Pearly Penile Papules (PPP)

Pearly Penile Papules usually present as small (1–3mm) pearly, dome-shaped bumps that typically appear around or under the corona of the glans (the head of the penis). They may be flesh-coloured, white or yellow and often appear in rows. They are painless and do not cause any adverse effects. They are not itchy and do not cause any penile discharge or smell. They may change over time, and often regress with age.

If a patient has had a genital examination with their doctor in primary care or in a specialist sexual health clinic, normally the doctors will not mention the presence of Pearly Penile Papules as it is not a specific medical illness and does not require any treatment.

Normally, Pearly Penile Papules appear right at the edge of the coronal ridge (i.e. the circumference at the base of the glans penis).

They can also appear in as many as 4-5 rows, with one of the rows appearing more prominent. In these situations, the rows of Pearly Penile Papules can also be present on the side wall of glans penis, declining towards coronal sulcus (as shown in the pictures).

Ectopic means “away from the usual site”. Ectopic PPPs are generally present in addition to typical PPPs.

Examples include:

• Ectopic PPP on the glans penis itself
• Ectopic Pearly Penile Papules on the coronal sulcus

Rarely PPPs may largely be present on the groove of the coronal sulcus. They can be so numerous and cluster together to give the appearance of an odd skin condition but the true nature of the lesions become quite apparent when the skin is examined after stretching it.

Many men have pearly white looking glands, symmetrically placed on both sides of the frenulum. These are called parafrenular glands, and can be treated at the same time as part of PPP treatment. However, some men may have a larger cluster of such glands.

Pearly Penile Papules appear as a part of development of secondary sexual characteristics early during adolescence. As one goes through the years of adolescence, the tiny pearly papules remain tiny in most individuals. However, they grow in others during these years and become conspicuous to become much more noticeable as the years go by, and reach their maximum size by 21 years of age.

Pearly Penile Papules reach a maximum size by the time adulthood has set it, typically 21 years of age. These spots rarely grow any further in size or number after this age.

Pearly Penile Papules tend to recede (become smaller in size) in some individuals in their 50s, presumably due to decline in testosterone level around this time.

There are no complications associated with having PPPs as they are a common and normal part of penile anatomy. They are not associated with sexually transmitted infection, personal hygiene or development of any cancers.

Anyone with a penis can have Pearly Penile Papules, however, they are found more commonly in younger people, with the highest incidence found in those aged 20–40. They generally appear after puberty, and may be more common in Black people and those who have not been circumcised.

They are thought to be an embryological remnant of penile spines, which are still present on the penis of some other primates.

Penile spines play an important role in animals such as ducks, where the friction of the spines in the female genital tract is thought to induce ovulation. The papules in humans often secrete an oily substance called sebum, which acts to lubricate the penis.

Pearly Penile Papules are not caused by an infection, neither are they an indication of poor personal hygiene.

No, they are not infectious and cannot be passed on to anyone else.

PPPs are not a sexually transmitted infection. Sexual activity appears to have no effect on the development, progression or regression of PPP, and they do not increase the risk of contracting an STI.

Pearly Penile Papules are diagnosed based on inspection of the lesions. It is important that examination is undertaken by a clinician experienced in dealing with penile skin conditions so that a correct diagnosis is made (and other possible diagnoses ruled out). Occasionally PPPs are misdiagnosed as Genital warts, and this results in unnecessary distress and unnecessary treatment.

Our approach to diagnosis includes:

• Taking patients concerns seriously – We don’t dismiss a patients concerns about spots on their penis, and listen with an understanding attitude
• Physical examination – undertaken in a private setting and an unhurried manner
• Discuss concerns & anxieties – Our healthcare professionals use their expertise in genital health to identify and rectify concerns and anxieties a patient may have during their consultation and clinical examination. Sometimes dermatoscopy can be used to study the lesions in greater detail.

In rare cases where the diagnosis is not clear, a biopsy may be taken off the lesions, which is examined under a microscope. It’s important to see an experienced healthcare professional to rule out other conditions such as sexually transmitted infections, which may require urgent treatment.

Pearly Penile Papules can be misdiagnosed as other conditions such as sexually transmitted infections, skin conditions and other normal conditions. They are most commonly misdiagnosed as genital warts or molluscum contagiosum.

The number, size, shape, symmetry as well as pattern of distribution of the lesions are taken into account in making a diagnosis of Pearly Penile Papules.

Pearly Penile Papules tend to be localised to the penile corona, whereas warts and molluscum can affect any part of the genitals. The size of the lesions can also help in the diagnosis; they are rarely larger than 1–3mm whereas molluscum lesions are typically 2–5mm in size and genital warts can be variable in size.

People with PPP often worry that they have genital warts, and this is the most common misdiagnosis. Other sexually transmitted infections that can be mistakenly diagnosed in a person with PPP include molluscum contagiosum, syphilis and scabies. PPP can also resemble other skin conditions such as folliculitis, an inflammation of the hair follicles; or lichen nitidus, a rare inflammatory skin condition.

PPP can also be mistaken for other variations of normal anatomy, such as the presence of sebaceous glands. Normal sebaceous glands include Tyson’s glands, which appear on either side of the frenulum (the band of tissue connecting the head of the penis to the underside of the shaft), and Fordyce spots, which typically appear along the shaft of the penis. PPP can also be mistaken for skin tags, another normal variation that does not require treatment.

Pearly Penile Papules are a perfectly normal feature of the body and treatment is not medically required.

However, we have seen many patients for whom life has come to a standstill and it is difficult to build/maintain relationships. In such an event, a simple procedure can help to regain your confidence and rebuild your life.

In many cases, Pearly Penile Papules regress with age, and the incidence of PPP is lower in older people. In most cases however, the papules persist harmlessly, and do not change much over time.

Many young men present to sexual health clinics with great concern or embarrassment after noticing these penile papules. Attention to these lumps can be drawn from changes due to puberty, or after a sexual contact, and can knock off confidence and cause concernn. The attention to these lumps can be drawn during changes of puberty or after a sexual contact, and can knock off the confidence of young men.

Sometimes a patient attends the clinic on multiple occasions to have STI checks to seek reassurance, and it may take a while for the patient to share their concern about PPPs with the nurse or doctor.

PPPs are an absolutely normal anatomical feature of the human body. However, many of us do not like their appearance, and can find it difficult to come to terms with them. This can lead to psychological distress, lack of confidence and finding it hard in developing fulfilling relationships. Many patients share with us that it is always in the back of their mind, affecting their focus on studies and work. Many people find it hard to discuss their concerns with anyone, even their doctors, as they have previously sought help to be told “it is normal” and their distress of the appearance dismissed.

In our experience, the underlying reasons tend to be one of the following:

• A sexual partner has commented
• That a sexual partner may comment about the appearance
• That a sexual partner may reject them thinking they have got genital warts
• In rare cases, PPPs can be really large enough to appear unsightly
• May remind them of unhappy childhood days and sexual trauma including coincidence with sexual abuse
• Had come to accept them somehow but their concern has resurfaced after separating them from their partner and they are back single again

PPP is not a sexually transmitted infection so there is no need to inform your partner that you have them. However, PPP are commonly mistaken for an STI such as genital warts, so it may be worth discussing with your partner and reassuring them that it is not an infection and cannot be transmitted to them.

Recurrence of PPPs is rare, and is a result of the on-going effect of male hormone testosterone. Use of supplemental testosterone can therefore slightly increase the chances of recurrence of PPPs.

Most people who have been successfully treated for PPPs will not get the lesions back. However, in a small minority of individuals, tiny papules may appear over the years. Such recurrences, if bothersome, can be easily treated.

Pearly Penile Papules are a part of normal genital anatomy and there is not a way to prevent them from occurring. Most people will develop PPP in their 20’s or 30’s, and it is less likely to develop PPP beyond the age of 40.

There are no lifestyle factors linked to the development of PPP, however maintaining a healthy lifestyle and practicing safe sex are recommended for everyone.

We recommend avoidance of taking testosterone supplements without medical supervision as it can slightly increase the risk of recurrence of PPPs.