A rare complication of a common surgical procedure

Pathology of the external genital organs

Dr. Emmanuelle Bourrat

Saint-Louis Hospital

The clinical case
Now it's your turn!
Co-prescription and advice

Clinical case presentation

This 5-year-old child had undergone circumcision 3 years previously because of a tight phimosis resistant to medical treatment. The following day, the operation was complicated by bleeding, requiring manual evacuation of the hematoma and a pressure dressing.

He presented with a very slowly progressing, erythematous, papular, polylobed plaque covering a quarter of the balanopreputial groove and extending slightly over the surface of the glans penis. The lesion was not painful but permanently oozed, causing maceration.
The rest of the mucocutaneous examination revealed no other abnormalities.

Your turn

What is your diagnosis?

Select 1 answer(s) from the following choices:

HPV-induced genital condylomatosis

Botryomycoma

Sarcoma

Lymphangioma

Wrong answer!

Good answer!

Selected diagnosis

The diagnosis of botryomycoma (or pyogenic granuloma) on a circumcision scar was clinically retained based on the circumstances of occurrence, the clinical aspect, the pediatric setting and the perfect similarity of this lesion with one of the rare cases published in the literature, which was confirmed by biopsy.

This benign vascular lesion, common in children, corresponds to hyperplasia of granulation tissue in reaction to trauma. It appears as a fleshy, soft, red, non-epidermized nodule that bleeds easily on contact.

Explanation of wrong answers

HPV-induced genital condylomatosis is not uncommon in children, and while the papillomatous appearance of these mucosal lesions was compatible, the bright red highly vascular staining was less so.
The superficial component of a microcystic lymphangioma (dilated lymphatic cisterns) associated with hemorrhagic changes could be evoked.
Sarcoma (including Kaposi’s sarcoma) is very rare in children, but should be considered in the presence of any progressive tumor, including in the genital organs.

Treatment

A therapeutic test in the form of topical corticosteroid therapy with betamethasone cream, which rapidly regressed all lesions, confirmed our diagnosis of pyogenic granuloma or botryomycoma.

Message from the expert

Pyogenic granuloma or botryomyoma of the balanopreputial groove appears to be a very rare (or under-reported) complication of circumcision. Topical corticosteroid treatment may suffice to control this excess of scar granulation tissue.

References

^{C Tomasini, P Puiatti, M G Bernengo Multiple pyogenic granuloma of the penis Sex Transm Inf 1998;74:221-222}