Petechia of the Penis: Sexual Habits or Adverse Drug Reaction?

Petechia are nonspecific cutaneous lesions appearing as circumscribed sub-epithelial hemorrhages, or appearing as small dark red or purplish spots as a result of capillaries rupture. The etiology is multifactorial, as petechia is mainly related to blood dyscrasia, infections, drug collateral effects, or traumatic mechanical stress [1,2].

Although these lesions are mostly found in other skin areas, petechia occasionally occur in the genital district under different conditions, such as lichen sclerosus or Henoch-Schönlein purpura [3,4]. Particularly, the most frequent sex practices-related petechia are those observed in oral cavity after oral sex (fellatio) [2,5]. These lesions are often challenging, for the relatively difficult recognition at this location, patient's reluctance regarding showing this body area or relating full history and sexual habits details. It is found that there are no related literature about oral sex-related petechia of the penis.

A 51-year-old man came to our attention for the presence of recurring small red macules, exclusively localized on the gland. The patient had these lesions were completely asymptomatic, and tended to resolve spontaneously in 3-10 days. The patient also claimed that the lesions had developed since 1 month, assuming a relapsing course. At the dermatological examination, the macules of the gland were irregularly circular in shape and prupuric in appearance, not disappearing on vitro pressure (Fig. 1). Complete blood cell, platelet counts and coagulative profile were normal and serologic investigation for common sexually transmitted diseases were negative. It was assumed that the patient had 100 mg acetyl-salicylic acid per day for a previous episode of heart ischemia one year earlier, denying other drugs assumption, or allergies. During the fourth visit for the recurrence of the same lesions, the patient argued that he had frequently started to receive fellatio since the development of the lesions. The patient was hence recommended to completely avoid oral sex practices and to temporarily suspend his therapy with acetylsalicylic acid. Two weeks later, he came back for re-examination and no petechia was apparent. Based on the self-monitoring, the patient stated that disappearance of pe-techia needed 3 days since oral sexual practices and acetylsalicy-late therapy were suspended. Then, the patient regularly reintroduced acetylsalicylic acid treatment and continued to avoid oral sex, without recurrence. Written informed consent was obtained from the patient, in order to publish this report and any accompanying images.

Petechia and other purpuric lesions are not worrisome themselves, but they should be warned for searching much more severe underling disorders immediately and completely, like blood dyscrasia. Hematic analysis for complete blood cell count can easily rule out severe underling conditions. Many other factors may trigger petechia, such as infection, drug uptake and mechanical stress [1]. It is necessary to make A deep inquiry for the patient's medical history, such as in our case where it is allowed to rule out possible causing or aggravating factors and to identify acetylsalicylic acid as a potential cofactor for the recurring events. Indeed, it is well known that acetylsalicylic acid impairs platelet aggregation via inhibition of platelet thromboxane A2 possibly predisposing to or inducing purpuric lesions [6,7]. However, the localisation of the lesion on the gland prompted to suspect for sexual habits involvement, as the patient reported to receive oral sex frequently. Suspects were confirmed as the lesions completely remitted upon oral sex practices suspension and the reintroduction of acetylsal-icylic acid therapy. The mechanism of action is what assumed to be the basis of the petechia formation induced by fellatio, which is made by mechanical trauma, as also reported for petechia of the palate, as well as an ex-vacuum caused by the suction mechanism [5].

Literature accounts for a conspicuous number of oral sex-related palatal lesion since 1928 [7]. Conversely, no previous studies have been ever conducted on the possible onset of penis petechia after oral sex. Here we firstly describe a case fellatio related petechia of the penis. Anyhow, the number of records is suspiciously lower than one would expect beaming in mind the widespread diffusion of such sexual practices. An additional major factor is likely to be the failure of always inquiring about sexual behaviours by physicians [5].

Although it is not harmful and usually self-solving, it is important to avoid recurrence of petechia for the identification and instruction of the patient about the causes of these events. Therefore, for fellatio can be associated with sexually transmitted diseases, the evaluation of patients for these infections should be considered.