2022 European guideline for the management of balanoposthitis.

BACKGROUND: This guideline is an update to the 2014 edition of the European guideline for the management of balanoposthitis. Balanoposthitis describes inflammation of the glans penis and prepuce and is caused by a range of disparate conditions including infection, dermatoses and premalignancy. OBJECTIVE: The main objectives of this guideline are to aid recognition of the symptoms and signs and complications of penile skin conditions and to offer recommendations on the diagnostic tests and treatment for a selected group of these conditions. METHODS: The previous guideline was updated following a literature review and priority was given to randomized controlled trial and systematic review evidence. RESULTS: The updated guideline includes amended management for infective balanitis to provide clear guidance for Group A streptococcal infections, management of on going Lichen sclerosus (to include circumcision and supportive management to reduce the recurrence of genital herpes and warts), additional regimens for Zoonoid change, use of calcineurin inhibitors in management and risk of premalignancy and change of nomenclaturefrom Premalignant conditions to Penile Intraepithelial neoplasia (PeIN). CONCLUSION: Balanoposthitis has a widerange of causes high quality evidence specific to the management of penile disease is not available for all the conditions described.

Anogenital warts: influence on quality of life in Dutch soldiers.

BACKGROUND: Anogenital warts are one of the most prevalent sexually transmitted virus infections in the Netherlands and cause frustration, shame, and even depression. This study was performed to determine the effect of having anogenital warts on the quality of life in Dutch soldiers with the use of a dermatology-specific quality of life (QoL) questionnaire. METHODS: We used the Skindex-29 QoL questionnaire in 100 predominantly heterosexual soldiers with clinically confirmed first episode of condylomata acuminate in this study. RESULTS: Results confirmed that first episodes of anogenital warts cause high mean scores on subscale Emotions with lower scores on the subscales Symptoms and Functioning. Sex, age, educational level, anatomical site, or number of anatomical sites did not influence the outcome in this study. CONCLUSIONS: Having anogenital warts influences QoL, especially with regard to intimacy, shame, and concern. Our data show that the Skindex-29 QoL questionnaire can be easily used in these patients with good internal consistency. Clinicians should be aware of the great emotional impact of anogenital warts on their patients.

Photodynamic therapy with systemic meta-tetrahydroxyphenylchlorin in the treatment of anal intraepithelial neoplasia, grade 3.

BACKGROUND AND OBJECTIVE: Anal cancer and preneoplastic anal lesions (anal intraepithelial neoplasia, AIN) rising especially in men having sex with men (MSM). There are no widely accepted treatment standards for AIN. Photodynamic therapy (PDT) using the systemic sensitizer meta-tetrahydroxyphenylchlorin (mTHPC) has the potential to treat the anal area even when the exact borders of the preneoplastic anal lesion cannot easily be visualized. STUDY DESIGN/MATERIALS AND METHODS: In this prospective intervention study, 15 HIV-positive MSM with AIN 3 were treated in 25 PDT-sessions using mTHPC intravenously administered at drug doses of 0.075-0.15 mg ml(-1) and illumination at 48 hours. The illumination was performed using a custom made applicator using either red light (652 nm) to a measured intended fluence of 10 and 20 J cm(-2) and green light (532 nm) to a measured intended fluence of 105, 210, and 340 J cm(-2) . Red and green illuminations were performed at a (green) equivalent fluence rate of 105 mW cm(-2) . RESULTS: Initial complete response was seen in 7/25 (28%) of treatments and another 4/25 (16%) initial partial responses. After an average 8 months, recurrences were detected in 7/11 (64%) of sessions that initially showed response. A total 4/25 (16%) showed persistent complete response 6-15 months after green light illumination. Red light illuminations caused more significant side effects combined with no persistent complete response. Reported side effects were intense pain, bloody and purulent rectal discharge, and anal stricture formation, in one patient. CONCLUSION: The results show that the use of systemic mTHPC is partially effective for the treatment of AIN 3.

[Granulomatous secondary syphilis; an uncommon presentation of a polymorphic disease]. / Granulomateuze secundaire syfilis: een zeldzame uiting van een polymorf ziektebeeld.

BACKGROUND: Due to a great diversity of clinical presentations secondary syphilis can mimic various skin diseases, which means that the diagnosis of this sexually transmitted condition can be missed. Occurrence of a granulomatous inflammatory reaction in secondary syphilis is rare and may be confused with other granulomatous dermatoses. CASE DESCRIPTION: We present a 37-year-old homosexual male with a granulomatous dermatitis due to secondary syphilis. The differential diagnosis based on clinical and histopathological findings was lengthy and the initial syphilitic serology results were negative, resulting in delayed diagnosis. After revision of the histopathology and repeated serological testing secondary syphilis could be diagnosed. CONCLUSION: Not only the clinical, but also the histopathological presentation of secondary syphilis is variable. To prevent transmission, treatment delay and complications, we recommend repeating syphilitic serology following negative results if there is clinical or histopathological suspicion of this disease, especially in patients displaying high-risk behaviour. Syphilis should be also excluded in granulomatous dermatoses with plasma cells.

Use of highly active antiretroviral therapy is associated with lower prevalence of anal intraepithelial neoplastic lesions and lower prevalence of human papillomavirus in HIV-infected men who have sex with men.

BACKGROUND: The incidence of anal intraepithelial neoplasia (AIN) and anal cancer is increased in HIV-positive men who have sex with men (MSM). Persistent high-risk human papillomavirus (HPV) infection is an important etiologic agent. METHODS: In this study, a group of 250 HIV-positive MSM was included to determine the prevalence of AIN and to investigate the role of highly active antiretroviral therapy (HAART), high-risk HPV, and other risk factors possibly associated with this prevalence. RESULTS: Among patients included, 108 (43.2%) had lesions suspicious for AIN. Histologic analyses showed AIN 1 in 24 patients (22.2%), AIN 2 in 6 patients (5.6%), and AIN 3 in 10 patients (9.3%). In multivariable analyses, the use of HAART was associated with the absence of AIN (P = 0.045). In MSM without HAART, HPV infection was detected significantly more often compared with those who used HAART (P = 0.010). AIN was associated with HPV types 16 and 6. CONCLUSIONS: In this cross-sectional study in 250 HIV-positive MSM, the use of HAART was associated with lower prevalence of AIN and a significantly lower prevalence of HPV. This association between the prevalence of AIN and the absence of HAART may contribute to the current debate on when to start HAART in HIV-infected individuals.

A dedicated applicator for light delivery and monitoring of PDT of intra-anal intraepithelial neoplasia.

The objective of this study was to develop an applicator for delivery of light and monitoring of photodynamic therapy (PDT) in the anal cavity for treatment of anal intraepithelial neoplasia grade III (AIN III), which can progress to invasive anal cancer. Forty-eight hours before treatment, patients participating in the study were injected with 0.03 (n=2) or 0.075 (n=2) mg kg(-1) m-THPC. For light delivery and monitoring of PDT, an applicator based on standard anoscopy equipment was developed which facilitates, in addition to a light treatment fiber, fiber optic probes to monitor blood saturation, blood volume, fluorescence and fluence (rate) at two different locations in situ. Patients were given a light dose of 10-17 J cm(-2) at a fluence rate of 45-50 mW cm(-2) based on in situ measured light treatment parameters. We demonstrate that the applicator does not influence the fluence rate profile of the light treatment fiber. Furthermore this study shows the possibility of monitoring blood saturation, blood volume, fluorescence and fluence (rate) during therapeutic illumination without changing the light treatment protocol.

Just a penile nodule...

In this paper we present a case history of a homosexual HIV-positive male with a painless nodule on the penis. Screening for sexually transmitted diseases did not detect any infection until the node perforated spontaneously. A diagnosis of lymphogranuloma venereum was made when chlamydia trachomatis type L2 DNA was extracted from the lesion. This case illustrates that standard screening may not be sufficient for making the diagnosis of lymphogranuloma venereum.

The use of serological titres of IgA and IgG in (early) discrimination between rectal infection with non-lymphogranuloma venereum and lymphogranuloma venereum serovars of Chlamydia trachomatis.

OBJECTIVES: To investigate whether serological titres of species-specific IgA and IgG antibodies in patients with rectal chlamydial infection could discriminate between infection with serovar L2 lymphogranuloma venereum (LGV) and infection with non-LGV serovars. METHODS: A total of 39 male patients with chlamydial infection of the rectum were tested for titres of IgA and IgG antibodies within 14 days after detection of the infection and 6 and 12 months after adequate treatment. Data were collected regarding demographics, sexual orientation, HIV serostatus, history of chlamydial infection, concomitant sexually transmitted infection (STI) or HIV infection, hepatitis C virus antibodies and new STIs during follow-up. RESULTS: Between May 2003 and November 2005, 24 men with confirmed L2 proctitis and 15 men with non-LGV rectal chlamydial infection were recruited. In multivariable analyses, both high titre of IgA within 14 days after detection of the infection and older age of the individual were found significantly associated with L2 proctitis (p<0.001 and p = 0.001, respectively). A total sum score of seven times IgA titre and individual's age >or=50 years resulted in an overall sensitivity of 92% and specificity of 100%. This total sum score was highly accurate for detection of LGV proctitis, with an area under the curve in a receiver operating characteristic curve of 0.989. CONCLUSIONS: An increased IgA antibody response and the age of the infected individual are of possible diagnostic value for (early) detection of LGV proctitis.

HIV incidence and HIV testing behavior in men who have sex with men: using three incidence sources, The Netherlands, 1984-2005.

BACKGROUND: In The Netherlands, the western part, including Rotterdam and Amsterdam harbors the majority of the known HIV-infected population, of whom men who have sex with men (MSM) comprise the largest transmission category. Given a general rise in sexually transmitted infections (STI) and risky sexual behavior, we examine the HIV incidence among MSM in the Netherlands with data from three different sources. METHODS: To describe the HIV epidemic among MSM we use: a prospective cohort study in Rotterdam (ROHOCO: 1998-2003, n = 265) and another in Amsterdam (ACS: 1984-2005, n = 1498]) plus an anonymous HIV surveillance study (Amsterdam STI clinic: 1991-2004, n = 3733) in which HIV-positive MSM were tested with a less-sensitive HIV assay. We evaluated calendar trends in HIV incidence, also focusing on age effects. RESULTS: Since the start of the HIV epidemic in the early 1980s, incidence has declined strongly in the ACS. In recent years, an increase was noted among older MSM attending the Amsterdam STI clinic (P = 0.0334). In both cohort studies, HIV incidence was lower and recent time-trends were not statistically significant. Among recently infected men at the STI clinic, only 40% accepted named HIV testing at their STI consultation. CONCLUSIONS: Data suggest that among MSM in the Netherlands, the HIV incidence is between one and four infections per 100 person-years. The epidemic expands among older STI clinic attendees. Prevention should be developed specifically for older men, along with a more efficient HIV testing approach such as routine HIV testing of MSM when they are screened for STI.

Incidence of sexually transmitted diseases and HIV infection in men who have sex with men related to knowledge, perceived susceptibility, and perceived severity of sexually transmitted diseases and HIV infection: Dutch MSM-Cohort Study.

BACKGROUND: This longitudinal study was conducted to investigate whether knowledge, perceived susceptibility, and perceived severity of HIV infection and sexually transmitted diseases (STDs) are associated with the incidence of STDs and new HIV infections among men who have sex with men (MSM). METHODS: A 3-year cohort study was conducted among 190 HIV-negative MSM. Data were collected on the incidence of STDs and new HIV infections, as well as on knowledge and perceived susceptibility to and perceived severity of HIV infection and STDs. Knowledge and perceptions were assessed in self-administered questionnaires. RESULTS: In the course of the 3-year study, six MSM (3.2%) HIV-seroconverted and 78 (41.1%) participants were diagnosed with at least one STD. MSM seemed to be better informed about HIV infection compared with STDs, and HIV infection was perceived as more severe than other STDs. In multivariable analyses, low perceived severity of HIV infection significantly (P = 0.025) predicted increased likelihood of infection with STDs or HIV, and the practice of anal intercourse was (marginally) associated with an increased risk of acquiring STDs or HIV (P = 0.052). CONCLUSIONS: A high perceived severity of HIV infection seems to induce sexual behavior that protects against STDs and HIV infection. More research is needed to establish the specific behaviors by which perceived severity of STDs/HIV influences the incidence of STDs and HIV.

Acquisition and clearance of perianal human papillomavirus infection in relation to HIV-positivity in men who have sex with men in the Netherlands.

This study was performed to establish the prevalence of perianal human papillomavirus (HPV) infection in relation to HIV-positivity in a group of men who have sex with men (MSM), and to correlate follow-up data with regard to acquisition and clearance of HPV infection. Data with regard to HPV prevalence and HIV serostatus during two visits were compared. At both visits participants underwent a routine venereological examination and swabs were taken from the perianal region for HPV DNA testing. During both visits HPV types 16, 18, 31, 33 and 52 were significantly more often detected in HIV-positive individuals. Persistence of HPV type 31 at the perianal region was significantly more often seen in HIV-positive MSM (p=0.036) while the incidence of type 16 may be associated with HIV positivity (p=0.059). In HIV-positive MSM significantly more high-risk HPV types were detected at the perianal region.

Incidence of sexually transmitted diseases and HIV infection related to perceived HIV/AIDS threat since highly active antiretroviral therapy availability in men who have sex with men.

OBJECTIVE: Concerns have been expressed regarding increase in risky sex because of the availability of antiretroviral treatments in Western countries. GOAL: The goal of this longitudinal study was to investigate the association between highly active antiretroviral therapy (HAART)- and postexposure prophylaxis-related beliefs and the incidence of sexually transmitted diseases (STDs) and new HIV infections in men who have sex with men (MSM). STUDY: Data on the incidence of STDs and new HIV infection, and the level of agreement with different HAART- and PEP-related beliefs from 151 HIV-negative MSM were compiled. RESULTS: Of all MSM, 65.6% tested negative for any STDs and 7 men HIV seroconverted. Perceiving less HIV/AIDS threat since HAART availability and younger age were significantly associated with a higher incidence of STDs. Perceiving less need for safe sex since HAART availability was significantly associated with an increased likelihood of HIV seroconversion. CONCLUSIONS: The results support the assumption that there is an association between the incidence of STDs and a decreased perception of HIV/AIDS threat resulting from HAART availability. Less perceived need for safe sex since HAART availability was associated with HIV seroconversion.

Human papillomavirus infection in men who have sex with men participating in a Dutch gay-cohort study.

BACKGROUND: To develop strategies for prevention and early treatment of human papillomavirus (HPV) anal and penile cancer, a better understanding of related sexual behavior risk factors is needed. GOAL: The goal of this study was to establish the prevalence of anal and coronal sulcus HPV in a group of men who have sex with men participating in a Dutch gay-cohort study, to identify risk factors associated with HPV infection in this group, and to investigate the presence of identical HPV types in couples with stable relationships. STUDY DESIGN: A cross-sectional study of 241 HIV-negative and 17 HIV-positive men who have sex with men visiting the sexually transmitted disease clinic of the Erasmus MC for a regular and scheduled examination. Participants underwent a routine venereological examination including HIV serologic analysis, and swabs were taken from the coronal sulcus and anus for HPV DNA testing. All subjects were asked to complete a questionnaire on sexual risk behavior. RESULTS: HPV DNA was detected at the coronal sulcus in 23.5% of the HIV-positive men and in 15.8% of the HIV-negative men (P=0.492). In anal specimens, HPV DNA was detected in 64.7% of the HIV-positive men and 32.8% of the HIV-negative men (P=0.015). High-risk HPV types (P=0.007) and 2 or more different HPV genotypes (P=0.006) were seen more often in anal specimens of HIV-positive persons than in specimens of HIV-negative persons. A factor possibly associated with the presence of anal HPV infection was a concomitant anal infection with Chlamydia trachomatis, gonococci, or herpes simplex virus (P=0.059). In only 16.7% of HPV-positive steady couples, both companions showed the presence of one or more identical HPV genotypes. CONCLUSION: In this study, anal HPV DNA was detected more often than HPV DNA at the coronal sulcus. HIV positivity was associated with a higher prevalence of high-risk, but not with low-risk HPV types, at the anus. No association was found between HIV positivity and presence of high-risk HPV at the coronal sulcus. No sexual behavioral determinants for the presence of HPV could be identified. Concomitant anal infection with C trachomatis, gonococci, or herpes simplex virus may be associated with HPV infection. In the majority of steady couples, partners were infected with different HPV types.