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A Pinpoint Orifice on the Glans Penis of a Young Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A healthy, uncircumcised man in his 30s presented with a 14-year history of dyspareunia and recurrent, purulent discharge from his penis. He had undergone multiple evaluations by dermatologists and urologists and had not responded to systemic antibiotics and topical corticosteroids. Physical examination revealed an erythematous, pinpoint orifice on his glans penis, with peripheral telangiectasias and a linear bluish structure on dermoscopy (Figure, A and B). Ultrasonography revealed a hypoechoic focal zone on the right side of the glans, with multiple hyperechoic bilaminar structures (Figure, C). A biopsy was performed (Figure, D).

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A. Pilonidal sinus

Surgical incision revealed multiple protruding hairs. The lesion was excised and sent for histopathological analysis, which revealed a sinus tract in the dermis lined by stratified epithelium and filled with hair shafts, surrounded by a lymphoplasmacytic inflammatory infiltrate (Figure, D). The wound healed by secondary intention, and the patient had a successful recovery with no signs of recurrence at 6-month follow-up.

A pilonidal sinus is a benign tract that contains hair fragments and extends from a skin-lined opening into the subcutaneous tissue. It is a chronic inflammatory condition most frequently located in the natal or gluteal cleft; this is why the condition was initially thought to be congenital. However, there is now consensus that pilonidal sinus is an acquired lesion.1 Some authors propose that local trauma and friction produce subcutaneous trapping of hair, leading to the formation of a cyst and then a sinus to drain the suppuration.1,2 However, more current reports suggest that these lesions may be localized forms of hidradenitis suppurativa.35 Pilonidal sinuses in unusual locations have been reported, including the scalp, neck, abdomen, groin, axilla, and even amputation stumps; these locations correlate with the classic sites of hidradenitis suppurativa. However, penile involvement is considered rare.6,7 The few reported cases all occur in uncircumcised men, suggesting that the prepuce plays a role in the mechanical forces needed for the implantation of hair; other factors, such as shaving, high body mass index, and hirsutism, have also been proposed as contributory. Clinical presentation varies and includes penile papules and swelling; in complicated cases, there may be abscess formation, coinfection, and even ulceration mimicking sexually transmitted infections and penile carcinoma.8 Additional findings that may point to the diagnosis are hair protruding from the cavity and a central orifice on dermoscopy.9 Treatment is surgical with excision of the tract and healing by secondary intention.

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Article Information

Corresponding Author: Catalina Hasbún Zegpi, MD, Department of Dermatology, Faculty of Medicine, Universidad de los Andes, Avenida Plaza 2501, Las Condes, Santiago, Chile (cphasbun@miuandes.cl).

Published Online: March 29, 2023. doi:10.1001/jamadermatol.2023.0142

Conflict of Interest Disclosures: Dr Wortsman reported receiving speaker fees from AbbVie and royalties from Springer Publishing outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish the case. We also thank Ivo Sazunic, MD, Laboratorio Histodiagnóstico Málaga, Santiago, Chile, for the histopathological analysis and images, Chris Bunker, MD, Department of Dermatology, University College London Hospitals, London, United Kingdom, for his help in drafting the manuscript. They received no compensation for their contributions to this work.

Rao  AR , Sharma  M , Thyveetil  M , Karim  OMA .  Penis: an unusual site for pilonidal sinus.   Int Urol Nephrol. 2006;38(3-4):607-608. doi:10.1007/s11255-005-4761-5 PubMedGoogle ScholarCrossref
Al-Qassim  Z , Reddy  K , Khan  Z , Reddy  IS .  Pilonidal sinus cyst of the penis: a rare manifestation of a common disease.   BMJ Case Rep. 2013;2013:bcr2013009718. doi:10.1136/bcr-2013-009718 PubMedGoogle ScholarCrossref
Benhadou  F , Van der Zee  HH , Pascual  JC ,  et al.  Pilonidal sinus disease: an intergluteal localization of hidradenitis suppurativa/acne inversa: a cross-sectional study among 2465 patients.   Br J Dermatol. 2019;181(6):1198-1206. doi:10.1111/bjd.17927 PubMedGoogle ScholarCrossref
Wortsman  X , Castro  A , Morales  C , Franco  C , Figueroa  A .  Sonographic comparison of morphologic characteristics between pilonidal cysts and hidradenitis suppurativa.   J Ultrasound Med. 2017;36(12):2403-2418. doi:10.1002/jum.14282 PubMedGoogle ScholarCrossref
Balan  I , Feleshtynskyi  Y , Dyadyk  O , Beketova  J .  Surgical view of morphological and pathogenetic identity of pilonidal cysts and acne inversa.   Pol Przegl Chir. 2022;94(4):27-31. doi:10.5604/01.3001.0015.5983 PubMedGoogle ScholarCrossref
Sion-Vardy  N , Osyntsov  L , Cagnano  E , Osyntsov  A , Vardy  D , Benharroch  D .  Unexpected location of pilonidal sinuses.   Clin Exp Dermatol. 2009;34(8):e599-e601. doi:10.1111/j.1365-2230.2009.03272.x PubMedGoogle ScholarCrossref
Shanmugathas  N , Yassin  M , Ross  C , Minhas  S .  Pilonidal sinus disease of the penis: a case report and review of the literature.   Andrologia. 2021;53(1):e13837. doi:10.1111/and.13837 PubMedGoogle ScholarCrossref
Cormio  L , Sanguedolce  F , Massenio  P , Di Fino  G , Carrieri  G .  Pilonidal cyst of the penis mimicking carcinoma.   Case Rep Urol. 2013;2013:984757. doi:10.1155/2013/984757 PubMedGoogle ScholarCrossref
Navarrete  J , Kutscher  P , Fiorella  D ,  et al.  Image gallery: pilonidal sinus of the penis.   Br J Dermatol. 2017;177(6):e354. doi:10.1111/bjd.16037 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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