CHAPTER 118 Androscopy
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.)
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).
• Recurrent condylomata. This could be from incomplete previous removal or failure to identify smaller lesions.
• 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.
Figure 118-1 Large condylomata.
(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)
Equipment
• High-quality fine tissue scissors (e.g., 5-inch curved Metzenbaum scissors) or sharp dermal curettes to obtain a biopsy/remove lesions.
• Aluminum chloride (Drysol) for hemostasis. Monsel’s solution may cause an extended period of hyperpigmentation but is also acceptable.
Technique
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.
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.
Figure 118-3 Patient encounter form.
(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)
Full access? Get Clinical Tree
