SYPHILIS
The scrotal skin is not an uncommon site for a primary syphilitic lesion.
The primary stage of syphilis is marked by the appearance of a single sore
(chancre), approximately 21 days after exposure. The chancre is usually firm,
round, small, and painless, lasts 3 to 6 weeks, and heals without treatment.
Regardless of location, the syphilitic chancre is grossly the same (see Plate
2-23). It may occur at the penoscrotal junction with barrier contraceptives.
Lesions of the scrotum, however, are much more common in later forms of
syphilis, especially during early and late relapses. They appear during relapse
within the first 2 years but have been observed many years later as well.
Anogenital cutaneous relapse occurs in 40% of cases and scrotal lesions occur
in 25% of relapsing cases.
In secondary syphilis, scrotal
lesions may occur with a generalized cutaneous, nonpruritic rash and mucous
membrane manifestation. This stage usually appears several weeks after the
chancre has healed. Secondary syphilis may also mimic many other cutaneous
diseases, but the generalized rash characteristically appears on the palms and
on the undersides of the feet. On the scrotum, this rash may resemble tinea
cruris, lichen planus (see Plate 3-6), or can appear as papules similar to
urticaria pigmentosa. Follicular, nodular, and pustular lesions are relatively
rarely observed on the scrotum, as secondary syphilitic rashes are more often
papular or annular in character. The moist papule is the most common syphilitic
lesion found on the scrotum. Annular recurrences are also observed in untreated
and insufficiently treated patients. Annular lesions are actually moist papules
with raised circular ridges that are elevated about 0.5 mm from the surrounding
skin and may be covered by a light scale that exudes serum. Later the papillae
appear as glistening or translucent elevated rings where the skin is stretched.
The lesions can be hidden within the scrotal skin folds. If the scrotum is
stretched, annular and papular lesions become obvious. Annular lesions may also
occur in the tertiary stage. In addition to rashes, symptoms of secondary
syphilis may include fever, swollen lymph glands, sore throat, patchy hair
loss, headaches, weight loss, muscle aches, and fatigue. These symptoms will
resolve without treatment but will progress to the latent and possibly late
stages of disease. The annular and papular forms of cutaneous secondary
syphilis are often misdiagnosed. Papular lesions sometimes develop into flat
condylomata lata, with an eroded surface caused by nonspecific hypertrophy of the
epidermis. They can be associated with condyloma acuminata near the rectum and
can be found in similar individuals at risk for sexually transmitted diseases.
However, it is important to differentiate these two lesions:
condyloma acuminata are dry, cauliflower-like, and bulky,
whereas condyloma lata are smooth, moist, and flat. It should be emphasized that
scrotal lesions, even in relapsing syphilis, are infectious.
The latent stage of syphilis
begins when primary and secondary symptoms disappear and this stage can last
for years. The late stages of syphilis develop in about 15% of untreated
patients and can appear 10 to 20 years after infection was acquired. In
late-stage syphilis, signs and symptoms include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia.
Ulceration on the scrotum in tertiary syphilis may occur from gummas of the
testis and epididymis, which may become adherent to the overlying skin. Such
chronic, indolent, and painless ulcers should not be confused with tuberculous
ulcers, sarcoma, or necrotic teratoma, which cause similar manifestations.
Lymphedema and mild pseudo-elephantiasis of the scrotum can results from obstruction of syphilitic inguinal lymph nodes.
