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and refer for biopsy if the condition does not resolve. Common organisms: yeast and Gardnerella.
Thrombosed Penile Vein and Sclerosing Lymphangitis: The shaft of the penis just under the skin and on
the surface of the erectile bodies contains numerous large veins that can develop clots. They will appear as
dark, hard, raised bumps that follow the course of the vein. Lymph channels can also become hard cords, but
will be more clear or lack color. These conditions probably result from overly vigorous intercourse.
Fournier’s Gangrene: This condition is life threatening and is most likely to occur in the severely injured
patient with poor circulation or diabetes. It presents as a rapidly spreading skin inflammation with development
of necrotic/purplish tissue.
Candidal Infection: Most cases will present as balanitis. Occasionally, the patient will present with a red
scrotum with satellite red lesions. The rash will be itchy, painful and tender.
Cellulitis: Patients will have diffusely red and painful scrotal or penile skin. The skin may be weeping,
thickened and have pustules. When the skin lacks pustules, it is important to determine if the skin changes are
a reaction to underlying inflammation such as epididymo-orchitis or torsion of the testis. In the latter cases, the
testis and epididymis are markedly tender. The patient can usually differentiate testis pain from skin pain. If
the inflammation shows dark areas suggestive of necrosis, the patient is developing Fournier’s gangrene.
Contact Dermatitis: Contact with chemicals and even some ointment may cause a profound inflammation
of the scrotal skin. The skin may have the appearance and tenderness of cellulitis. History of exposure
is extremely important.
Objective: Signs
Using Basic Tools: Swelling, tenderness and redness; purulent discharge in the case of severe phimosis;
swollen lymph nodes.
Using Advanced Tools: Lab: Urinalysis for presence of glucose, leukocytes, blood or nitrite; KOH prep
of the weepy material on the skin may show the presence of yeast elements such as budding yeast or
strands called hyphae.
Assessment:
Differential Diagnosis
Sexually transmitted disease lesions are usually much more focal than these inflammatory conditions.
Plan:
Treatment
Phimosis: Keep the penis clean with soap and water several times per day. Broad-spectrum antibiotics
such as ciprofloxin 500 mg po bid or Keflex 500 mg po qid x 1 week may be used if purulent discharge is
noted from the meatus. If the phimosis is symptomatic and severe, perform a dorsal slit (procedure below)
and refer for circumcision later.
Paraphimosis: Try to reduce the foreskin by pushing the glans in and pulling the edematous skin forward.
You may be able to decrease some of the swelling with direct compression prior to reducing the foreskin. If the
constricting band around the penis is very tight, it may be necessary to put some local anesthetic and incise
the band with a dorsal slit (procedure below). Refer for circumcision.
Balanitis: Wash the penis several times a day and apply antifungal cream such as Nystatin, Mycolog or
Lotrimin bid. If a wet prep shows no yeast elements, can give Flagyl 500 mg po bid x 1 week.
Thrombosis of Penile Vein and Sclerosing Lymphangitis: Refrain from any sexual activity. Use NSAIDs
such as ibuprofen.
Fournier’s Gangrene: Perform emergent aggressive surgical debridement. Broad-spectrum IV antibiotics
such as ampicillin 2 gm q 8 h, gentamicin 5 mg/kg qd and Flagyl 500 mg q 6 h are usually warranted.
Candidal Fungal Infection: Keep skin dry and antifungal medications such as Nystatin, Mycolog or
Lotrimin bid for 1 week or single dose fluconazole 150 mg po. See ID: Candidiasis section for more
information.
Cellulitis: Treat with dicloxacillin 500 mg po q 6 h or Keflex 500 mg po q 6 h for mild cases. For severe
cases, treat with oxacillin 2 gm IV q 4 h or vancomycin 1 gm IV q 12 h.
Contact Dermatitis: For mild, treat with topical 1% hydrocortisone and oral diphenhydramine (Benadryl).
In severe cases, add prednisone 50 mg po qd and wean by 10 mg /day over 5 days. If there is a question
of infection, treat for cellulitis also.