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A 26-year-old Portuguese man attended the emergency department complaining of scrotal skin bleeding. He described an episode of spontaneous bleeding while at work as a labourer, which stopped within 30 min. He could not identify a precipitating factor for the bleed. He was openly worried about the possibility of a sexually transmitted infection, but denied attendance at genitourinary medicine services for this problem. He denied any urethral discharge, dysuria or sexual dysfunction and was exclusively sexually active. He had no prior medical history and was not taking any regular medication.
On examination the man was haemodynamically stable and systemically well. There were numerous (>50) 1-2mm dark red, erythematous papules over the scrotum (fig 1A), sparing the shaft of penis, inner thigh and abdomen. A small area of encrusted blood was visible on his left hemi-scrotum, deemed to be the bleeding site (fig 1B). There was no active bleeding. There were no intra-scrotal swellings palpable and no evidence of varicocele or epididymal pathology. His abdomen was soft and non tender, with no masses palpable. Urinalysis detected no abnormality.
1-to 2mm dark red, erythematous papules over the scrotum (A), encrusted blood on the left hemi-scrotum, deemed to be the bleeding site (B) Informed consent was obtained for publication of this figure.
On further questioning, the man had noticed the papular lesions many years before, but they had remained asymptomatic. He was...