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Hidradenitis Suppurativa — Genitourinary Disease

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent disease of the hair follicle with a prevalence of approximately 1% in Europe and North America, presenting with painful nodules, abscesses, draining sinus tracts, and disfiguring scarring in apocrine-bearing intertriginous areas.[1][2] Approximately one-third or more of patients have genital involvement, making this a condition frequently encountered — and often misdiagnosed — by urologists and gynecologists.[5][7] For the reconstructive urologist, advanced genitoperineal HS produces draining sinus tracts, urethrocutaneous fistulae, urethral strictures, scrotal/vulvar architectural destruction, secondary lymphedema, and — in long-standing disease — squamous cell carcinoma arising within chronic sinuses.

Epidemiology and Pathogenesis​

Women are affected at a 3:1 ratio compared to men; onset typically occurs between ages 18–39.[4][5] The average diagnostic delay is approximately 10 years, during which patients consult dermatologists, gynecologists, surgeons, and primary care physicians and receive multiple misdiagnoses.[2]

Pathogenesis begins with follicular plugging and rupture, triggering an inflammatory cascade driven by TNF-α, IL-1β, and IL-17, leading to immune cell infiltration, tissue destruction, and fibrosis.[1][6] Risk factors include genetic predisposition, obesity, smoking, and hormonal influences.[6]

Hurley Staging​

StageDescription
IAbscess formation, single or multiple, without sinus tracts or cicatrization
IIRecurrent abscesses with tract formation and scarring, single or multiple widely separated lesions
IIIDiffuse or near-diffuse involvement, or multiple interconnected tracts and abscesses across the entire area

Genital and Perineal Anatomy of Involvement​

Anatomic sites of urologic/urogynecologic relevance:

  • Mons pubis, inguinal folds, and vulva/labia in women
  • Scrotum, penile shaft, and perineum in men
  • Perianal and gluteal regions in both sexes

Genital HS is particularly challenging due to functional and reconstructive concerns unique to these anatomic zones. The JAMA Surgery multidisciplinary review by Hamad et al. emphasizes that genital HS requires coordinated care among dermatology, surgery, and urology/urogynecology.[5]

Urologic Complications​

ComplicationNotes
Urethrocutaneous fistulaChronic perineal HS can erode into the urethra; documented in case series including fistula with concurrent phimosis[8]
Urethral strictureChronic perineal inflammation and fibrosis drive stricture formation requiring reconstructive intervention[9][8]
PhimosisScarring from penile/preputial HS produces acquired phimosis[8]
Scrotal/genital lymphedemaLymphatic obstruction from fibrosis and scarring; see Scrotal Lymphedema[10]
Genitourinary infectionsPatients on adalimumab have >2-fold increased serious GU infection rate vs psoriasis patients on the same therapy (IRR 2.22; 95% CI 1.22–3.86)[11]

For urethrocutaneous fistula and urethral stricture technique, see Urethrocutaneous Fistula and Scrotal Reconstruction.

Urogynecologic Considerations​

HS disproportionately affects women of childbearing age; obstetrician-gynecologists are uniquely positioned for early diagnosis during routine well-woman examinations.[12][13]

Vulvoperineal HS: Involvement of the vulva, labia, mons pubis, and perineum causes severe scarring, contractures, and tissue destruction impairing urinary and sexual function. Vulvar HS is frequently misdiagnosed as Bartholin cyst, folliculitis, sexually transmitted infection, or Crohn disease.[7]

Sexual dysfunction: Approximately 67% of HS patients report sexual difficulties, driven by pain, malodorous discharge, genital scarring, and psychological distress; validated screening (FSFI, IIEF) is recommended.[14][2]

PCOS association: HS carries a >3-fold risk of PCOS (prevalence up to 9%), suggesting shared hormonal and metabolic pathways.[3]

Menstrual flares: Many women report perimenstrual HS flares, indicating hormonal modulation of disease activity.[5]

Pregnancy: HS management during pregnancy and breastfeeding requires careful medication selection, as many systemic therapies have limited safety data in this population.[13]

Malignant Transformation​

Squamous cell carcinoma (SCC) arising within chronic HS lesions is rare but devastating, occurring most commonly in the gluteal (47.5%), perianal (18.9%), and genital (13.9%) regions.[15]

FeatureData
Mean latency from HS onset to SCC~25 years[15]
Population predominantly affectedCaucasian men, smokers, severe disease[16]
Metastasis rate~54%[15]
Mortality~59%[15]
Malignant degeneration rateUp to 4.6% in groin/perianal/perineal severe disease[17]
Vulvar/perianal/perineal cancersTend to present at advanced stage[18]
SCC Surveillance

North American guidelines recommend periodic skin examination of chronic perineal and buttock lesions and biopsy of any new, rapidly growing, or treatment-refractory lesion.[3][19] HPV vaccination has been proposed as a potential preventive strategy.[20]

Surgical Management​

Surgical treatment of genitoperineal HS requires a multidisciplinary team (dermatology, reconstructive urology/urogynecology, wound care, rheumatology/immunology).[9]

Principles:

  • Wide local excision remains the mainstay for Hurley Stage III genital disease; excision to the subcutaneous plane with 1 cm margins[3][2]
  • Perianal, vulvar, and inferior breast locations carry higher recurrence rates after surgery[3]
  • Biologic therapy should not be interrupted during the perioperative period[2]

Two-stage reconstruction: Radical excision → negative-pressure wound therapy → delayed split-thickness skin grafting has shown >90% graft take and no recurrence at ~19 months.[21] For flap and graft options by defect location, see Scrotal Reconstruction and Buried Penis Repair.

Medical Management​

AgentClassFDA StatusNotes
Adalimumab (Humira)Anti-TNFApproved 2015First biologic approved for HS; 2× weekly dosing
Secukinumab (Cosentyx)Anti-IL-17AApproved 2023SUNSHINE/SUNRISE RCTs (HR IHS4-50 ~45% vs ~33% placebo at Week 16)[1]
Bimekizumab (Bimzelx)Anti-IL-17A/FApproved 2023Dual IL-17 inhibition; phase 3 data pending full publication
Tetracyclines / clindamycin + rifampicinAntibioticsOff-labelModerate disease; combination 12-week course
Hormonal therapyOCPs, spironolactoneOff-labelPerimenstrual flare suppression
Resorcinol 15% peelTopicalOff-labelFor individual lesions

Agents under investigation include JAK inhibitors (upadacitinib), apremilast, fostamatinib, and others targeting the IL-17 and JAK/STAT pathways.[22]

Key Takeaways for the Reconstructive Urologist​

  • Differential diagnosis: HS should be considered for any patient with recurrent "boils," abscesses, or draining sinuses in the groin, perineum, or genitalia present for >6 months.[3][5]
  • Multidisciplinary care: Urologists/urogynecologists play a critical role in managing complications (fistulae, strictures, lymphedema) and reconstruction after wide excision.[9]
  • SCC surveillance is mandatory in patients with long-standing perineal/genital HS — biopsy any suspicious or refractory lesion without delay.[15][19]
  • Sexual dysfunction screening should be routine given the high prevalence.[14][2]
  • Early dermatology referral for biologic therapy may alter disease trajectory and reduce the need for extensive surgical reconstruction.[13][2]

References​

1. Kimball AB, Jemec GBE, Alavi A, et al. "Secukinumab in Moderate-to-Severe Hidradenitis Suppurativa (SUNSHINE and SUNRISE): Week 16 and Week 52 Results of Two Identical, Multicentre, Randomised, Placebo-Controlled, Double-Blind Phase 3 Trials." Lancet. 2023;401(10378):747–761. doi:10.1016/S0140-6736(23)00022-3

2. Sabat R, Alavi A, Wolk K, et al. "Hidradenitis Suppurativa." Lancet. 2025;405(10476):420–438. doi:10.1016/S0140-6736(24)02475-9

3. Alikhan A, Sayed C, Alavi A, et al. "North American Clinical Management Guidelines for Hidradenitis Suppurativa: A Publication From the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, Evaluation, and the Use of Complementary and Procedural Management." J Am Acad Dermatol. 2019;81(1):76–90. doi:10.1016/j.jaad.2019.02.067

4. Wipperman J, Bragg DA, Litzner B. "Hidradenitis Suppurativa: Rapid Evidence Review." Am Fam Physician. 2019;100(9):562–569.

5. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary Update on Genital Hidradenitis Suppurativa: A Review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

6. van Straalen KR, Prens EP, Gudjonsson JE. "Insights Into Hidradenitis Suppurativa." J Allergy Clin Immunol. 2022;149(4):1150–1161. doi:10.1016/j.jaci.2022.02.003

7. Ogunleye AA, Ndem IE, Bui H, Sayed CJ. "Vulvoperineal Hidradenitis Suppurativa: Diagnosis, Treatment, and Management of Deformities." Obstet Gynecol Surv. 2021;76(10):644–653. doi:10.1097/OGX.0000000000000944

8. Chaikin DC, Volz LR, Broderick G. "An Unusual Presentation of Hidradenitis Suppurativa: Case Report and Review of the Literature." Urology. 1994;44(4):606–8. doi:10.1016/s0090-4295(94)80072-3

9. Michel C, DiBianco JM, Sabarwal V, Stein DM. "The Treatment of Genitoperineal Hidradenitis Suppurativa: A Review of the Literature." Urology. 2019;124:1–5. doi:10.1016/j.urology.2018.10.013

10. Yuan JT, Naik HB. "Complications of Hidradenitis Suppurativa." Semin Cutan Med Surg. 2017;36(2):79–85. doi:10.12788/j.sder.2017.022

11. Wafae BGO, Charrow AP, Stein D, Barbieri JS, Noe MH. "Risk of Serious Infection With Adalimumab in Hidradenitis Suppurativa Compared With Psoriasis." JAMA Dermatol. 2025;161(11):1116–1122. doi:10.1001/jamadermatol.2025.2881

12. Collier EK, Parvataneni RK, Lowes MA, et al. "Diagnosis and Management of Hidradenitis Suppurativa in Women." Am J Obstet Gynecol. 2021;224(1):54–61. doi:10.1016/j.ajog.2020.09.036

13. Sayed CJ, Hsiao JL, Okun MM. "Clinical Epidemiology and Management of Hidradenitis Suppurativa." Obstet Gynecol. 2021;137(4):731–746. doi:10.1097/AOG.0000000000004321

14. Matusiak Ł. "Profound Consequences of Hidradenitis Suppurativa: A Review." Br J Dermatol. 2020;183(6):e171–e177. doi:10.1111/bjd.16603

15. Sachdeva M, Mufti A, Zaaroura H, et al. "Squamous Cell Carcinoma Arising Within Hidradenitis Suppurativa: A Literature Review." Int J Dermatol. 2021;60(11):e459–e465. doi:10.1111/ijd.15677

16. Cohen PR, Cohen-Kurzrock RA, Riahi RR. "Cancer and Hidradenitis Suppurativa." Clin Dermatol. 2024;42(6):585–601. doi:10.1016/j.clindermatol.2024.09.014

17. Abu Rached N, Rüth J, Gambichler T, Ocker L, Bechara FG. "A State-of-the-Art Systematic Review of Cancer in Hidradenitis Suppurativa." Ann Med. 2024;56(1):2382372. doi:10.1080/07853890.2024.2382372

18. Makris GM, Poulakaki N, Papanota AM, et al. "Vulvar, Perianal and Perineal Cancer After Hidradenitis Suppurativa: A Systematic Review and Pooled Analysis." Dermatol Surg. 2017;43(1):107–115. doi:10.1097/DSS.0000000000000944

19. Agdogan Ö. "Gluteal-Anogenital-Perineal Reconstruction in Patients With Chronic Hidradenitis Suppurativa and Related Squamous Cell Carcinoma." J Wound Care. 2026;35(1):76–83. doi:10.12968/jowc.2024.0123

20. Abu Rached N, Käpynen R, Doerler M, et al. "HPV-16-Induced Squamous Cell Carcinoma in Hidradenitis Suppurativa: HPV Vaccination May Be Useful." Cancers. 2025;17(4):702. doi:10.3390/cancers17040702

21. Fuchs N, Pavljak L, Hauptman D, Mance M. "Two-Stage Surgical Management of Anogenital Hidradenitis Suppurativa in Patients on Biologic Therapy: A Retrospective Case Series." Int Wound J. 2026;23(4):e70874. doi:10.1111/iwj.70874

22. Jaguan D, Nguyen KT, Goldfarb N. "Selective Small Molecule Inhibitors for Hidradenitis Suppurativa: Today and Tomorrow." J Am Acad Dermatol. 2024;91(6S):S31–S36. doi:10.1016/j.jaad.2024.09.014