy of Dermatology
Brief communications DISCUSSION
'
?
~ ['...
Fig. 1. Median raphe cyst developed acutely after sexual intercourse. Fig. 2. Multilobulated cyst lined by stratified columnar epithelium. sexual intercourse. It had reached its present size within 24 hours. He denied dysuria or a penile discharge. Physical examination revealed a soft, nontender, multilobulated, cystic mass 1 cm in diameter on the distal third of the ventral penile shaft (Fig. 1). The cyst was slightly mobile and had a translucent blue hue. The patient had no significant adenopathy and his sexually transmitted disease evaluation was negative (rapid plasma reagin, human immunodeficiency virus serology, Chlamydiaand Neisseria gonorrhoeae cultures of the urethra and the cystic fluid). An excisional biopsy specimen demonstrated a multilobulated cyst lined by stratified columnar epithelium (Fig. 2). Scattered intraepithelial muciearrnine-positive mucous cells were noted. Some areas demonstrated decapitation-type secretion; however, no myoepithelial cells or papillary projections were observed.
Mcdian raphe cysts (MRCs) have a characteristic appearance and location. Although they usually form along the median raphe of the ventral shaft of the penis, they may form anywhere along the raphe from the anus to the glans penis. These cysts are typically asymptomatic unless they are secondarily infected; Neisseria gonorrhea is the most common organism.t Surgical excision with primary closure is the treatment of choice and was performed on our patient without evidence of recurrence. Three theories to explain the origin of MRCs have been proposed. The first postulates these cysts are due to a defect in the embryologic closure of the median raphe. During the development of the external genitafia there is incomplete fusion of the urethral folds that leaves rests of urethral epithefium beneath the median raphe. These rests later give rise to the cysts. 2, 3 The second theory proposed by Cole and Helwig4 hypothesizes that the cysts that contain mucous cells (mucoid cysts) develop from ectopic pcriurethral glands of Littre. These glands normally secrete a mucoid fluid during sexual arousal. The third proposed by Paslin s states that an anomalous outgrowth and sequestration of columnar epithelium occurs from the urethra after normal closure of the median raphe. This in turn leads to formation of nonmucinous MRCs. We postulate that there was a potential cystic space along the median raphe of this patient and that trauma along with enhanced mucoid secretion from sexual activity precipitated the macroscopic development of a cyst. To our knowledge this is the first report of a noninfected median raphe cyst that developed acutely after sexual intercourse. REFERENCES
1. SowminiCN, VijayalakshmiK, CheUamuthiahC, et al. Infectionsof the medianrapheof the penis. Br 3"VenerealDis 1973;49:469-74. 2. Asarch RG, Gofitz LE, Sausker WF, et al. Median raphe cysts of the penis. Arch Dermatol 1979;115:1084-6. 3. Neff JH. Congenitalcanalsand cystsof the genito-perineal raphe. Am J Surg 1936;31:308-15. 4. ColeLA, HelwigEB. Mueoidcystsof the penileskin. J Urol 1976;115:397-400. 5. Paslin D. Urethroidcyst. Arch Dermatol 1983;119:89-90.