Photo Rounds

Genital bumps

A 21-year-old man presented to his family physician (FP) with bumps on his penis. He acknowledged having unprotected sexual intercourse with more than 6 women in the past year. This was the first time he’d sought care for the problem. He was otherwise healthy.

What's your diagnosis?


The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

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