Background BASHH Guidelines recommend a biopsy to exclude premalignant conditions in persistent balanitis. PIN is a well recognised condition that can be difficult to identify. In UK GUM clinics, the incidence of reporting of PIN is rare compared to international studies raising the possibility of under-diagnosis. Locally, our clinic guidelines and policies have changed in line with BASHH guidance.

Aims We describe the clinical presentation, diagnostic process and management of PIN cases presenting to the sexual health clinic.

Results Five cases were identified from August 2010 to March 2011. The median age was 38 years (range 31–52). 1/5 was an HIV infected MSM. Duration of symptoms ranged from 3 months to 18 years. 3/5 were initially managed inappropriately; having a delayed biopsy. In each case the condition manifested differently; with clinical appearances ranging from solitary hypertrophic lesions to multiple verrucous and leukoplakic lesions. The HIV positive patient had the most atypical and florid lesions. All of the men were uncircumcised; 2/5 were current smokers and 2/5 were previous smokers. One case had possible previous exposure to agricultural chemicals. Histologically: all biopsies had evidence of HPV infection, 4/5 had PIN3 and 1 had PIN1. 2/5 also had anal intraepithelial neoplasia; 1 presented to the surgeons with an anal lesion, but his penile lesion was missed. All were referred to local urology and three were reviewed further at a tertiary centre. 1/5 was treated with topical imiquimod only, 2/5 were treated initially with topical imiquimod then subsequent surgery with resolution of lesions and two had a surgical intervention as first line treatment.

Discussion Men presenting with atypical penile lesions should have a penile biopsy in line with BASHH guidance and a high index of suspicion for other genital dysplastic conditions, for example, AIN and clear local pathways for referral should be in place.