S é r g io M a n c in i N ic o la u , N e ls o n V a le n te M a r tin s , P a u lo E d u a r d o F e r r a z , J o ã o N o r b e r to S tá v a le , W a g n e r J o s é G o n ç a lv e s , E d m u n d C h a d a B a r a c a t, G e r a ld o R o d r ig u e s d e L im a
Im p o rta n c e o f p e n isc o p y , o n c o lo g ic c y to lo g y a n d
h isto p a th o lo g y in th e d ia g n o sis o f p e n ile in fe c tio n b y
h u m a n p a p illo m a v iru s
Department
of Obstetrics and Gynecology and Department
Df Pathological
Anatol1zy,
Escola Paulista de Medicina
- São Paulo, Brazil
Introduction: M ale genital infection by hum an papillom avirus is of particular im portance since it is often asym ptom atic. The patient generally presents no clinicallesion. Therefore, m en represent an im portant reservoir of virus, playing a special role in the transm is-sion and perpetuation of the disease. P atients and m ethods: In the present prospective clinicai trial study, 190 sex partners of w om en w ith genital infection by hum an papillom avirus, associated or not w ith cervical intraepithelial neoplasia, w ere investigated. A li patients w ere unaw are of or denied the presence of a genitallesion. R esults: C ytologic exam ination revealed koilocytosis in 9 cases (4.7% ) in the urethra and in 3 cases (1.6% ) in the corona of the glans and the distai prepuce. P eniscopy w ith the previous use of 5% acetic acid revealed w hite lesions in 97.9% of the patients. Toluidine blue stained m ost of the lesions. A t least one fragm ent revealed koilocytosis in the histopathologic study of 97 cases (51.05% ). C onclusion: The three m ethods com plem ent one another; allow ing a m ore precise diagnosis of this infection in m en.
U N ITE R M S : P eniscopy, papillom avirus, H P V , colposcopy
IN TR O D U C TIO N
G
b e in ge n ita l w a rts h a v e b e e n k n o w nre fe rre d to b y s e v e ra l s in c e a n c ie n t titn e s ,G re e k a n d R o m a n w rite rs . T h e y w e re c o n s id e re d to b e a v e n e re a ld is e a s e tra n s m itte d a m o n g m a le h o m o s e x u a ls . T h e y w e re th e n
c a Ile d c o n d y lo m a , a te rm o f G re e k o rig in th a t is s till u s e d .
T h e ro le o f p a p illo m a v iru s in th e e tio lo g y o f
c o n d y lo m a is w e ll d e fin e d . M o le c u la r b io lo g y s tu d ie s h a v e
le d to a b e tte r u n d e rs ta n d in g o f th e in fe c tio n . G e n ita l
in fe c tio n m a y b e c a u s e d b y m o re th a n 2 0 o f th e 7 0 ty p e s o f p a p illo m a v iru s k n o w n u p to th e p re s e n t. B a s e d o n th e ir
p ro p e rtie s a n d o n th e id e n tific a tio n o f th e v iru s in b o th
A d d r e s s f o r c o r r e s p o n d e n c e : S é r g io M a n c in i N ic o la u
R . J o s é A n to n io C o e lh o , 2 2 8 -A p to . 3 1 S ã o P a u lo /S P - B r a s il- C E P 0 4 0 1 1 - 0 6 0
m a lig n a n t a n d p re tn a lig n a n t c o n d y lo m a to lls le s io n s , th e y
a re c la s s ifie d in to lo w ris k (6 a n d 1 1 ) a n d h ig h ris k (1 6
a n d 1 8 ) ty p e s a s p ro p o s e d b y S y rja n e n ( 1 9 8 9 ) .
A fte r th e s tu d ie s o f M e is e ls a n d F o rtin (1 9 7 6 ) a n d
M e is e ls e t a I. ( 1 9 7 7 ) , th e in te re s t in th e in fe c tio n w a s re n e w e d . T h e a u th o rs d e s c rib e d th e c y to lo g ic a l,
c o lp o s c o p ic a n d h is to p a th o lo g ic fe a tu re s o f th e fe tn a le
g e n ita l in fe tio n b y th e h u m a n p a p illo m a v irlls .
T h e re a l in te re s t in p a p illo m a v irlls in th e g e n e s is o f
c e rv ic a l c a n c e r s e e m s to h a v e e tn e rg e d fro lll th e
id e n tific a tio n o f m o rp h o lo g ic a l. a s p e c ts o f v ira l c e rv ic a l
in fe c ti0 n c o m p a tib le w ith in tra e p ith e lia l n e o p la s ia b o th
in te rm s o f o n c o lo g ic c y to lo g y a n d h is to p a th o lo g y (M e is e ls
a n d F o rtin , 1 9 7 6 ) .
T h e h ig h in c id e n c e ra te s o f th e v ira l in fe c tio n a n d
th e re la tio n to c e rv ic a l n e o p la s ia , in a d d itio n to th e fa c t
th a t th e m e n h a d n o v is ib le p e n ile le s io n , le d th e
in v e s tig a to rs to m a k e u s e o f o th e r d ia g n o s tic m e th o d s fo r
a n e a rlie r id e n tific a tio n o f th e in fe c tio n .
S ão P aulo M edicai Journal/R P M 115(1): 1330-1335, 1997 N IC O LA U , S .M .; M A R TIN S , N .V .; FE R R A Z, et aI. -Im portance of peniscopy, oncologic cytology and histopathology in the diagnosis of penile infection by
T a b le 1 1
P a tie n t d is tr ib u tio n b y a g e a t in itia tio n
o f s e x u a l a c tiv ity
Levine et aI. (1984) were the first investigators to
use magnification to examine the penis of the partners of
the women with condyloma.
The aim of the present study was to ascertain the
incidence ofthe infection and the value of magnified penile
examination, cytology and histopathology in the diagnosis
of papillomavirus lesions in the penis of men whose sex
partners presented the same disease.
P A T IE N T S A N D M E T H O D S
A g e
< 1 0
1 0 - 1 5
1 5 - 2 0
2 0 - 2 5
2 5 - 3 0
> 3 0
T o ta l
N u m b e r
2
69
1 0 69
3
1
1 9 0
1 .0 5
3 6 .3 2
5 5 .7 9
4 .7 4
1 .5 8
0 .5 3
1 0 0 .0
A total of 190 sex partners of women with genital
infection by human papillomavirus, associated or not with
intraepithelial cervical neoplasia, diagnosed by colposcopic,
histopathologic and cervicovaginal cytologic examinations,
were studied between April 1988 and M arch 1991.
All patients were submitted to careful anamnesis.
Patients with genitallesions caused by human papillomavirus
and visible to the naked eye were excluded from the study.
The age of the patients ranged from 18 to 71 years,
with a predominance of 20-to 39-year range (126 cases or
66.3% ) (TabIe I). W hite patients were greater in number
(144 or
75.80/0).
Forty-two were black (22.1 % ) and fourwere asian (2.1% ). Sexual activity had started more
frequently between 15 and 20 years (106 cases or 55.8% ),
as shown in Table 11. One hundred and fifteen (60.5% )
patients were married and 82 (43.2% ) had had sexual
intercourse with more than one partner. One hundred and
forty-four patients (75.8% ) did not use condoms.
TabIe 111 shows the history of sexually transmitted
diseases, which was positive in 87 (45.8% ) patients. The
most frequently reported disease was gonococcal urethritis
(46 patients or 52.9% ). In 7.4% of cases, the patients
reported urogenitaI surgeries such as posthectolllY,
CirCUlTIcision or correction of hypospadias.
T a b le 1 1 1
P a tie n t d is tr ib u tio n b y p r e v io u s s e x u a lly
tr a n s m is s ib le d is e a s e
After anamnesis, the penis, distaI urethra and scrotum
were examined with a coIposcope (D.F. Vasconcelos)
under 4- and 6-fold magnification. The examination strictIy
required the following steps:
1- Examination of the entire penis and scrotum with
the patient in the sitting position.
11 - Examination of the 2 distaI centimeters of the
urethra, using a urethraI speculum specially designed for
this purpose.
111- Collecting of material for cytoIogic examination
from the glans, from the distaI prepuce and from the distaI
urethra.
IV - W rapping of the penis and scrotum with gauzes
soaked in 5% acetic acid. PIacement of a cotton tip soaked
in the same solution into the distaI urethra. The acid was
in contact with the structures for 5 minutes.
A g e
1 0 - 1 9
2 0 - 2 9
3 0 - 3 9
4 0 - 4 9
5 0 - 5 9
6 0 - 6 9
7 0 - 7 9
T o ta l
T a b le I
P a tie n t d is tr ib u tio n b y a g e
N u m b e r
3 5 9 67 3 1
25
3 21 9 0
1 .5 8
3 1 .0 5
3 5 .2 6
1 6 .3 2
1 3 .1 6
1 .5 8
1 .0 5
1 0 0 .0
S T O n u m b e r
G o n o r r h e a 4 6
C o n d y lo m a 1 4
N o n - g o n o c o c c a l u r e th r itis 1 1
S y p h ilis 8
C o n c r o id 4
G o n o r r h e a a n d S y p h ilis 1
L y n p h o g r a n u lo m a V e n e r e u m 1
G e n ita l H e r p e s 1
P e d ic u lo s is 1
T o ta l 87
Peniscopy
5 2 .9
1 6 .1
1 2 .6
9 .2 4 .6 1 .1 1 .1 1 .1 1 .1
1 0 0 .0
N IC O L A U S .M .; M A R T IN S N .V .; F E R R A Z P .E . e t a l.- Im p o r ta n c e o f p e n is c o p y , o n c o lo g ic c y to lo g y a n d h is to p a th o lo g y in th e d ia g n o s is o f p e n ile in fe c tio n b y
hllm~n n~nillnm~\Iin IC:::
1 3 3 2
v -
R ep eated ex am in atio n o f th e p en is an d d istaI u reth ra, after relT Io v in g th e g au zes an d co tto n tip o T h ech aracteristics an d sites o f th e im ag es rev ealed w ere th en id en tified .
V I - S o ak in g o f th e p en is an d scro tu m w ith 1 %
to lu id in e b lu e, rem o v in g th e ex cess w ith 2 % acetic acid
after 3 1 1 lin u tes.
In th e p resen t stu d y , w e d efin e p en isco p y p erfo rm ed
b efo re an d after th e u se o f acetic acid an d to lu id in e b lu e
as w id en ed p en isco p y .
Cytology
Itllm ed iately after th e first ex am in atio n , m aterial fo r
cy to lo g y w as co lIected "frO lll th e d istaI u reth ra, th e d istaI
p rep u ce an d th e co ro n a o f th e g Ian s w ith a b ru sh co m m o n ly
u sed fo r en d o cerv icaI sm ears (T erreiro et aI., 1 9 9 0 ).
His
topa thologyD irect b io p sies w ere co Ilected in o rd er to o b tain
rep resen tati v e frag lllen ts o f each ty p e o f lesio n , id en tified
b y p en isco p y w ith an d w ith o u t acetic acid an d to lu id in e
b lu e. T h e b io p sies w ere o b tain ed u n d er an esth esia, u sin g
a 2 -3 -1 1 lm w id e d en llato m e. H em o stasis w as o b tain ed w ith
a co tto n tip so ak ed in co n cen trated m eth acreso lsu lfo n ic acid ap p lied o n to th e raw area.
In cases in w h ich u reth ral lesio n co u ld b e easily
reach ed , b io p sies w ere ev en tu ally o b tain ed u sin g th e
fo rcep s fo r th e u terin e cerv ix o f th e G ay lo r ty p e, m o d ified
b y M ed in a (M ed in a et aI., 1 9 7 7 ).
th is alteratio n "k o ilo cy to tic aty p ia", a ten ll o rig in atin g frO lll
th e G reek
koilos,
w h ich m ean s h o le O I'cav ity .T h e in itial ex am in atio n w ith th e p en isco p e rev ealecl
su sp ect lesio n s in 7 2 p atien ts (3 7 .9 % ).
T h e Ieu co acetic lesio n s w ere fo u n d in 1 8 6 cases
(9 7 .9 % ), w ith m acu les, m icro p ap u les, 1 1 licro sp icu les,
an n u lar m icro ero sio n s, an d h y p ertro p h ic p ap ilIae in th e
co ro n a o f th e g lan s w ith a leu co acetic su rface (F ig . I).
T o lu id in e b lu e stain ed 1 1 l0 S to f th e lesio n s d escrib ecl
ab o v e, m ain ly th e cen tral area o f th e 1 1 licro p ap u les an d o f
th e an n u lar lesio n s (F ig . 2 ). In S O llle in stan ces, it stain ecl
areas in w h ich n o leu co acetic lesio n s h ad b een p rev io u sly
fo u n d . S im ilarIy , so m e leu co acetic lesio n s w ere n o t stain ecl
b y to lu id in e b lu e. P ap illo m ato u s u reth ral lesio n s w ere
o b serv ed in 4 cases (2 .1 0 /0 ); k o ilo cy to sis w as n o t d etected
in o n ly o n e o f th ese cases.
C y to lo g y rev ealed k o ilo cy to sis in 9 cases (4 .7 % )
in th e u reth ra, an d in 3 cases (1 .6 % ) in th e co ro n a o f th e .
g Ian s an d d istaI p rep u ce. K o ilo cy to sis w as d etected in
th e b io p sy sp ecim en s in th ese 3 cases. O n ly tw o
(22.20/0)
o f th e n in e cases o f u reth ral cy to lo g y w ith k o ilo cy to sis
p resen ted a p ap ilIo m ato u s lesio n u p o n ex alllin atio n o f
th e d istaI u reth ra. T h ese Iesio n s w ere S U b lllitted to b io p sy
an d k o ilo cy to sis w as d etected b y h isto p ath o lo g ic
ex am in atio n .
B io p sies w ere co lIected frO lll alI p atien ts. In th e 4
p atien ts in W h O lT Ith e acetic acid test p ro v ed n eg ati v e, S O llle
ep ith elial areas w ere stain ed w ith to u lid in e b lu e an el w ere
b io p sied . In o n e p atien t, sm aII lesio n s w ere o b serv ed after
th e in itial ex am in atio n w ith m ag n ificatio n .
R E S U L T S
T h e d iag n o sis o f h u m an p ap illo -m av iru s in fectio n w as b ased o n th e
cy to lo g ic an d h isto p ath o lo g ic alteratio n s
co m p atib le w ith k o lo cy to sis, i.e.,
p resen ce o f Iarg e, ro u n d an d v acu o lized
sq u am o u s ceIls, w h ich m ay b e Io cated at
an y lev eI o f th e stratified ep ith eliu m ,
th o u g h h arelly in th e b asaI o r p arab asal
lay ers.
T h e ceIl sh o w s a Iig h t p erin u clear
h alo an el a h y p erch ro m atic an el retracted
n u cleu s w h ich seem s to b e su sp en d ed in
em p ty sp ace. B in u cleated fo rm s are
C O lT Im o n .K o ss an d D u rfee (I 9 5 6 ) ~ al1 ed
F ig u r e 1 - L e u c o a c e tic le s io n s w ith m ic r o p a p u le s a n d a n n u la r m ic r o e r o s io n s o n th e
d is ta i p r e p u c e .
S ã o P a u lo M e d ic a i J o u r n a llR P M 1 1 5 ( 1 ) : 1 3 3 0 - 1 3 3 5 , 1 9 9 7 N IC O L A U S .M .; M A R T IN S N .V .; F E R R A Z P .E .; e t a I. - Im p o r ta n c e o f p e n is c o p y , o n c o lo g ic c y to lo g y a n d h is to p a th o lo g y in th e d ia g n o s is o f p e n ile in fe c tio n b y
F ig u r e 2 - L e u c o a c e tic le s io n s o n th e d is ta i p r e p u c e s ta in e d w ith to lu id in e b lu e .
K oilocytosis w as detected in at least one fragm ent in 97 (51.05% ) of the 190 patients.
H istopathologic exalnination also detected Inollusculn contagiosuln in 3 patients, and genital herpes in another.
D IS C U S S IO N
Several investigators have recom lnendeel exalnination of the penis w ith the aid of an optical instrulnent, the colposcope, w ith the aim of eliagnosing genital infections, specially w hen these are subclinical or not visible (Levine et aI., 1984; R osem berg, 1985; B arrasso et aI., 1986; K rebs anel Schneider, 1987; R osem berg and R eiel, 1987).
A lthough sO lne authors use the term colposcopy of the penis (B arrasso et aI., 1986; K rebs and Schneider,
1987), w e prefer to call it peniscopy. O ther w ords such as androscopy O I'genitoscopy are also useel.
The criterion used in the present study for the cytologic and histopathologic eliagnosis of this viral infection w as the presence of koilocytosis.
C onsidering the criteria described in the cytology, w ith
1000/0
results proving positive in the presence of cytoplaslnic anel nuclear alterations, w e reached a cytologic diagnosis of the penile and urethral infection in 1.6% and 4.7% of the cases, respectivelly.In spite of the few positive cases detected, urethral cytology w as Inore effective than cytology of the elistal prepuce and the corona ofthe glans. O nly 2 patients presenteel papilIolnata in the distaI urethra anel the others eliel not have aIteration of the aspects w hen uneler Inagnfication. C ytologic finelings w ere itnportant for the eliagnosis.
In the distaI part of the penis, cytology w as positive in cases w here histopathology show ed koilocytosis. The s p e c i m e n s h a el In a n y u n n u c 1e a t e el keratinized cells, thus being inappropriate for the identification of koi 10cytosis.
The ideal ti nle for collecti ng Inaterial for cytology w ith a brush shoulel no t b e t h e s a In e as fo r p e r f o nn i n g peniscopy. The brush injures the gIans anel prepuce epitheliuln and the urethral Inucosa, possibIy leading to false-positive peniscopic findings.
Peniscopy detecteel lesions Ú l alI cases, anel w as considered to be positive. In 97.9% it show eel alterations w ith acetic acid and in the others only w ith tolllieline blue.
W e used a 5% acetic acid concentration. The Inain action of the acid is to coagulate cytoplasnlic anel nuclear proteins of the epithelial cells, turning theln w hite. It is a progressive, superficial, and reversibIe processo In w onlen, it occurs betw een 10 and 30 seconels anel elisappears after 30-40 seconds (C artier, 1986). In Inen, not only the latency tilne but also its effect lasts longer.
The urethra shouId be equally exalnineel w ith acetic acid, for sO lnetim es it is possible to eletect snlall lesions not visible under silnple Inagnification. In fact, W osnitzer (1988) recom m ends exalnining the urethra w ith a coIposcope, both before and after the use of acetic aciel in order to eletect sm all lesions not visible to the nakeel eye.
The effect of 1% toluidine bllle in aqueous solution
is noteel in the nuclei. Since this is a cell elye that behaves as a base, it has affinity for, and binels to, aciel structures sllch as D N A and R N A , silnilarly to Inethylene blue (Junqueira anel C arneiro, 1977).
N icolau et aI. (1991) cO lnpareel the etfects of the 2 solutions (acetic aciel and toluidine) in 863 biopsies anel concluded that acetic acid reacteel slightly Inore frequently w ith lesions w ith koilocytotic cells.
In the present stuely, w e concluded that the tw o tests cO lnplelnent each other, since sO lne lesions show ed reaction w ith only one of the tw o solutions. Therefore, both tests should be applied. The action of the dye has the
N IC O L A U S .M .; M A R T IN S N .V .; F E R R A Z P .E .; e t a I. - Im p o r ta n c e o f p e n is c o P Y , o n c o lo g ic c y to lo g y a n d h is to p a th o lo g y in th e d ia g n o s is o f p e n ile in fe c tio n b y
h l J m ~ n n ~ n ill( ) m ~ v in I~
1334
ad v an tag e o f lastin g m u ch lo n g er, w h ich p erm its to d ecid e
ab o u t th e area to b e b io p sied an d to an esth etize it b efo re
th e lesio n d isap p ears.
M an y lesio n s rev ealed b y p en isco p y d o n o t p resen t
k o ilo cy to sis. A larg e p art o f th em w ere d etected b ecau se
o f in flam m ato ry o r in fectio u s p ro cesses cau sin g
b alan o p o sth itis. U su alIy p atien ts are n o t circu m cised (in
th e p resen t stu d y , o n ly 7 .4 % w ere). T h is h am p ers
ap p ro p riate h y g ien e an d facilitates th e g ro w th o f in fectio u s
. ag en ts su ch as
Candida albicans,
Gardnerella
vaginalis,
h erp es siI1 1 p lex ,
Tricholnonas
vaginalis,
b actero id s an do th er an aero b ic o rg an ism s (P eu th erer et aI., 1 9 7 9 ; C ree et
aI., 1 9 8 2 ; K in g h o rn et aI.,1 9 8 2 ).
W e p referred to ex am in e th e p atien t w h ile seated
b ecau se th is p o sitio n is m o re cO I1 1 fo rtab le fo r b o th
ex am in er an d p atien t.
In m ed icaI literatu re th ere are rep o rts o f m acro sco p ic u reth raI lesio n s in 0 .5 -5 % o f cases (O riel, 1 9 7 1 ; C etti,
1 9 8 4 ). In th e p resen t stu d y , d istaI u reth ro sco p y rev ealed
lesio n s in 2 .1 % b u t th ere w ere cy to Io g ic alteratio n s in
4 .7 % . T h is is th e reaso n fo r p erfo rm in g b o th p ro ced u res.
H isto p ath o Io g ic ex am in atio n w as p erfo rm ed in alI
p atien ts, sev eral lesio n s b ein g b io p sied in each case. T h e g reat m ajo rity o f th e lesio n s w ere flat. W e co u ld n o te n o
co rrelatio n b etw een th e clin icaI asp ect o f th e lesio n an d
th e an ato m o p ath o lo g ic alteratio n s; th u s, it is n ecessary to
b io p sy alI lesio n s, esp ecialIy th e flat o n es.
In th e p resen t stu d y , in traep ith eIial n eo p Iasia w as
fo u n d to b e asso ciated w ith th e v iraI in fectio n in 1 .5 8 % o f
cases. T h ese Iesio n s w ere u n rem ark ab le w h en ex am in ed
b y p en isco p y .
T h e b io p sies w ere w ell to lerated . T h e m o st d ifficu It
step w as an esth esia, w h ich is sO I1 1 ew h at u n co l1 1 fo rtab Ie.
T h e sp ecil1 1 en is sm all, w h ich allo w s p erfo rm in g o f
l1 1 0 re th an o n e b io p sy , w ith a b etter rep resen tatio n o f th e
Iesio n s. In ad d itio n , d u e to th e sm all size o f th e b io p sy ,
th e h eaIin g p erio d is sh o rt, ap p ro x im ately 2 w eek s.
A b o u t 5 0 % o f th e cases d id n o t p resen t k o i Io cy to sis.
A cco rd in g to th e m o st recen t rep o rts, it is p o ssib le th at
th ese p atien ts are carriers o f a v iru s in th e p en is, u reth ra
an d sem en , esp ecialIy v iru ses o f th e ty p es asso ciated w ith
p rem aIig n an t an d m alig n an t lesio n s (G ru ssen d o rf-C o n en
et aI., 1 9 8 6 ; M cC an ce et aI., 1 9 8 6 ; O stro w et aI., 1 9 8 6 ;
V ilIa et aI., 1 9 8 6 ; D el M istro et aI., 1 9 8 7 ; O 'B rien et aI.,
1 9 8 9 ; S eIv ey et aI., 1 9 8 9 ).
B ased u p o n th ese facts, it b eco m es clear th at, fro l1 1 a
clin icaI p o in t o f v iew , th e ex am in atio n o f th e p en is w ith
m ag n ificatio n is in su fficien t; p erfo rm in g o fp en isco p y after
ap p ly in g acetic acid an d to lu id in e b Iu e is n ecessary .
CONCLUSIONS
I. P en isco p y alIo w ed th e d iag n o sis o f p ap ilIo l1 1 av iru s
in fectio n , esp ecialIy w ith th e u se o f acetic acid an d
to lu id in e b lu e; th e w h ite Iesio n s w ere p resen t in 9 7 .9 %
o f th e cases an d in th e o th ers th e Iesio n s w ere stai n ed
w ith to lu id in e b Iu e.
2 . A Ith o u g h a p ap illo m ato u s lesio n w as rare (2 .1 % ), th e
ex am in atio n o f th e d istaI u reth ra, p referen tially w ith
a sp ecu Iu m , w as im p o rtan t fo r th e d iag n o sis.
3 . N in e p atien ts (4 .7 % ) p resen ted p o sitiv e cy to lo g y
fin d in g s in th e d istaI u reth ra, b u t o n Iy 2 o f th el1 1 h ad
m acro sco p ic lesio n s.
4 . C y to Io g y o f th e co ro n a o f th e g Ian s an d o f th e d istaI
p rep u ce rev ealed a Io w freq llen cy o f k o iIo cy to sis, b u t
h isto p ath o Io g y w as p o sitiv e in alI th ese cases.
5 . In 9 7 p atien ts (5 1 .0 5 % ), h isto p ath o lo g y d em o n strated
k o ilo cy to sis in at Ieast o n e o f th e sev eral b io p sy sp eC lm en s.
6 . In traep ith elial n eo p lasia w as fO lln d in asso ciatio n w ith
th e v iraI in fectio n in 1 .5 8 % o f th e p atien ts.
S ã o P a u lo M e d ic a i J o u rn a l/R P M 1 1 5 (1 ): 1 3 3 0 -1 3 3 5 , 1 9 9 7 N IC O L A U S .M .; M A R T IN S N .V .; F E R R A Z P .E .; e t a I. -Im p o rta n c e o f p e n is c o p y , o n c o lo g ic c y to lo g y a n d h is to p a th o lo g y in th e d ia g n o s is o f p e n ile in fe c tio n b y
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