Sclerosing lipogranuloma of penis: Case Report

Case report: A 45-year-old patient presents to Emergency Department due to lesions on penis. Inspection showedscarring with ulcers and signs of inflammation on ventral side of penis


INTRODUCTION
In the time ofthe ever increasing expansion of cosmetic procedures, increasing the volume of the penis by injecting various substances (paraffin, silicone, vaseline, mineral oils) remains a highly controversial procedure with a history that spans for over ahundred years.Although this procedure has been abandoned in most of the developed countries, there are stillcases being reported in Asia, especially in the Middle East, Southeast Asia, Korea, as well as in some Eastern European countries [1].
These substances are injected subcutaneously in the hope that they will increase the volume of the penis.The procedure is most often performed by patients themselves or byanother person without adequate medical education.Due to the inability of tissue lipases to hydrolyze the injected substances, they persist in the penile tissue and subsequently cause alocal inflammatory reaction [2].
Injecting these substances will, in most cases, cause immediate reaction.Most commonly, a local inflammatory reaction with redness, swelling, thickening of the penile skin (these symptoms can create the illusion that the procedure was successful), while focal ulceration and necrosis may occur in more serious cases.Depending on the sensitivity of the patient's tissue and the purity of the injected material, sclerosing lipogranuloma may form.If injected into blood vessels, these substances can result in embolism with a potentially fatal outcome [3].
Usually, a painless mass is formed after the injection of these substances.This mass can persist unchanged for many years.Massaging the area in which substances are injected may lead to spreading these substances into the surrounding tissue of the penis, scrotum, and even local lymph nodes (penile cancer must be ruled out).After a certain period, in some patients, the painless mass will become firm, painful, hyperpigmented, with possible ulceration and necrosis [1].
Diagnosis is made by a pathohistological analysis of the material obtained by a biopsy.Ultrasound or magnetic resonance imaging can be used to assess the extent of the changes [6].
Treatment includes surgical resection of the change with subsequent reconstruction.The main goal is to enable normal sexual function with the best possible cosmetic results [7,8].

CASE REPORT
A 45-year-old patient initially came for an examination in August 2020 due to changes on his penis.He stated that about 8 months ago, after a sexual intercourse, he felt an itching sensation on his penis.He was prescribed a local antibiotic therapy by his general practitioner, but the symptoms did not decrease and further changes appeared on his penis in the form of swelling, redness and small ulcers with purulent content.Three months later, the patient reappears for an examination, and this time he states that hehad injected various substances (including Vaseline and others that he hadn't specified) into the penile tissue.
During the inspection, scarring with ulcers and initial signs of inflammation were noticed on the ventral side of the penis.After the examination, the patient was referred to an urologist.A part of the scar lesion with signs of inflammation was excised,a biopsy was taken, and then a reconstruction was made as the final therapy.
Pathohistological analysis of biopsy material revealed fragments of skin and subcutaneous connective tissue.Ulcerations with inflammatory infiltrate, areas of hyperkeratosis and parakeratosis were present on parts of the epidermis.Inflammatory infiltrate rich in epithelioid histiocytes filled with lipid vacuoles was present in the subcutaneous connective tissue, and in addition, smaller focal necrosis and cystic changes in the form of "Swiss cheese" were alsoobserved (Figure 1).Based on pathohistological findings and clinical data, he was diagnosed with sclerosing lipogranuloma.
Following the surgical treatment, the patient hadn't experienced any further symptoms and no relapse of the sclerosing lipogranuloma has occurred to this date.

DISCUSSION
Penis size has been a source of concern for men ever sincethe earliest history, and attempts of penile augmentation can be found throughout the history in many tribes around the world.Some of these attempts would involve deliberately exposing the penis to the bites of venomous snakes, making holes in the glans of the penis into which various objects would then be placed, as well as many similar attempts [9].In modern times, the first use of mineral oils to fill tissue defects was performed in 1899 by a surgeon Robert Gersuny, who injected Vaseline into the scrotal sac of a boy after a bilateral orchiectomy with good results [10].The success of this procedure has led to the use of Vaseline, and after that paraffin, silicone and other mineral oils to fill various soft tissue de-fects on different parts of the body -breasts, eyelids, cheeks, muscles and various other body parts [10,11].
The first complications of these procedures were described as early as 1906, which led to the abandonment of these procedures in most countries [12].
Barnhard and Smetana were the first ones to use the name sclerosing lipogranuloma in 1948 for a granulomatous adipose tissue reaction resulting from an injury.Barnhard and Smetana also concluded that the same reaction occurs when the foreign substances such as paraffin, silicone and other mineral oils are injected into the human tissue [13].
www.hophonline.orgRegardless of the identified risks, the practice of injecting these substances into the penile tissue with the goal of increasing penile girth has continued sporadically in non-medical circles, with a particularly high frequency in Asia and Eastern Europe [14].Most often, these substances are injected by patients themselves [14], or by so-called traditional medicine practitioners in some Asian countries [1].By reviewing different case reports, we can conclude that men of different ages appear with sclerosing lipogranulomas [14,15].
The diagnosis of sclerosing lipogranuloma is usually made by anamnesis, detailed examination andpathohistological examination of the material obtained by a resection or biopsies.It would be ideal to find out from the patient when and which substances he had injected into the penile tissue.Due to the sensitivity of the topic, most patients will not admit that they had injected substances into the penile tissue.
Examination may reveal redness, swelling, deformities of the penile skin, palpable or non-palpable mass, mobile or fixed for deeper structures, softer or firmer in consistency and sometimes with superficial changes in the form of ulceration or necrosis.In rare cases, a puncture site may be seen [14].Recently, the importance of MRI and ultrasound examinations to assess the involvement of deeper structures has been emphasized [6].
The final diagnosis of sclerosing lipogranuloma (also known as paraffinoma, siliconoma, depending on the type of injected substance) is made by a pathohistological examination of the material obtained by a biopsy or a resection.First of all, it is necessary to exclude the existence of penile cancer.
The pathohistological presentation of sclerosing lipogranuloma depends on the time that has elapsed since the injection of the substance.However, it usually presents itself as an ulceration of the epidermis, possibly with surrounding hyperkeratosis and parakeratosis.Characteristic cystic changes in the form of "Swiss cheese" can be observed in the subcutaneous connective tissue, which are seen as seemingly empty vacuolar spaces surrounded by connective tissue (Figure 2).Encapsulated mineral oils can be observed in these areas by special methods of staining (Oil Red O).There is also an inflammatory infiltrate rich in epithelioid cells, macrophages, neutrophils and lymphocytes, as well as more or less present foci of necrosis (Figure 3) [1,14,15].
The method of choice for treatment isresection of the lesion with subsequent reconstruction.Several different procedures have been described, all with similar success rates [16].Very rarely, postoperatively, relapse of the lesion may occur [2].

CONCLUSION
Enlarging the penis by injecting various substances is a dangerous and controversial procedure, abandoned in medical circles, and is usually performed by patients themselves or by personswithout medical education.This procedure can be fatal in extreme cases, and will never provide the expected results.The method of choice for the treatment of sclerosing lipogranuloma is surgical resection with subsequent reconstruction, while conservative approach using antibiotics has very limited effect.

Figure 1 .Figure 2 .
Figure 1.Sclerosing lipogranuloma of the penis, HEx50, Epidermis on the right, seemingly empty vacuolar spaces ("Swiss cheese" cystic changes) in the middle with foci of necrosis in the bottom right corner