Multiple Penile Horns: Case Report and Review

Anthony Fiore, Phillip Cea, Paul Tucci, and Joseph C. Addonizio
From the Department of Urology, New York Medical College, Valhalla, New York


ABSTRACT — We report a case of unusually large multiple penile horns following removal of condylomata acuminate. Penile horns can grow rapidly, although malignant degeneration is uncommon. Wide excision with deep biopsy of skin at the base of the lesion probably is appropriate treatment. (J. Urol., 139:1055-1056, 1988)


Cutaneous horns are masses of cornified material that develop from a wart or acanthosis.(1) Although common on the scalp, they are rare on the glans penis with fewer than 100 cases reported in the literature since the first case was published in 1854.(2) We report a case of 2 penile horns, which represents the largest such lesions reported since 1944.

Case Report
A 32-year-old man presented with multiple condylomata acuminate on the preputial skin and glans penis. He underwent circumcision with cryosurgical ablation of the lesions on the glans penis. Condylomata recurred 7 weeks later around the coronal sulcus, and there were 2 hard masses that began as small irregularities over the dorsum and ventral aspect of the glans at the coronal sulcus. The lesion produced itching and pain on movement, and interfered with sexual intercourse. A purulent discharge from the necrotic ventral penile horn also was noticed. No enlargement of the lymph nodes was palpable. In less than 4 months the lesion on the dorsum of the glans penis grew 5 cm. in length and 2 cm. in diameter, and the lesion on the ventral aspect of the coronal sulcus grew 3 cm. in length and 2 cm. in diameter. The horns were excised without difficulty and the defect was covered with a rotational flap of penile skin. Convalescence was uneventful and the patient has done well.

Microscopically, the specimen showed marked hyperkeratosis, parakeratosis, and marked acanthosis. An area at the base of the horn revealed squamous cell atypia, although no evidence of squamous cell carcinoma was found on deep biopsies of the circumferential skin surrounding the base of these lesions.

Discussion
The etiology of penile horns is unclear, although their association with and histological resemblance to condylomata acuminata suggest that they are a particularly striking form of this more familiar lesion. If so, presumable horns also are of viral origin.(3-4) Trauma and phimosis may be contributory.(5) Penile horns can grow with extreme rapidity.(6) Taylor described a horn that grew to a length of 3 inches in 6 months,(7) and 1 lesion in our patient grew only slightly less rapidly. Malignant change should always be suspected in such fast-growing lesions but, as our case demonstrates, it is not invariably present.

Clinically, the penile horn may produce pain, irritative symptoms, dysuria and interference with sexual intercourse. Ulceration is uncommon. Microscopically, the horn shows marked hyperkeratosis, acanthosis, dyskeratosis, papillomatosis and chronic inflammatory infiltration of the adjacent dermis.(1) Malignant changes have been noted in 12 of the approximately 100 reported cases, with such lesions exhibiting all of the characteristics of penile carcinomas. (6,8-9) However, there are no reports of metastases.

We believe that wide local excision should be the initial treatment, with deep biopsies of the skin surrounding the base of the lesion for accurate histological diagnosis. (10) Alternative approaches with either carbon dioxide or neodymium:YAG laser therapy have been reported by many authors for condylomata acuminate. Giant condyloma also has been treated successfully with the carbon dioxide laser.(11) Large lesions usually require more than 1 treatment session but the lesser degree of scarring with superior cosmetic results make laser therapy attractive. Because of the size of these lesions, podophyllin effective against condylomata probably is not appropriate. Circumcision is warranted to reduce the risk of recurrence. If malignancy is found in the horn histologically, partial penectomy with or without regional lymph node dissection should be considered, as in any penile carcinoma. Neodymium:YAG laser therapy of malignant lesions of the penis has been suggested by many authors, and Hofstetter and Frank have the largest experience.(12) They reported on the use of this modality in 17 patients who refused conventional surgical therapy. Cosmetic results were excellent with only one local recurrence during a followup period of 11 to 39 months. Although these results are encouraging and primary laser therapy may prove to be the treatment of choice in selected cases, we believe that presently penectomy remains the preferred modality.

References
1. Ewing, J. E.: Neoplastic Disease. Philadelphia: W. B. Saunders Co., 1940.

2. Jewett, P. A.: Case of horn on the glans penis. New York Med. Times, 3: 79,1854.

3. Huggins, C. B. Discussion of Taylor’s paper. Trans. Amer. Ass. Genito-Urin. Surg., 37: 107, 1944.

4. Rous, P.: The nearer causes of cancer. J.A.M.A., 122: 573, 1943

5. Presman, D., Rolnick, D. and Turbow, B.: Penile horn. Amer. J. Surg., 104: 640, 1962.

6. Hassan, A. A., Orteza, A. M. and Milam, D. F.: Penile horn: review of literature with 3 case reports. J. Urol. 97 315, 1967

7. Taylor, J. A.: Penile horn. J. Urol., 52: 611, 1914.

8. Raghavaiah, N. V., Soloway, M. S. and Murphy, W. M.: Malignant penile horn. J. Urol., 118: 1068, 1977.

9. Lebert: Uber Keratosis etc. Breslau, 1864.

10. Willscher, M. K., Daly, K. J., Conway, J. F., Jr. and Mittelman M. A.: Penile horns: report of 2 cases. J. Urol., 132: 1192, 1984.

11. Rosemberg, S. K., Fuller, T. and Jacobs, H.: Continuous wave carbon dioxide laser treatment of giant condyloma acuminate of the distal urethra and perineum: technique. J. Urol., 126: 827 1981.

12. Hofstetter, A. and Frank, F.: Laser use in urology. In: Surgical Application of Lasers. Edited by J. A. Dixon. Chicago: Year Book Medical Publishers, chaps. 8, p. 146, 1983.

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