Smegma remains a diagnostic dilemma

Abstract

A healthy, uncircumcised, two-year-old male presented with a six-month history of an asymptomatic, mobile, yellowish nodule near the base of the glans penis. An examination revealed a 1 × 0.5 cm, yellowish-white, soft, and mobile nodule between the glans and the foreskin of the penis (Fig. 1). No signs of infection or irritation were noted and the rest of the body was free of lesions. Ultrasound revealed soft tissue thickening, excluded a solid formation. The urine dipstick test was negative. Based on the clinical features, the diagnosis of a smegma cyst was reached. A smegma cyst is composed of epithelial debris, fat, and proteins and is covered by a well-formed, epithelial wall [1]. When there is no covering sac of lump, it is called the smegma pearl. Frequently located on the ventral surface of the glans, within the subpreputial space, the urethral meatus is not affected and the prepuce is partially retractable. It develops in uncircumcised patients. As phimosis resolves the inner foreskin, adhesions begin to undergo a gradual process of separation from the glans penis. Smegma may become entrapped during this process, forming smooth, palpable pearls [2]. It is neither damaging nor irritating. The differential diagnosis concerns either acquired or congenital penile cysts (e.g., trichilemmal cysts, preputial Epstein pearls, dermoid cysts, median raphe cysts, para meatal cysts, mucoid cysts, epidermoid cysts, pilosebaceous cysts, juvenile xanthogranuloma) [3]. Given the paucity of published reports, these collections are a diagnostic challenge for clinicians unfamiliar with this entity and a source of concern for parents. Smegma pearls are a benign entity. Bimanual retraction or gentle expression may be performed with a risk of paraphimosis, irritation, and recurrence [2,3]. Thus, these techniques must be discussed with the parents considering the spontaneous resolution. In the case of chronic evolution, smegma may evolve to preputial stones in adults and the elderly. No investigations or treatments are required. Only monitoring and parental reassurance are recommended.