Androscopy

CHAPTER 118 Androscopy



John L. Pfenninger


Androscopy is an office procedure mainly used to identify condylomata. It examines the male genitalia under magnification after acetic acid has been applied. It can be used to evaluate any dermatologic disorder/lesion in the genital areas and also to ensure complete removal of lesions. Another term for this procedure is penoscopy.


Recent literature documents that the human papillomavirus (HPV) is the cause of cervical dysplasia and cervical cancer. Whether the virus alone leads to cancer is unknown. Yet, HPV is the necessary, if not the single sufficient cause for cervical cancer. HPV is very contagious and it is most readily spread through sexual contact. Intromission is not necessary because skin-to-skin contact is enough. It may also be transmitted in yet-unknown ways in a minority of cases. Fomites do not transmit the disease. Condoms provide only partial protection from HPV but do help prevent spread.


The clinical significance of condylomata and HPV in men is less serious than it is in women, but men act as carriers and may transmit the disease to sexual partners. Although rare, HPV can cause penile carcinoma. Anal-receptive homosexual men have 50 times the rate of anal carcinoma compared to the incidence in the average population. An increased rate of anal carcinoma in anal-receptive women can also be anticipated, but there is no literature to document this.


There are over 100 types of HPV. Eight to 10 of these characteristically infect the genital areas. Condylomata acuminata, the visible lesions that we commonly see, are caused by noncarcinogenic strains, such as types 6 and 11. The subclinical types, identified only by examination under magnification after acetic acid staining, are more likely to cause neoplastic changes; frequently these are types 16 and 18. (See Chapter 137, Colposcopic Examination, Chapter 142, Human Papillomavirus DNA Typing, and Chapter 155, Treatment of Noncervical Condylomata Acuminata.)


There is no evidence that treatment of male partners of women who have dysplasia lessens the likelihood of persistence or recurrence in the woman. It is uncertain why condom use is beneficial because the infection is a regional disease. In men, it is present on the penis, scrotum, perineum, and perianal areas. What is visible is only a focal manifestation of a diffuse involvement. In women, it is present on the cervix, vagina, vulva, and the perineal and perianal areas. Winer and colleagues (2006), however, in a well-designed study showed significant protection in women with consistent condom use by their male partners.


Some clinicians question the value of carrying out an androscopic examination. Identification and treatment of condylomata is not the only reason to perform androscopy. Patient education is perhaps the most valuable aspect of this procedure. The man must be informed of the significance of his disease and the necessity of maintaining a single-partner committed relationship. It is no longer a matter of moral or religious persuasion, but rather a good health practice to be monogamous (as are exercising, not smoking, eating low-fat foods, and so forth). Men spread the disease even when visible lesions are not apparent. Only through education can they change their habits.


Men who have HPV can affect their partners in several ways. Not only do they spread the virus by skin-to-skin contact, but HPV has been shown to be present in the semen and in the sperm cell itself. Men who smoke have nicotine and its byproducts in their ejaculate as well as on their hands (important during manual stimulation), which may be a cofactor in HPV persistence. Those who are subject to passive smoking have lower folate levels—a known risk factor for cervical cancer.


The common factors for penile carcinoma include lack of hygiene, sex outside of marriage, smoking, and HPV infection. Clinically differentiating mild, moderate, and severe dysplasia of the penis (penile intraepithelial neoplasia [PIN]) is nearly impossible without obtaining biopsy samples. Anorectal cancer frequently contains the HPV, and some now recommend obtaining a Papanicolaou (Pap) smear of the pectinate (dentate) line on a regular basis to detect anal dysplasias in high-risk individuals. High-resolution anoscopy (HRA), which uses magnification (usually a colposcope) and acetic acid staining, can identify precursor lesions for treatment (see Chapter 99, High-Resolution Anoscopy).



Indications



• Visible condylomata on the penis, scrotum, or anus. Staining and examination with magnification will identify smaller lesions that are easier to treat and often not visible to the naked eye. This is likely to decrease recurrences. Androscopy also confirms that the entire lesion has been removed when surgical or ablative therapies are used. Early and complete treatment may reduce the recurrence of the disease. Figure 118-1 shows an example of large condylomata. Examination under magnification will aid in completing removal once the bulk of the lesion has been removed and also identify any smaller lesions that are not immediately obvious. Completing the removal under magnification helps in limiting the depth of excision because penile skin is so thin.

• Partner with recurrent or persistent condylomata acuminata or cervical dysplasia. There is some evidence that if the male partner presents with a high viral load, the immune system response of his partner may be overwhelmed by the virus. High viral load may exist if the man has extensive visible acuminate lesions or a diffuse acetowhite staining of the penis (Fig. 118-2).

• Psychological reassurance.

• Chronic perineal or perianal irritation.

• Recurrent condylomata. This could be from incomplete previous removal or failure to identify smaller lesions.

• Medical–legal examinations in child abuse cases.

• History of other sexually transmitted infections. Although rarely performed for this reason, androscopy with a negative result helps reassure patients that currently there are no HPV lesions.

• Necessity for patient education. Performing a procedure is better received by the patient than just “coming in to talk.” A biopsy-proven diagnosis speaks a thousand words of reinforcement.

• Penile lesions of uncertain significance.

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Figure 118-1 Large condylomata.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)



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Figure 118-2 A, White epithelium seen on the scrotum after application of 5% acetic acid. B, Condylomata seen on the penis after application of 5% acetic acid. Lesions were not visible before staining.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)



Equipment



• Spray bottle with 5% acetic acid (white vinegar).

• Colposcope (or a high-quality hand-held magnifying lens).

• High-quality fine tissue scissors (e.g., 5-inch curved Metzenbaum scissors) or sharp dermal curettes to obtain a biopsy/remove lesions.

• Pickups.

• Formalin jars.

• Aluminum chloride (Drysol) for hemostasis. Monsel’s solution may cause an extended period of hyperpigmentation but is also acceptable.

• 1 to 5 mL lidocaine 1% or 2% without epinephrine.

• 30-gauge needle.

• 1- to 5-mL syringe (depending on size and number of lesions).

• Radiofrequency unit with smoke evacuator, 85% trichloroacetic acid (TCA), or an infrared coagulator if condylomata are to be treated. (See Chapter 155, Treatment of Noncervical Condylomata Acuminata.)


Preprocedure Patient Preparation


It is always best if the patient is well informed about the nature of the disease before the procedure. Provide the patient with educational material. Prior to the visit, encourage the patient to watch a 21-minute videotape (available from Creative Health Communications/The National Procedures Institute, Midland, Mich) that discusses the implications of HPV infection in men and women. Viewing the videotape will help the patient focus on questions that he or his partner may have, and it will allow the practitioner to avoid repetitious explanations of the same counseling information. Written handouts are also available from many organizations. No preoperative medication is needed for the procedure, and the patient can be reassured that there will usually be minimal discomfort, even if biopsies are obtained. More discomfort may be experienced should treatment be undertaken, however.



Technique


Although the examination may take only 10 minutes, patients frequently have numerous questions and concerns. Unless the patient is well known to the practitioner, at least 20 minutes should be allotted for this examination—longer if treatment is undertaken.


1 After the patient is placed in the examination room, the nurse instructs him to spray the entire genital and anal area with 5% acetic acid (white vinegar) and allow it to soak for 5 minutes.

2 Obtain a detailed sexual history (Fig. 118-3, Androscopy Encounter Form).

3 Place the patient on an examination table with stirrups, and position as a woman is positioned for a Pap smear. Conduct a visual inspection first and note any lesions.

4 Spray the entire genital and perineal area again. Allow the solution to run freely over the perineum and anus.

5 Inspect the entire anogenital area under magnification, including the meatus of the penis. Generally a colposcope is used on low power (3× to 5×). Move the penis and scrotum forward and back to bring them into focus (unlike colposcopy, where the cervix is stationary and the scope is adjusted into focus). There is no study comparing good hand-held magnification to colposcopy.

6 Grossly apparent warts that were previously seen will generally turn white with the acetic acid. Previously unseen, small, “flat,” or subclinical lesions will also now be identifiable on the penis, scrotum, perineum, or rectum. They will show up as white areas, referred to as acetowhite changes (see Fig. 118-2).

7 Sample any atypical lesions with an unusual vascular pattern (mosaicism or punctation; see Chapter 137, Colposcopic Examination) or pigmentation. The pigmentation in lesions that predicts dysplasia will look different from that of a freckle or nevus; it will be a nondiscrete, brownish discoloration (Fig. 118-4). If no atypical lesions are seen, sample one or two of the acuminate lesions or the acetowhite areas to document the presence of HPV and that there is no dysplasia (Fig. 118-5). It is very convincing to have the pathology report confirm your clinical diagnosis, which reinforces the findings to the patient. It also is not always possible to tell clinically what the lesions are.

8 A penile biopsy specimen is easily obtained by using sharp tissue scissors. (A punch biopsy is not needed—you are not sampling the cavernosa!) If only one or two small lesions are to be sampled, simply tent up the skin by pinching it at its base (Fig. 118-6). Looking through the colposcope, obtain a 3- to 4-mm sample with the sharp tissue scissors or remove the entire lesion. No anesthetic is required if only one to two small lesions will be sampled, and this method is often less painful than the injection with anesthesia. Only a very superficial sampling is needed. If the lesions are larger, or more than two samples are to be obtained, it is best to anesthetize with 1% to 2% lidocaine without epinephrine. Using a 30-gauge needle minimizes any discomfort.
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Figure 118-3 Patient encounter form.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Androscopy

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