Bluish-coloured Papule over the Penile Shaft

Sir,

A 16-year-old male presented with an asymptomatic bluish-coloured papule over the shaft of the penis for 8 months. There was no history of bleeding from the lesion. There was no previous history of trauma, infection, surgery, and fever. His sexual history and family history were non-significant. On examination, there was a solitary round-shaped bluish-coloured papule with a smooth surface [Figure 1]. Along with this, there were a few tiny skin-coloured grouped papules over the shaft of the penis. His pelvic ultrasonography was normal. Skin biopsy from the lesion showed hyperkeratotic and acanthotic epidermis. The dermis showed numerous ectatic dilated vascular channels [Figure 2a] which showed negative staining for CD34 [Figure 2b] and focal strong positivity for D2-40 [Figure 2c]. Based on these findings, diagnoses of penile lymphangiomas were made.

Figure 1.

Solitary round-shaped bluish-coloured papule with a smooth surface and a few skin-coloured grouped papules over the shaft of the penis

Figure 2.

(a) Subepithelial tissue contains dilated vascular channels lined by flattened epithelial cells. Also, note fibrin and lymphocytic cell collection (hematoxylin and eosin, ×100). (b and c) These vascular channels show negative staining for CD34 (internal control positive, b, X400) but show focal strong positivity for D2-40 (c, ×1000)

Lymphangiomas are benign malformations of the lymphatic system.[1] They can be congenital or acquired.[2] Congenital lymphangiomas occur because of failure of foetal lymph vessels to involute or join with the central lymphatic system.[1] Acquired lymphangiomas usually develop in the areas of skin affected by obstruction or destruction of lymphatic drainage.[3] Various causes of acquired lymphangiomas are trauma, bacterial infections of lymphatic channels (cellulitis), tuberculosis, filariasis, lymphogranuloma venerum, malignancy, radiotherapy, pregnancy, and so forth.[1,2,4] However, in the present case, lesions appeared spontaneously.

Clinically, lymphangiomas present as crops of papulovesicular lesions filled with a clear or serosanguinous fluid resembling frogspawn. It can be blue-black in colour because of the accumulation of blood. It may be associated with intermittent swelling, leakage of clear or bloody lymph, and secondary bacterial infections. With a chronic course, lesions may develop a warty surface.[5] The common sites of involvement are the trunk, axilla, thigh, gluteal area, and oral cavity.[4] However the penis is an uncommon site, and the lesions may be present on the shaft or coronal sulcus of the penis.[1] Rarely, they can present as solitary lesions.[4,5] Histopathologically, lymphangioma circumscriptum (LC) is characterised by dilated lymph spaces in the upper dermis and the subcutis. The lumen is filled with the lymphatic fluid and may contain red blood cells and a few inflammatory cells.[2]

These lesions can be confused with genital warts and molluscum.[1] Other differentials that were considered in the present case were angiokeratoma of Fordyce and pyogenic granuloma. Angiokeratoma of Fordyce commonly involves the scrotum and can be present on the shaft of the penis. It presents as multiple discrete bluish keratotic papules which easily bleed. Histopathologically, they are characterised by dermal vascular ectasia with overlying hyperkeratosis of the epidermis.[6] Pyogenic granuloma or lobular capillary haemangioma is a benign vascular tumour of the skin or mucous membranes characterised by rapid growth. It commonly presents over extremities as solitary friable erythematous papules with the bleeding surface.

Usually, no treatment is required if lesions of penile lymphangiomas are small and asymptomatic. However, the patient can be treated if there is a cosmetic concern and to prevent recurrent infections, especially in larger lesions. Various therapeutic modalities are surgical destruction, laser ablation, electrocautery, cryotherapy, sclerotherapy, and so forth.[2] In our patient, radiofrequency ablation was performed. Recognition and awareness of penile lymphangiomas are important to alleviate the fear of having a sexually transmitted disease in a patient.

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Conflicts of interest

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