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Male genital disease in HIV and AIDS.

The first case of acquired immune deficiency syndrome (AIDS) was described in 1981. (1) In the past 29 years the number of AIDS cases has increased at a rapid pace and in 2004 it was estimated that 34-42 million people were living with HIV infection. (2)

The situation is even worse in sub-Saharan Africa, where in 2003 it was estimated that 25 million people were living with HIV infection. A suspected 3 million new cases and 2.2 million deaths due to AIDS were reported that year. (3)

The three modes of transmission of HIV are: unprotected intercourse, contact with blood, and mother-to-child transmission. There are several urological risk factors involved in the transmission of HIV.

Urological risk factors in HIV transmission

* Sexually transmitted infections (STIs). All STIs have a similar mode of transmission and there is evidence that genital ulcers and non-ulcerative STIs facilitate HIV transmission. (4)

* Antiretroviral therapy and genital secretions. Although patients on antiretroviral treatment may have lower HIV levels in their blood, sexual transmission may still be possible. (5)

* Circumcision status. Uncircumcised men have an increased risk of infection by way of STIs and HIV. (6)

* Specific sexual behaviour. Male-to-female transmission is more prevalent than vice versa. (7) In anal intercourse the insertive partner is less likely to contract HIV than the receptive partner.

Male genital manifestations of HIV infection

HIV can present in different forms in the male urogenital tract. The different manifestations are summarised in Table I.

Table I. Male genital manifestations of HIV

Non-malignant conditions

* Sexually transmitted infections

* Genital herpes simplex virus (HSV)

* Human papillomavirus (HPV)

* Syphilis

* Chancroid

* Urethritis

* Molluscum contagiosum

* HIV-related genito-urinary tract infections

* Prostatitis

* Epididymitis and orchitis

* Necrotising fasciitis (Fournier's gangrene)

Neoplasms

* Kaposi's sarcoma (KS)

* Non-Hodgkin's lymphoma (NHL)

* Squamous genital cancers

* Testicular cancer

Sexually transmitted infections

Genital herpes simplex virus (HSV)

HSV types 1 and 2 are very common in HIV-infected men. (8) The course of the infection may be prolonged and intravenous acyclovir may be necessary to cure the lesions. Patients with acyclovir-resistant HSV have been described and need treatment with foscarnet or topical cidofovir gel.

Human papillomavirus (HPV)

Warts (condylomata acuminata) are found on the penis, urethra, scrotum and perineum.

Other clinical presentations of HPV include bowenoid papulosis and epidermodysplasia verruciformis. Men with extensive penile warts should be screened for HIV.

Syphilis

There is a high prevalence of syphilis in HIV-infected populations, especially homosexual men. (9) It progresses faster from secondary to tertiary syphilis in HIV-infected men, who, with early syphilis, have a high risk for the development of neurological complications and treatment failure of standard regimens.

Chancroid

Chancroid, caused by Haemophilus ducreyi, is a co-factor for HIV transmission. Chancroid in HIV-infected individuals may be resistant to standard regimens. Ulcers heal more slowly and prolonged courses of treatment may be needed.

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Urethritis

Patients with HIV have a high risk for the development of urethritis caused by Neisseria gonorrhoeae and Chlamydia trachomatis. There is a link between AIDS and Reiter's syndrome (10) (urethritis, uveitis and arthritis), but the association is poorly understood.

Molluscum contagiosum

It is caused by a sexually transmitted pox virus and is found in 10-20% of AIDS patients, most often on the face and genital areas. The lesions can become very large and widespread in AIDS patients. (11) HIV-infected patients with molluscum contagiosum usually have a CD4 count of less than 250 cells/[mu]l. Molluscum contagiosum lesions may simulate more serious infections, such as cutaneous pneumocytosis, histoplasmosis and cryptococcosis, and should be confirmed by biopsy.

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HIV-related genito-urinary tract infections

Prostatitis

It is found in up to 8% of HIV patients (12) and presents as acute prostatitis. It can be associated with superimposed urinary tract infections.

Epididymitis and orchitis

In autopsy studies 39% of AIDS patients have signs of opportunistic testes infections. Infections usually cause atrophy of the testes with spermatogenetic arrest and depletion of Leydig's cells. Immunocompromised patients can also develop epididymitis caused by atypical organisms such as Candida and cytomegalovirus. (13)

Necrotising fasciitis (Fournier's gangrene)

It may be the presenting condition in previously undiagnosed AIDS patients. (14) All patients with this life-threatening infection should be screened for HIV.

Neoplasms

Kaposi's sarcoma (KS)

Two types of KS are described, i.e. the classic type, which occurs in patients with lymphoma or immune deficiencies, and the epidemic type, which is associated with AIDS. KS can affect any skin area, including the male genitalia. A new herpesvirus, human herpesvirus 8, is associated with all cases of KS. (15) An experienced observer can easily diagnose the typical purple indurated plaques, but the diagnosis needs to be confirmed by biopsy.

Non-Hodgkin's lymphoma (NHL)

Patients with NHL usually have widespread disease at presentation and genitourinary sites may be involved primarily or secondarily. (16) Since the introduction of antiretroviral therapy the incidence of KS has decreased and therefore NHL is the most common AIDS-associated malignancy in patients on therapy.

Squamous urogenital cancers

HIV-infected patients have a higher risk of developing HPV-associated squamous cancer of the penis as well as precancerous lesions associated with HPV. A study in the USA confirmed that HPV accounts for 50% of all penile carcinomas. (17) Several studies on squamous carcinoma at other sites, such as the cervix, anorectum and oral cavity, have confirmed that these cancers have a higher incidence in HIV-infected patients. (18) However, only a few cases of invasive penile cancer in the HIV-infected population have been described. (19) In an as yet unpublished study at the Department of Urology, University of the Free State, Bloemfontein, we found that 56% of patients with penile carcinoma were HIV positive. (20)

Testicular cancer

Testicular tumours are 50 times more common in the HIV-infected population than in non-infected individuals. (21) These tumours are also more often bilateral and there is a great risk of high-grade lymphoma in the testes. This is important when considering treatment, because all the known chemotherapeutic regimens will lead to further immune suppression.

Conclusion

It is clear that several dermatological conditions and tumours of the male external genitalia are associated with HIV infection. Patients with these lesions should be screened for HIV.

References available at www.cmej.org.za

References

(1.) Krieger JN. Urologic implications of AIDS and HIV infection. In: Campbell's Urology. 9th ed. 386.

(2.) World Health Organization: The World Health Report in 2004-changing history. http://www.who.int/wht

(3.) United Nations. Joint United Nations Project on HIV/AIDS: 2004 Report on the Global Aids Epidemic. Geneva: UN, 2004.

(4.) Simonsen JN, Cameron DW, Gakinya MN, et al. Human immunodeficiency virus among men with sexually transmitted diseases. Experience from a center in Africa. N Engl J Med 1988;319(5):274-278.

(5.) Smith DM, Wong JK, Shao H, et al. Long term persistence of transmitted HIV drug resistance in male genital tract secretions: Implications for secondary transmission. J Infect Dis 2007;196(3):356-360.

(6.) Auvert B, Buve A, Ferry B, et al. Ecological and individual level analysis for HIV infection in four urban populations in Sub-Saharan Africa with different levels of HIV infection. AIDS 2001;15 (Suppl 4):S15-30.

(7.) Mayer KH, Anderson DJ. Heterosexual HIV transmission. Infect Agents Dis 1995;4(4):273-284.

(8.) Centers for Disease Control and Prevention. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV and HIV and recommendations for post exposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50:1.

(9.) Wawer MJ, Sewankambo NK, Serwadda D, et al. Control of sexually transmitted diseases for AIDS prevention in Uganda: A randomized community trial, Rakai Project Study Group. Lancet 1999;353(4152):525-535.

(10.) Winchester R, Bernstein DH, Fischer HD, et al. The co-occurrence of Reiter's syndrome and acquired immune deficiency. Ann Intern Med 1987;106(1):19-26.

(11.) Izu R, Manzano D, Diaz Perez JL. Giant molluscum contagiosum presenting as a tumor in an HIV infected patient. Int J Dermatol 1994;33(4):266-267.

(12.) Leport C, Rousseau F, Peronne C, et al. Bacterial prostatitis in patients infected with the human immunodeficiency virus. J Urol 1989;141(2):334-336.

(13.) Randazzo DN, Michalski FJ. Cytomegaloviral epididymitis in a patient with the acquired immune deficiency syndrome. J Urol 1986;136(5):1095-1097.

(14.) McKay TC, Waters WB. Fournier's gangrene as the presenting sign of an undiagnosed human immunodeficiency virus infection. J Urol 1994; 152:1552-1554.

(15.) Chang H, Wachtman LM, Pearson CB, et al. Non-human primate model of Kaposi's sarcoma--associated herpes virus infection. Phos pathog 2009;5(10):e1000606.

(16.) Vaccher E, Spina M, Talamini R, et al. Improvement of systemic human immunodeficiency virus-related non-Hodgkin lymphoma outcome in the era of highly active antiretroviral therapy. Clin Infect Dis 2003;37(11):1556-1564.

(17.) Barnholtz-Sloan JS, Maldonado JL, Pow-Song J, et al. Incidence trends in primary malignant penile cancer. Urol Oncol 2007;25(5):361-367.

(18.) Kestelyn PH, Stevens A-M, Ndayambje A. HIV and conjunctival malignancies. Lancet 1990;336:51-52.

(19.) Aboulafia DM, Gibbons R. Penile cancer and human papilloma virus in a human immunodeficiency patient. Cancer Invest 2001;19:266-272.

(20.) Vermeulen LP, Wentzel SW, Beukes C, et al. HIV in penile carcinoma: Prevalence and influence on age at diagnosis.

(21.) Wilson WT, Frenkel E, Vuitch F, et al. Testicular tumors in men with human immunodeficiency virus. J Urol 1992;147(4):1038-1040.

SCHALK W WENTZEL, MB ChB, MMed (Urol)

Professor and Head, Department of Urology, University of the Free State, Bloemfontein

Correspondence to: S W Wentzel (wentzels@ufs.ac.za)
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Title Annotation:MORE ABOUT ... HIV-RELATED SURGERY
Author:Wentzel, Schalk W.
Publication:CME: Your SA Journal of CPD
Article Type:Report
Geographic Code:6SOUT
Date:Aug 1, 2010
Words:1580
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