Max, 19, presents with multiple lumps on his genitals. He has noticed them recently as he has a new sexual partner and has become more aware of the appearance of his genitals.
The lumps are painless, not itchy, and more obvious when his penis is erect.
Max is otherwise well with no urethral discharge, urinary symptoms, testicular pain or fevers. He has no significant past medical history, including of STIs, takes no medications and has no known allergies.
On examination there are multiple small slightly elevated papules on the shaft of the penis. They are not tender and are more visible when the skin is stretched. Genitourinary examination is otherwise normal.
What is the most likely diagnosis?
Correct!
Fordyce spots are heterotopic sebaceous glands, which mostly occur on the oral and genital mucosa and skin. They are considered a normal anatomical variant, are not sexually transmitted, nor are they infectious.
Fordyce spots usually appear as small (1-5mm) discrete papules that are yellow-white and are often confused with STIs. They usually appear in puberty, when gland enlargement is stimulated by hormonal factors. Thus their appearance can cause high levels of anxiety in young adult patients.
They are generally harmless and require no treatment, however electrosurgery and laser treatment can be used if there are significant cosmetic concerns. Patients should be advised to avoid picking or squeezing the spots as this carries a risk of scarring.
Genital HSV usually results in painful, fluid-filled vesicles and is thus generally easy to diagnose based on the typical clinical features.
Genital warts can be distinguished from Fordyce spots by their dermoscopic appearance of cauliflower-like structures. They often protrude out of the skin surface.
Pearly penile papules occur exclusively on the coronal sulcus of the glans penis — these are also considered a normal anatomical variant.
In this case, simple reassurance was the management approach, and the patient was most satisfied to know that the appearance of his genitals was certainly normal.