Giant inflamed fibroepithelial scrotal polyp mimicking an anogenital wart

History

A 22-year-old man presenting to the sexual health clinic with a genital lump. His GP had referred him following telephone triage during the coronavirus pandemic. He reported that this lump had been present for 1 year and had gradually increased in size. The lesion was causing considerable distress and affecting mobility and personal hygiene due to its location.

He reported he had never engaged in sexual activity. There was no history of systemic dermatoses or previous genital lumps.

On initial review, there was a large flesh coloured cauliform lesion attached to the inferior surface of the scrotal skin, measuring approximately 7cm in diameter (see Figure 1– image). There was evidence of an exudate with associated malodour. He was initially prescribed a course of oral flucloxacillin for 10 days to treat bacterial superinfection, and subsequently tried imiquimod due to characteristic warty features, but without success. He was then referred to Urology for surgical opinion.OPEN IN VIEWER

Written consent was obtained from the patient for this case to be published.

Investigations

A sexual health screen was performed, and all tests were negative including chlamydia and gonorrhoea NAAT in his urine. Blood tests taken for syphilis serology and HIV screening returned negative.

Treatment

Following initial contact with Urology, the patient was listed for surgical excision which was performed using a combination of knife and cutting diathermy. The lesion was very vascular, but bleeding was easily controlled. The patient received post-op antibiotics and was discharged home the same day.

Outcome and follow up

Postoperatively, a scrotal ultrasound was performed which excluded extension of the lesion into the testes. It found mildly dilated veins in the left hemiscrotum suggestive of a small varicocele. An ultrasound of the kidneys was unremarkable.

The pathology report of the lesion revealed features of an inflamed fibroepithelial polyp, with dense inflammation and granulation tissue noted in the submucosa. There were no features of dysplasia or malignancy. As the pathology report was inconsistent with the clinical diagnosis, a re-look was requested which corroborated the initial findings.

Discussion

Fibroepithelial polyps are common, and may have a smooth or irregular surface. They are usually located on the eyelids, neck, axillae, and the groin. They are benign, pedunculated and papillomatous, characteristically with both epidermal and stromal components, usually with a maximum size of 1cm.^1,2

Giant fibroepithelial polyps however are rare. The term describes lesions that are larger in size, often more than 5 cm. ³ They may involve the scrotum and penis in men, or the vulva in women. The gross appearance may be polypoid, globular, nodular or condylomatous. ⁴

The aetiology of giant fibroepithelial polyps is unclear. They are however considered a reactive process due to local pressure. Those located on the penis may be due to long term condom use,³ chronic catheter use and one case report was described in a man who practised genital hanging kung fu. ⁴

Diagnosis is usually clinical, and histopathology is helpful where there is diagnostic uncertainty. ³

There are only two case reports of giant scrotal fibroepithelial polyps in adult males, and as far as we know this is the first case report where the gross appearance is characteristically warty or condylomatous. Our initial clinical diagnosis was a giant condyloma of Buschke and Lowenstein, but due to the absence of any sexual risk factors, and lack of response to imiquimod, our patient had a surgical resection and histopathology confirmed the lesion as an inflamed fibroepithelial polyp.

Our findings may be of interest to clinicians working in sexual health, urology and primary care who may wish to consider fibroepithelial polyps in their differential diagnosis when managing anogenital lumps.