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LETTER TO EDITOR |
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| Year : 2023 | Volume
: 44
| Issue : 1 | Page : 97-98 |
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Saxophone penis: A sequel to penoscrotal hidradenitis suppurativa
Nitin Krishna Patil, Aditya Kumar Bubna
Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
| Date of Submission | 27-Dec-2021 |
| Date of Decision | 21-Oct-2022 |
| Date of Acceptance | 27-Oct-2022 |
| Date of Web Publication | 06-Jun-2023 |
Correspondence Address:
Dr. Aditya Kumar Bubna
Department of Dermatology, Katihar Medical College, Karim Bagh, Katihar - 854 106, Bihar
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijstd.ijstd_112_21
How to cite this article:
Patil NK, Bubna AK. Saxophone penis: A sequel to penoscrotal hidradenitis suppurativa. Indian J Sex Transm Dis 2023;44:97-8 |
How to cite this URL:
Patil NK, Bubna AK. Saxophone penis: A sequel to penoscrotal hidradenitis suppurativa. Indian J Sex Transm Dis [serial online] 2023 [cited 2023 Sep 30];44:97-8. Available from: https://ijstd.org/text.asp?2023/44/1/97/378156 |
Sir,
The term “saxophone penis” refers to penile twisting, along its longitudinal axis, thereby conferring to it an appearance that closely resembles a saxophone.[1]
It has been suggested that long-standing penoscrotal inflammation culminates in lymphatic fibrosis. Further, diminished blood supply to the dorsal penis heralds contraction of connective tissue that results in dorsal bending of the penis. As vascularity of the ventral penis is not compromised, blood extravasation continues, leading to edema that lifts the distal penis upward and outward, making the dorsal penile curvature more prominent that finally assumes the configuration of a saxophone.[2]
Conditions resulting in saxophone penis (reported in the past) include lymphogranuloma venereum (tertiary stage), penile tuberculosis, and primary lymphedema.[1]
We hereby report saxophone penis in a patient of penoscrotal hidradenitis suppurativa (HS).
A 47-year-old male presented with a 2-month history of gradually progressive painful lesions involving the penoscrotal region. It began as nodular lesions involving the pubic area initially, which then spread to involve the penis and scrotum. He gave history of three similar episodes in the past 2 years which improved after the intake of antibiotics. This time, however, despite the intake of antibiotics, there was no improvement. No history of exposure or trauma was obtained. Furthermore, no comorbidities were identified. His spouse was apparently healthy.
Examination revealed deep-seated nodules, abscesses, and sinuses in the penoscrotal region. The penis was grossly enlarged and had assumed the shape of a saxophone [Figure 1]a. Notable sparing of the gluteal and perianal areas was observed [Figure 1]b. No obvious lesions were detected over the axilla and groins. There was no evidence of inguinal lymphadenopathy. Routine blood examinations, including the Mantoux test, serum venereal disease research laboratory test, and HIV 1 and 2 did not demonstrate any underlying abnormality. Serological tests for lymphogranuloma venereum like complement fixation test and microimmunofluorescence test were not done due to unavailability. Chest X-ray was normal. Although penoscrotal ultrasonography was suggested (to rule out deeper lymphatic involvement), our patient was unable to get that done. Histopathology from the scrotal lesion delineated a ruptured cyst lined by stratified squamous epithelium containing lamellated keratin and inconspicuous hair shafts. Surrounding it was a mixed inflammatory infiltrate composed predominantly of lymphocytes and histiocytes. Few giant cells, neutrophils, and plasma cells were also observed [Figure 2]a and [Figure 2]b. | Figure 1: (a) Deep-seated nodules, abscesses, and sinuses in the penoscrotal region. The penis is grossly enlarged and has assumed the shape of a saxophone. (b) Notable sparing of the gluteal and perianal region can be observed
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 | Figure 2: (a) A ruptured cyst lined by stratified squamous epithelium containing lamellated keratin, and inconspicuous hair shafts can be identified within the cyst cavity (H and E × 10). (b) A dense mixed inflammatory infiltrate composed predominantly of lymphocytes and histiocytes can be seen. Few giant cells, neutrophils, and plasma cells can also be visualized (H and E × 20)
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Based on the above findings, a diagnosis of HS was made and the patient was started on prednisolone (20 mg once daily), clindamycin (300 mg twice daily), and rifampicin (300 mg twice daily) for 4 weeks and asked to review. The patient was subsequently lost to follow-up.
HS is a chronic, inflammatory disease characterized by painful, deep-seated, inflamed lesions in apocrine gland-bearing body parts, namely, the axilla, groins, buttocks, infra/intermammary folds, and perineal region.
HS limited to the penoscrotal area is not a common occurrence. In most cases, the disease also involves other classical sites, especially the axilla. There have been only a few reports delineating penile and scrotal HS, details of which have been elucidated in [Table 1]. | Table 1: Previous reports of penile and scrotal hidradenitis suppurativa and their comparison with our case
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Based on the above publications, we infer that HS involving the penoscrotal region generally elaborates unusual and severe phenotypes.
Our patient differed from the above reports by having the disease limited to the pubis, penis, and scrotum. Besides, saxophone morphology was another peculiar finding that we observed. Further, while dealing with our patient, we realized the need for appropriate counseling regarding problems associated with obstructive lymphedema, and the requirement for regular and timely follow-up.
In our opinion, this presentation of penoscrotal HS has not been previously described. We therefore would like to highlight this unusual clinical morphology and the necessity for a cutaneous biopsy in all such cases, to enable diagnostic confirmation and prompt institution of appropriate therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Acknowledgment
The authors would like to thank Dr. Leena Dennis Joseph; MBBS, MD (Professor, Department of Pathology, Sri Ramachandra University, Porur, Chennai 600116) for helping us with histopathologic evaluation[5].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Maatouk I, Moutran R. Saxophone penis. JAMA Dermatol 2013;149:802.  |
| 2. | Kumaran MS, Gupta S, Ajith C, Kalra N, Sethi S, Kumar B. Saxophone penis revisited. Int J STD AIDS 2006;17:65-6. |
| 3. | Baughman SM, Cespedes RD. Unusual presentation of hidradenitis suppurativa with massive enlargement of penis. Urology 2004;64:377-8. |
| 4. | Gibas A, Matuszewski M, Michajłowski I, Krajka K. Acne inversa of the scrotum and penis – Aggressive urological treatment. Cent European J Urol 2012;65:167-9. |
| 5. | Kok K, Lahiri A. Penile degloving: An unusual presentation of hidradenitis suppurativa. Ann R Coll Surg Engl 2012;94:e101-2. |
[Figure 1], [Figure 2]
[Table 1]
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