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Editor,—We recently reported five patients with sexually/non-sexually transmitted ulcerative diseases complicated by perforation on the dorsal surface of the prepuce.1 We could find reports of only three similar cases in the indexed literature. During screening of our STD clinic files we found record of another patient with dorsal perforation of the prepuce; however, it was not due to genital ulcer disease, but to condylomata acuminata. This patient, a 22 year old man had unprotected sexual intercourse with a commercial sex worker about 6 months before reporting to our STD clinic in January 1994. About 1 month after sexual contact, he developed small papular lesions on the glans penis. Lesions enlarged rapidly and started eroding the undersurface of the prepuce. Finally, 3 months later, the prepuce was perforated. Examination revealed a large, circular defect on the dorsal aspect of the prepuce through which multiple papulonodular, warty lesions were visible (fig 1). Warty lesions were also visible all around the preputial opening. On retraction of the prepuce (which was difficult), the whole glans penis, corona, and frenulum and undersurface of the prepuce were studded with multiple warts varying in size from 2 mm to 1.5 cm. The surface of the lesions was verrucous. Histopathological examination of one of the warty lesions showed features consistent with condyloma acuminatum. Serology for HIV and syphilis were negative.
In our earlier report all patients with dorsal preputial perforation had ulcerative diseases involving genitalia. Maite and Hay2 earlier reported a patient with genital warts treated with topical podophyllin, who presented later with perforation of the dorsal surface of prepuce. They considered it as delayed podophyllin damage. Our patient had not been treated before with podophyllin. The identical presentation in our and the reported patient suggests that warts themselves and not podophyllin are responsible for perforation. Condylomas particularly in immunocompromised individuals may attain a very large size and rarely become locally invasive and destructive.3 In our patient, however, condylomas were not very large and there was no evidence of immunosuppression.
Our patient had condylomas all over the glans, but perforation took place only on the dorsum of the prepuce, confirming that this site is more susceptible to this complication.
Incidentally, two more patients with perforation on the dorsal surface of the prepuce as a complication of chancroid and genital herpes have been depicted in A colour atlas of AIDS in the tropics.4 Both patients were HIV seropositive. This suggests that this complication is not uncommon (though underreported), more so in tropics. HIV infection by altering the course and severity of genital lesions of sexually transmitted diseases probably makes this complication more frequent. Out of the 10 patients reported/published, half were HIV seropositive.