Traumatic lesion leading to petechiae on the junction of the hard and soft palate, contracted from performing fellatio. In this case, differential diagnosis includes herpes, other viruses and bacterial infection with streptococcus

Ulcer on the buccal floor contracted from performing cunnilingus. Observe the sharp uneven borders of the anterior teeth. Differential diagnosis includes diseases that cause mouth ulcers, such as syphilis or herpes. In this case, as in the previous case, if the patient is HIV positive the infectiousness of the lesion will be higher. However, if the patient is HIV negative they will be more susceptible to contamination with HIV and other infections every time they practice oral sex

Patient in her 50s referred to the STD clinic due to a genital tumour. She was very worried as she thought it was a malignant or serious venereal disease. This was simply a sebaceous cyst, which was at first treated by removal of the inner mass and then on another occasion by removal of the capsule. It is extremely important to keep in mind that we must consider STDs in our everyday practice. However, we must also remember that not everything found on the genitals is an STD. Establishing a diagnosis based on assumptions and without verifying the epidemiological history and performing thorough clinical and laboratory examinations represents low-quality medical practice. Therefore, we must follow global medical care routines in full

Patient referred for peniscopy as his partner obtained oncological colpocytology results suggesting HPV. He did not present any lesion suggesting he was infected with this virus. He was diagnosed with a dermal cyst on the scrotum

Patient presenting large cervical polyps (arrow) that extends to the vaginal introitus. This was the reason for her referral. After a routine check up with direct examination of a vaginal swab we diagnosed vaginitis caused by Trichomonas vaginalis. Serological screening for syphilis, HIV, hepatitis B and C was non-reactive. We prescribed a course of injections against hepatitis B

Patient referred to the Fluminense Federal University (UFF) STD clinic for treatment of bartholinitis. This was not a case of bartholinitis, but an abscess in the area close to the right labia majora. The patient reported that she had had similar symptoms on three previous occasions and that these had reduced upon local application of a stupe and antibiotic cream. Incision and drainage, as well as systemic antibiotic therapy, are the procedures that should be used to treat this. We must emphasize the fact that many of these processes start after depilation followed by folliculitis

Twenty-six-year-old patient referred by the urology clinic presenting extensive balanitis with stinging. He reported this being the first time these symptoms had appeared. He denied receiving any previous treatment and said that the symptoms had appeared 24 h previously. Serological screening for HIV and syphilis was non-reactive. Bacteriology exams of a swab taken from the lesion using the Gram technique and dark field microscopy did not provide a clearer diagnosis. Stained cytology using the Papanicolaou and Giemsa techniques was non-specific. The patient was advised to wash using boric acid solution and topical application of Uncaria tomentosa gel 5%, which lead to complete cure within 4 days

Patient seen at the UFF STD clinic after referral from the public health system, presenting classic symptoms of fungal balanitis (a). He reported that he sought medical attention for these symptoms and was given an IM dose of penicillin benzathine without being examined. Direct examination of a swab taken from the area did not provide a diagnosis of fungus. However, stained cytology was positive for hyphae. He was treated with itraconazol and given advice on hygiene. One week later he was fully recovered (b)

Nineteen-year-old patient referred by a private health company for treatment of bartholinitis. The symptoms had persisted for over a week despite the use of oral antibiotics, azithromycin and ciprofloxacin. She was not experiencing fever or intense pain. She reported that the swelling did not hurt but was causing her discomfort (sic). Note in panels (a, b) that there is no inflammation. The clinical diagnosis was Bartholin’s cyst. Panels (c–f) show the marsupialisation of the gland. In (g), a drainage tube was left attached for just 24 h, as if left for longer this could facilitate a secondary infection of the gland

Thirty-five-year-old patient, referred to the STD clinic at the Valença Faculty of Medicine in Rio de Janeiro by the Family Health Program (PSF) in the same city, with a history of vaginal tumours that were observed during sampling for oncological colpocytology carried out by a non-medical professional at this service. Examination carried out at the STD clinic revealed that this was a Gartner duct cyst ( a ), a disease with a low prevalence, and that it was not related to any STD. These are remnants of the mesonephric ducts on the lateral part of the vulva

(a) Patient presenting a vegetating lesion on the vulva that had been present for a few months and on various occasions had been treated with trichloroacetic acid solution and podophyllin, as it was thought that it was a case of condyloma acuminata. (b) After examination, we proceeded to perform surgical exeresis. Histopathology revealed this to be a case of syringoma, a benign tumour that is rarely seen on the vulva. This is understood to be an adenoma on the ducts of the intra-epidermal eccrine sweat glands

(a) This is practically identical to the previous case. (b) This was also a case of syringoma. We consider exeresis of the tumour and histopathology to be good practice. There are both aesthetic and emotional aspects related to the presence of a lesion on the genitals. It is unusual for somebody to have a genital lesion and not think that this is associated with an STD. The previous case was worse, as the partner underwent two peniscopies to screen for HPV and it was established with certainty that he had contaminated his partner with HPV

Another case where histopathology was used to diagnose syringoma on the vulva

Patient referred from a health centre after intramuscular administration of 500 mg of ceftriaxone to treat bartholinitis. She was very anxious and was complaining of pain and a tumour on her vulva. At the beginning of the consultation she denied any situation association with sexual activity. However, when there was just one doctor in the room and the patient was feeling more confident she reported that she had been raped by three men and had suffered violent injuries to her vulva. This is a learning point: many patients need time and confidence to talk about intimate details. Health teams should be careful to create an adequate environment in order to listen to their patients. Every one of us takes the time we need to speak

This patient came to the clinic in an anxious state as he had been accused by his partner of having transmitted HPV to her. He just had some numerous sebaceous cysts on his scrotum. It is worth remembering that not everything on the genitals is an STD. It is not uncommon for a patient to receive colpocytological (PAP) results suggesting HPV and their partner not present anything. However, the complete routine should not be delayed, including serological screening and finding out the patient’s vaccination status

(a) Patient presenting a cyst containing a serous substance on his penis. (b) Totally cured after exeresis

Patient seen at a private health clinic referred for treatment of warts on his penis. He actually presented small vegetative verrucous lesions on his penis, which are characteristic of condyloma acuminata. Histopathological examination proved this hypothesis to be correct. During the appointment, in line with our normal routine, we examined the penis, the scrotum and the perineal and perianal regions. We found some abnormalities in this area, however, they were just sebaceous granules (a), eliminating the possibility of this being a case of HPV infection in the perianal area

Many men present these anatomical formations on the penis (arrows). Sometimes they are iatrogenically given “treatment” for HPV. As well as physical iatrogenesis, some of these patients are affected emotionally, as they are “labelled” as having an STD that develops into cancer. These anatomical formations are physiological

This patient presented this genital epidermal cyst and a history of recurring genital herpes

(a, b) This patient arrived at the clinic with a case of edema on his foreskin and an ulcer on his penis. He reported that he had a cockscomb-type vegetative lesion on his penis. To cure this, he applied an unknown liquid sold by a pharmacy salesperson in his neighbourhood. He reported that soon after the first two applications the ulcer appeared, developing pain, necrosis and edema. As well as being caustic, this product caused topical irritation. We did not find out what the liquid was as the patient did not return for follow up

(a, b) Patient referred to the STD clinic for treatment of a genital ulcer with a hypothetical diagnosis of lymphogranuloma. This was actually a case of paraphimosis. The patient claimed that it had been this way for 2 days and that when he went to the health centre he was referred to our clinic

This is very similar to the two previous cases, although it was not paraphimosis but dermatitis caused by a primary irritant through the topical use of a solution for the treatment of mycosis. The product contained the metalloid iodine. Soon after using this medication to treat the itching caused by the mycosis, the patient noticed this severe edema

What follows is a series of cases involving edemas on the penis with four different causes. All of these cases were seen at the STD clinic at the Federal University of Ceará University Hospital in the city of Fortaleza. The importance of anamnesis, clinical examination, classic STD laboratory examinations and an epidemiological approach are essential in deciding the therapeutic approach to be taken. (a) The edema appeared after the appearance of a genital ulcer noticed around 7 days after sexual relations with an occasional partner without protection. VDRL was 1:2 and serological screening for HIV and hepatitis B was negative. The patient was treated for syphilis and the symptoms disappeared the following week. (b) Edema on the penis that appeared after unprotected sex with his girlfriend, his exclusive partner. During the consultation he reported pain in his penis but no secretions or adenomegalies. He reported that he normally had a lot of difficulty externalizing his glans (phimosis). He was referred to the urology department and advised to apply a gold saline compress and an oral anti-inflammatory. The glans reduced in size after a urological procedure and the patient was later referred for postectomy. (c) Patient complaining of edema and an ulcer on his penis that had appeared 24 h previously. He reported that the edema had appeared after an attack of severe genital itching. He reported itching in other areas of the body and that this worsened at night. When asked if other family members had displayed similar symptoms, he said that they had. In the photo there are traumatic ulcers on the penis, glans and hand. We also found lesions on the buttocks, abdomen and underarms. We recommended treatment for scabies with oral ivermectin 6 mg, 2 pills once a week repeated after 1 week, and advised that all symptomatic family members seek medical attention. (d) Patient presenting edema on his foreskin for 3 days. He had been experiencing stinging and purulent urethral discharge for 10 days, which began 6 days after having unprotected sex. Bacteriological examination of the urethral discharge was positive for intracellular Gram-negative diplococci in polymorphonuclears. We recommended oral ciprofloxacin 500 mg and oral azithromycin 1 g, both in a single dose. We advised his to use cold saline compresses and an oral anti-inflammatory. The symptoms disappeared within 3 days

(a, b) Young adult presenting a serious case of hypertrophy of the papillae, which can be easily confused with HPV infection. This patient had been seriously emotionally abused by their sexual partner, who accused him of having HPV

Another case of hypertrophy of the papillae. It is obvious that in some situations the patient can present condyloma acuminata lesions in the middle of the papillae, and only these should be treated. However, care must be taken during examination to avoid causing iatrogenesis

The same situation of hypertrophy of the papillae, also known as hirsuties coronae glandis

(a–c) Hirsuties coronae glandis, which is often confused with condyloma acuminata, or HPV infection

Another patient referred to the UFF STD clinic to treat HPV lesions. These were actually anatomical elements—Fordyce granules that have nothing to do with HPV infection. The patient insisted that he did not want to continue with this “problem”. He was given an explanation of what they are and that the best solution was to do nothing to avoid aggravating the area

Twenty-year-old patient with a high economic and cultural level presenting hyperchromic lesions on his glans and the inside of his foreskin. The patient as well as his father, who is a health professional, requested that a biopsy of the lesion be carried out, as they wanted to confirm or exclude the possibility of HPV infection, as this hypothesis was causing them stress. Histopathological examination of a small fragment revealed that this was a case of melanocytic nevus, which is not an infectious disease and not related in any way to HPV. This was the cause of so much distress for the patient, his father and his girlfriend

Young adult patient seen at the UFF STD clinic referred for a peniscopy as his sexual partner presented oncological colpocytology (PAP) results showing cells with koilocytosis, suggesting HPV. The patient reported that he had already been examined by a urologist who had referred him for treatment for HPV at our clinic. This situation is actually physiological (pearly penile papules in the peroneal groove and Fordyce granules, which are sebaceous glands on the penile shaft) and is in no way related to HPV infection. Guidance on sexual and reproductive health should be given. We discovered from the patient history that he had not been vaccinated against hepatitis B. Therefore, we prescribed a course of injections for this. On March 9, 2011, an excellent article was published online in Nature 471 describing alterations in human DNA that had made certain anatomical formations disappear, such as “spines” on the penis. These ridges exist in chimpanzees (and in various mammals) and increase sensitivity, making ejaculation happen faster. It is believed that these “spines” also remove the sperm of any rivals that have copulated with their mate previously. Therefore, this mechanical removal could help to ensure that pregnancy occurs as a result of the most recent coitus. On the other hand, the smoother penis of modern man may be linked to the adoption of monogamous relationships. Without these anatomical formations, man has made coitus last longer. Who knows, perhaps the formation of pearly penile papules/Fordyce granules/hirsuties coronae glandis are remnants of these old penile “spines”?

Twenty-one-year-old single patient, a student, seen at the STD clinic of the Federal University of Ceará University Hospital in Fortaleza, complaining of genital warts he had suffered from for around 4 years. He reported having just one sexual partner in the last 2 years. He did not report any previous STDs. Examination of the genital area (peniscopy) after application of acetic acid 5% did not reveal any lesions suggesting HPV or any other infectious agent. He was informed that this was not an STD and that it was simply an enlargement of the glands in this region (a). Unfortunately, cases like this are sometimes “diagnosed and treated” as thought they were HPV infection. As well as physical trauma (to the local area), people can undergo significant emotional, social and marital stress, etc.

Pearly penile papules. These are normal anatomical structures situated on the edge of the glans (the corona) or on the frenulum (arrow). They are common, with a reported incidence in 19% of the population. These are isolated skin-coloured papules that are 1–2 mm in diameter and form a circle on the edge of the glans, sometimes with a keratotic (spiculated) surface, and are often misdiagnosed as molluscum contagiosum or condyloma acuminata. They have a regular appearance resembling a riverbed covered in pebbles, which is different to condyloma acuminata. Both conditions can take on a whitish appearance after application of acetic acid. Histology reveals the lesions to be angiofibromas. No treatment is required. In Fig. 11.37, although the patient’s skin is black, the papules are very white and prominent. He reported difficulty in explaining to his partner that this was anatomically normal and was not a disease. In extreme cases, exeresis is recommended for emotional and aesthetic reasons

Vestibular papillomatosis was given various names in the past, including terms such as vulvar papillomatosis and microwarts. The term vestibular papillomatosis was recently established by the International Society for the Study of Vulvovaginal Disease (ISSVD). Vestibular papillomatosis is described as small papular projections that are generally located on the posterior part of the vestibule, and is considered to be a normal anatomical variant. Vestibular papillomatosis is quite normal. Stimulated by hormones during puberty, in some women a prominently thick rough surface can be found on the labial epithelium. This condition is very common in the second and third trimesters of pregnancy. These structures can be seen in asymptomatic women who generally complain of itching or burning, associated particularly with coitus. Its clinical relevance is controversial. In some cases vestibular papillomatosis may be associated with HPV infection. In cases of vulvovaginal infection, these structures can increase in volume. Secretions in the vaginal introitus can also be completely physiological. This was the case here.

(a, b) Patient over 50 years old presenting a minor case of Behçet’s disease, or Behçet’s syndrome (arrow)

(a, b) Behçet’s syndrome. Young patient with a well-confined chronic ulcer with raised borders and a clean base. This was a very painful lesion. Serological screening for syphilis and HIV was negative, as was bacterioscopy of the lesion. It was treated with a corticosteroid after many treatments, including the syndromic approach for ulcers, but with no success. (c) While examining the oropharynx, we noticed a small ulcer on the palate, over to the left, which was visible after removal of the patient’s superior prosthetic denture. The patient did not present iritis uveitis, which is part of the triad of symptoms associated with Behçet’s syndrome

Behçet’s ulcer (arrow). Unfortunately, many patients only receive correct diagnosis after initial approaches to treat STD ulcers have been applied

(a, b) Vulvar and oral lesions associated with Behçet’s disease (arrow)

(a–c) Another case of orogenital Behçet’s syndrome. Normally diagnosis is not simple and almost always a number of unsuccessful treatments are attempted with no success. Recurrence is a constant factor

(a, b) Although considering Behçet’s Syndrome could be the classic approach, this case does not fit in with this kind of clinical picture. The patient reported that this was the third time that this problem had occurred. It was not possible to establish the etiology and the lesions disappeared after a week without the patient using any medication. All routine examinations were negative. In 2 years of follow up the patient did not present any recurrence

(a, b) Perineal amyloidosis. Vegetative genital lesions are frequent, however etiological elucidation can be difficult as it involves clinical aspects that are unknown to gynaecologists. A 57-year-old white female smoker who had been pregnant eight times, given birth twice and undergone two abortions and had started her menopause at 48, was referred to the UNICAMP (Campinas University) Gynaecology Clinic after having been evaluated by various professionals, including a dermatologist and an oncologist, with no diagnosis being established. She presented two prominent violet-coloured lesions with a soft and fleshy consistency and a small inner haemorrhagic area, measuring approximately 2 cm and 5 cm respectively, stretching from the furcula to the left gluteal fold. The lesions were pruritic and presented spontaneous discharge of a bloody and fetid secretion. The patient presented the following previous pathologies: diabetes, arterial hypertension and congestive heart failure, which developed after an acute myocardial infarction 5 years previously. Her symptoms included: dyspnoea, chest pain and edema of the lower limbs. She was taking NPH insulin, digoxin and furosemide. A diagnosis of eosinophilic granuloma had been suggested and two local biopsies were carried out that surprisingly confirmed a diagnosis of “primary cutaneous amyloidosis”. Electron micrographs were obtained which revealed intracytoplasmic production of filamentous deposits (amyloid) in fibroblasts. Therefore, this excluded the possibility of this being a case of precursor lesions of plasmacytic dyscrasias, as the plasmocytes did not present any relationship with the etiology of the lesion

(a–e) This patient presented these monthly symptoms during menstruation. After receiving various treatments, biopsies, investigations and diagnostic hypotheses, dipirona was finally identified (used for dysmenorrhoea) as the cause of the orogenital symptoms. The patient reported that she started to take this medicine regularly the previous year

(a, b) This patient reported recurring symptoms of genital herpes, but the situation shown here shows the genital symptoms after use of sulfa-based local medication for the “treatment” of the ulcers caused by HSV