The perils of penile enhancement: case report of a fulminant penile infection

BACKGROUND

Penile enhancement with injectable agents is a rising trend and yet has received little scientific attention despite the potential for serious complications. These include cosmetic, functional and systemic complications that may require complex penile reconstructive surgery. We report a case of delayed severe infection following penile filler insertion leading to multi-organ failure and intensive care support.

CASE PRESENTATION

A 31-year-old man presented with fevers and progressive pain and swelling of the penile shaft, 3 days after unprotected sexual intercourse. The patient received subcutaneous hyaluronic filler injections at a cosmetic clinic for penile enlargement two months prior to presentation. Relevant social history include polysubstance abuse and multiple sexual partners. Physical examination revealed gross penile oedema and erythema, with a ventral curvature of the penile shaft and a superficial abrasion on the distal ventral penile shaft. Within 24 h the patient developed septic shock with anuria, hypotension and fevers to 40 °C, requiring transfer to the Intensive Care Unit (ICU) for vasopressor and inotropic support. Intraoperative penile exploration revealed multiple pus stained fillers which were drained and grew Streptococcus Pyogenes on cultures. There was no abscess or evidence of necrotising fasciitis intraoperatively. The patient improved with intravenous antibiotics and was stepped down from the ICU after four days and discharged on day eight. One month post admission there was significant superficial skin loss to both ventral and lateral aspect of the penis, with healthy granulation tissue at the base. The patient opted for conservative management with regular dressings. He reported normal sexual and urinary function three months post admission.

CONCLUSION

This is the first published case of sepsis from a penile infection in the context of hyaluronic acid penile fillers. In an era of escalating demand for penile cosmetic procedures, there is an increasing need for early recognition and appropriate management of penile filler infections. We report an unusual case of a localised penile infection rapidly progressing to sepsis with multi-organ failure requiring intensive care support. The case demonstrates early surgical intervention with targeted antimicrobials can result in successful eradication of infection, with satisfactory cosmetic and functional outcomes for patients.

Recurrent Pilonidal Sinus Cyst on Penis

Pilonidal sinus, including one or more sinus canals and hairs, is a disease with a chronic course showing acute attacks which is often encountered in the general population, usually affecting young adults, at a rate in males twice that of females. Pilonidal sinus on the penis is so rare that very few cases have been reported in literature. A 20-year-old male presented to the urology outpatient clinic with the complaint of a suppurative lesion with discharge on the skin of the penis which had been ongoing for approximately three months. Clinical examination revealed an indurated, erythematous, ulcerative lesion, 3 cm x 2 cm in size, in the middle of the ventral aspect of the penile shaft. We present the first case in literature of recurrent pilonidal sinus related to Actinomyces israelii, located on the penis.

Catheter-induced urethral erosion

Indwelling bladder catheters are often placed when a patient requires voiding assistance. Long-term use of these catheters has been associated with significant morbidity This case presentation describes a complete erosion of the glans, urethra, and penile skin, up to the penoscrotal junction, as an outcome from long-term use of an indwelling bladder catheter. Appropriate nursing interventions can prevent this devastating health care outcome.

Syphilis is back: presentation of three cases at the ENT department

PROBLEM

Syphilis is a sexually-transmitted disease caused by the spirochete Treponema pallidum, and is transmitted either through sexual contact or vertically across the placenta. Rates of infection were at a low point in the early 1990s. Since then, increasing numbers of new cases of infections have been observed in all Western countries.

AIM

Presentation of three patients with syphilis who presented within a short period of time in an ENT outpatient clinic.

CONCLUSIONS

One must be aware of the increasing incidence of syphilis, even in head and neck disciplines. Typical symptoms of an early infection are an ulcerous lesion in the mouth, with or without cervical lymphadenopathy. The main therapy is high doses of penicillin G administered intramuscularly. Other simultaneous sexually-transmitted diseases, especially HIV infection, must be excluded. Unnoticed and untreated patients may develop late and life-threatening complications.

Penile actinomycosis clinically diagnosed as an epidermal cyst: a case report

A 27-year-old man presented at our hospital with a 1.5 cm, spherical, soft and movable subcutaneous mass at the mid portion of the ventral aspect of the penile shaft. The possibility of an epidermal cyst was considered and a simple resection was performed. Histologically, the lesion was a unilocular cyst without an epithelial lining, containing eosinophilic necrotic material and a few dispersed scalloped sheets of actinomycotic granules. The centre of the largest granular body demonstrated many fragments of foreign substance. The patient was treated successfully with combined antibiotic therapy.

Early syphilis and syphilitic hepatitis following unprotected insertive oral sexual intercourse: case report

We present a case of early syphilis in a HIV negative bisexual man after an oral insertive intercourse with clinical overlap of primary and secondary stages, and laboratory and other criteria for syphilitic hepatitis. Moreover, we herein stress the importance of awareness of the high-risk behaviors and report syphilitic hepatitis without jaundice, a usually unrecognized clinical condition, emphasizing the clinical and therapeutic importance of its occurrence among syphilitic cases.

Cutaneous BCG of the penis after intravesical therapy for bladder cancer: a case report in a 66-year-old male

OBJECTIVE

Transitional cell carcinoma of the bladder is commonly treated with intravesical BCG. We report a cutaneous complication of BCG after therapy in 66-year-old male 4 years after initiating treatment.

MATERIALS AND METHODS

A case review including pathological slides, laboratory data, and radiographic findings.

RESULTS

Biopsy findings showed an ill defined granulomatous process with chronic inflammation and necrosis.

CONCLUSION

The patient was managed on antituberculous therapy for a period of 6 months with resolution of symptoms.

First case of "bubonulus" in L2 lymphogranuloma venerum

Since 2003, an ongoing lymphogranuloma venereum (LGV) proctitis outbreak has been reported in industrialised countries with a new variant designated L2b. Only men who have sex with men (MSM) are affected and most are HIV co-infected; delayed or incorrect diagnoses are frequent. We report a rare clinical case of LGV primary stage called "bubonulus" with penile adenopathy and secondary local acute lymphoedema in an MSM seropositive man. This is the first case described of this clinical presentation with a L2b genovar strain, occurring immediately after use of a sex toy. It suggests that this presentation is favoured by host immunity and behavioural factors. These factors may also play a part in the new outbreak of LGV.

Donovanosis treated with thiamphenicol

Ten patients with donovanosis were treated with thiamphenicol for two weeks. In eight of them, included two HIV infected patients, lesions healed. The safety profile of thiamphenicol makes it a useful and cost-effective agent in the management of donovanosis. Randomized controlled trials should be conducted with these treatment options.

Drug-resistant genital tuberculosis of the penis in a human immunodeficiency virus non-reactive individual

The genitourinary tract is the most common site for extrapulmonary tuberculosis (TB). Penile TB is extremely rare comprising less than 1 % of all genital TB cases in males. It most commonly presents either as a superficial ulcer on the glans or around the corona. Diagnosis of penile TB is often difficult because it can mimic numerous other diseases. The association of TB with AIDS, and the increasing incidence of multiple drug resistance has further compounded the problem. The case described herein involves a patient with multidrug-resistant smear-positive penile TB that was undiagnosed initially due to the lack of clinical suspicion of TB, and once diagnosed failed to respond to first line antitubercular drugs because of multiple drug resistance.

Human papillomavirus and circumcision: A meta-analysis

BACKGROUND

Determine the relationship of circumcision status to the risk for genital infection with human papillomavirus (HPV).

METHODS

A MEDLINE search and a review of references in published articles were used to identify publications from peer-reviewed journals in Index Medicus with data on circumcision status in patients with and without HPV infections. Inclusion criteria included diagnosis by culture, biopsy, or PCR, determination of circumcision status by physical examination, and multiple site sampling including the shaft of the penis. A meta-analysis was performed with sensitivity analyses.

RESULTS

Sixteen articles contained data on circumcision status in patients with and without HPV infections. Eight studies used accurate diagnostic methods. Only three articles satisfied the strict inclusion criteria. There was no significant association between circumcision status and HPV infection (random-effects model summary effect OR=1.20, 95%CI=0.80-1.79) in these three studies. If the eight studies using accurate diagnostic methods are adjusted for the method of determining circumcision status and failure to sample the penile shaft using meta-regression the summary effects odds ratio is 1.25 (95%CI=0.95-1.67).

CONCLUSIONS

The medical literature does not support the claim that circumcision reduces the risk for genital HPV infection. To correctly assess the risk of HPV infection in circumcised males, the penile shaft needs to be sampled for HPV infection.

A hat trick of ulcerating pathogens in a single genital lesion

We report on a patient from a London clinic, (a Jamaican heterosexual man known to have herpes) who has donovanosis and syphilis in a single genital ulcer. The case highlights the importance of careful clinical examination of genital ulcers.

Association of penile lichen sclerosus and oncogenic human papillomavirus infection

BACKGROUND

Data on the prevalence of human papillomavirus (HPV) infection in patients with penile lichen sclerosus (LS) are scant and controversial.

AIM

To investigate the prevalence of HPV infections in patients with penile LS.

METHODS

HPV infection was assessed by polymerase chain reaction (PCR) in paraffin-embedded penile biopsies obtained from the glans or inner foreskin of 46 adult patients with penile LS, and in brush cytology smears of penile healthy mucosa from an equal number of randomly selected control males matched for age. Statistical evaluation was performed using conditional logistic regression analysis.

RESULTS

PCR disclosed the presence of HPV infection in 17.4% of LS patients (HPV 16, six cases; HPV 18, one case; HPV 45, one case). Amongst the controls, HPV infection occurred in 8.7% of patients (HPV 16, two cases; HPV 53, one case; HPV 70, one case). Statistical regression analysis confirmed that the rate of HPV infection was higher amongst patients with genital LS than amongst healthy controls [odds ratio (OR), 2.55; 95% confidence interval (CI), 0.73-8.89].

CONCLUSIONS

Infection with oncogenic "high-risk" HPV types in patients with genital LS may enhance the risk of penile cancer arising on LS.

Spontaneous penile (cavernosal) abscess: case report with discussion of aetiology, diagnosis, and management with review of literature

The rare presentation of spontaneous, corpus cavernosal abscess with evident pus discharge is reported. The 19-year-old English man was successfully treated with surgical drainage and antibiotics with long-term sequelae in form of mild, left-sided penile deviation, but normal erectile function. Though he did not require any further surgical intervention for correction of chordee at that time, there remains a possibility of it getting worse over time, which may ultimately need surgery for correction. The possible aetiology, diagnosis, and treatment of this rare condition are briefly discussed.

Effect of circumcision on genital colonization ofMalasseziaspp. in a pediatric population

This study aimed to determine the prevalence of yeast fungi in samples from the glans penis and prepuce of circumcised and uncircumcised children. Impression preparations were made on modified Dixon and Leeming-Notman agar without cycloheximide. The isolates were identified by morphological and physiological characteristics. The yeasts were detected in 32 (28.6%) of 112 children, 12 (18.2%) being among 66 circumcised and 20 (43.5%) among 46 uncircumcised children. The most common species was Malassezia globosa (40.6%) followed by, Malassezia furfur (31.3%), Malassezia slooffiae (15.6%), Candida albicans (6.3%), Candida tropicalis (3.1%) and Candida parapsilosis (3.1%). The colonization with yeasts, and especially lipophilic species was more frequently observed among uncircumcised versus circumcised children. While age was not found to be a factor (P > 0.05), circumcision was responsible for increasing the colonization rate by 4.8 times (95% CI: 1.6-14.5) (P < 0.01). The circumcision status was not found to effect the distribution of Malassezia spp.

Primary involvement of penile skin in lepromatous leprosy

Skin lesions in lepromatous leprosy (LL) are usually multiple and widespread. Though the lesion may occur anywhere on the skin, male genitalia is rarely involved. In all cases reported so far about penile lesions of LL, there were lesions on the other parts of the body also. In some of the cases scrotum was also involved. We report here a patient who presented himself with a single macular lesion of leprosy on the shaft of his penis diagnosed as a case of lepromatous leprosy on slit-skin smear and histopathological examinations.

[Genital sites of Buruli ulcer (BU): clinical and therapeutic aspects]

BU of the penis and scrotum is a rare disease that can potentially induce extensive lesions. The authors describe the clinical characteristics and treatment in the light of two cases. BU induces irreversible necrotic lesions and despite the knowledge of the micro-organism responsible (Mycobacterium ulcerans), no medical treatment is currently effective. Excision of wounds and skin grafts remain the treatment of choice, and give excellent results.

Nine male cases of tinea genitalis

Nine cases of tinea genitalis observed in Siena and Terni (Italy) between 1988 and 2003 are reported because of their infrequency. The patients were males ranging in age from 23 to 45 years. The lesions, situated on the penis, glans and scrotum, were preceded by dermatophytosis in other sites (groin five cases; feet two cases; toenails two cases; hands in one; beard in another). Mycological examination consisting of direct microscopy and culture led to isolation of Trichophyton rubrum in five cases, Epidermophyton floccosum in two and T. mentagrophytes var. interdigitalis in the others. Clinical diagnosis is not always easy. In three cases the lesions had been misdiagnosed as eczema.

Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap

Abstract A 47-year-old man was admitted with the chief complaint of a urethral defect. An approximately 17-cm defect of the urethra seemed to have been occurred by the infection of implanted foreign bodies in the penile skin. Reconstruction of the urethra and the ventral skin was performed with a free radial forearm flap. A fistula formed at the proximal anastomosis after the operation, but was controlled conservatively. Urethral stricture at the proximal anastomosis subsequently developed. A urethral stent made of shape memory alloy was placed with the preservation of voiding function.

Corpora cavernositis caused byActinomycetes

We present the case of a 58-year-old diabetic who developed corpora cavernositis following drainage of a perianal abscess. To our knowledge this is the first such case caused by Actinomycetes, which spread from the perianal abscess by direct extension through Buck's fascia, which was probably breached during drainage of the abscess.

Penile tuberculoid leprosy in a five year old boy

A 5-year-old contact of a lepromatous leprosy patient with a tuberculoid lesion on the anterior aspect of the shaft of the penis is reported. The child was clinically suspected to have borderline tuberculoid leprosy during a survey of contacts of leprosy patients, which on histopathology revealed features of subpolar tuberculoid leprosy. The father of the child was recently detected as a case of lepromatous leprosy and was started on multibacillary regime of WHO multidrug therapy. The reason for the localization of the lesion to the shaft of the penis is also suggested. Skin as a route of transmission of tuberculoid leprosy is also emphasized.

Pilonidal sinus of the glans penis associated with actinomyces case reports and review of literature

Pilonidal sinus is a well-recognized condition that occurs most commonly in the sacrococcygeal area of younger men. It is hypothesized to be an acquired chronic inflammation condition due mainly to hair trapped beneath the surface. A pilonidal sinus in the sacrococcygeal region is associated with recurrent infection, abscess formation, cellulitis, fistulae, and rarely, squamous cell carcinoma. A pilonidal sinus of the penis is a rare entity. The association of a penile pilonidal cyst and Actinomyces is even more uncommon with only three cases reported previously. Two cases of pilonidal sinus are reported in this paper. One of the cases was associated with actinomycosis. Pilonidal sinus of the penis should be considered in the clinical and pathological differential diagnosis and has to be distinguished from balanoposthitis, epidermal cyst, and carcinoma. The knowledge about possible association with actinomycosis is important to ensure early treatment.

Sclerosing lymphangitis of the penis

Nonvenereal sclerosing lymphangitis is a rare penile lesion consisting of a minimally tender, indurated cord involving the coronal sulcus and occasionally adjacent distal penile skin. This disorder most often occurs after vigorous sexual activity and resolves spontaneously. However, as evidenced by 2 of the 3 cases reported, this condition also may be associated with underlying sexually transmitted disease that necessitates specific therapy.

[Genital histoplasmosis. Presentation of a clinical case]

OBJECTIVES

On December 1905 Darling, resident histopathologist on the Panama Channel area, observed a parasite in the large mononuclear cells of different organs. Negroni in 1914 described the first Argentinean case. Lung, oral, nasal, and laryngeal involvement are common. On the other hand, genital involvement is uncommon. The objective of this war is to communicate the case of a patient with genital histoplasmosis.

METHODS/RESULTS

A 60-year-old Argentinian male started two years before with penile lesions and pruritus. Two partial penile resections had been performed in 1999, but pathology reports were not available. The lesions evolved towards ulceration and bleeding. Surgical toilette was carried out. A partial penectomy and glanuloplasty with an original technique were performed. Pathology revealed intracellular and extracellular spherical microorganisms. Morphologically it was histoplasma capsulatum. The histoplasmosis is an endemic mycosis. The infection takes place when inhaling the microconidiae of the fungus filamentous phase. Only a small number of people develop the disease after infection. Diagnosis is made by discovering of 2-3 micron yeasts with Giemsa stain.

CONCLUSIONS

If a patient from the histoplasmosis endemic area has a granular lesion, a mycotic disease should be considered.

Cutaneous tuberculosis of the penis and sexual transmission of tuberculosis confirmed by molecular typing

A case of culture-positive primary cutaneous Mycobacterium tuberculosis infection of the penis was diagnosed in a male patient; 1 year later, endometrial tuberculosis was diagnosed in the patient's wife. These organisms were confirmed to be indistinguishable by use of molecular techniques.

Frequency and spectrum of Malassezia yeasts in the area of the prepuce and glans penis

OBJECTIVE

To investigate the frequency and spectrum of lipophilic Malassezia yeasts within the area of the glans penis and preputial space in healthy men, most of whom were uncircumcised.

SUBJECTS AND METHODS

As the glans penis and the prepuce are abundant in sebaceous glands, 130 clinically healthy men were examined for the presence of Malassezia spp. Two impression preparations each were made on modified Dixon (mDixon) and Leeming-Notman agar. The media were used with no added cycloheximide to allow the identification of the full spectrum of Candida yeasts. After 10 days of incubation at 32 degrees C Malassezia and Candida yeasts were differentiated by micromorphological and biochemical criteria.

RESULTS

Malassezia spp. were found as part of the microflora of the glans penis in 49% of the men. The two media yielded comparable results for isolation frequency and spectrum: On mDixon agar, 47.6% of the isolates were identified as M. sympodialis, 42.8% as M. globosa, 4.8% as M. pachydermatis and 2.4% as M. furfur. Candida spp. (especially C. albicans) were found in 20.8%. There were no significant differences in the distribution of different Malassezia spp with age.

CONCLUSIONS

Malassezia yeasts may belong to the resident microflora of the male genital region, which is supported by the finding that free sebaceous glands ('Tyson's glands') normally occur at this site. They may also be involved in pathological processes of the glans penis, e.g. balanitis, seborrheic eczema or psoriasis.

Penile cellulitis

A37-year-old married man presented to his GP with a 4-day history of itching and painless swelling of his penis. He was treated with a compound antifungal, anti-inflammatory disinfectant cream (Timodine cream, Reckitt & Colman, Hull) without response. Three days later, the patient attended the accident and emergency department at his local hospital with the same complaint. He was diagnosed as having an ‘infected penis’, and was advised instead to attend the genitourinary medicine (GUM) clinic.

At the GUM clinic, the patient denied any history of allergy or genital trauma before his complaint. He was in a monogamous sexual relationship with his wife, and only practised peno-insertive vaginal intercourse. He had sexual intercourse 2 weeks previously. There was no significant past medical history.

On examination, he was overweight and apyrexial. There was a painless diffusely swollen penis with a ring of crusts at the tip of the foreskin and purulent discharge around the glans penis. There was no urethral discharge and no inguinal lymphadenopathy (Figure 1). There was tenderness on attempting to retract the foreskin. Routine urinalysis for pyuria and proteinuria were negative. Screening for urethral gonococcal and chlamydial infections were negative. However, culture of the purulent discharge taken from the subpreputial sac grew beta-haemolytic group A Streptococcus pyogenes. The patient was initially treated with a 2-week course of amoxycillin and flucloxacillin, and his condition improved dramatically after 4 days.

Necrobacillosis in free-living male European bison in Poland

In the Bialowieza Primeval Forest (Poland) a chronic disease of the external genital organs has been observed in free-living male European bison (Bison bonasus) since 1980. Investigations on this disease started in the late 1980s. The most striking findings are necrotic and ulcerative lesions of the prepuce and penis of bison aged from 6 mo to >10 yr. Histologic examination of tissue samples from the prepuce of six bison (9-mo- to 8-yr-old), and from the penis of two bison (3- and 8-yr-old), were characteristic of necrobacillosis. Masses of slender, Gram-negative, rod-like or filamentous bacteria occurred in necrotic tissue. At the periphery of necrotic tissue filamentous bacteria were often arranged in large clusters and strands that advanced towards healthy tissue. Immunolabeling and electron microscopy also suggest that these organisms are Fusobacterium sp.

Penile skin diseases

Many dermatoses become manifest in the genital region. Some of them are specific for this anatomical site; other lesions of the penis are associated with systemic dermatological diseases. Medical history, clinical inspection of the whole integument and optional microbiological or histological examination of the lesions will lead to a correct diagnosis. Dermatoses of the penis (glans penis and/or prepuce) may be symptoms of general diseases or specific alterations of the genital region. The differential diagnoses of penile dermatoses include infections, balanitides, neoplastic diseases, trauma, papulosqamous or systemic diseases, fixed drug reactions, allergic or irritant contact dermatitis and miscellaneous lesions. Since andrologists pay special attention to the inspection and palpation of the male genital region, they should possess knowledge of dermatologically relevant penile lesions.

Mycotic infections of the penis

Balanitis/balanoposthitis caused by Candida albicans is the most frequent mycotic infection of the penis. Its incidence is increasing and it seems to be primarily transmitted by sexual intercourse. Although the groin is a common site for tinea, dermatophytic infections of the penis are rare. Penile involvement in systemic mycosis is usually a sign of severe disease. In immunocompromised individuals, nearly every fungal agent may cause the disease. It normally presents as ulceration, and biopsy and culture can help to confirm the diagnosis. In most cases, superficial infections of the penis respond satisfactorily to local antifungal treatment, especially if provovatice factors and the possibility of sexual transmission are considered. Systemic treatment is recommended in cases of widespread dermatophytic infection, candidosis or systemic mycosis.

Health status of bulls used for natural breeding on farms in south west Scotland

One hundred and nine breeding bulls were examined during the period November 1992 to June 1993 on farms in south west Scotland for evidence of infectious diseases associated with breeding. Preputial washings were collected to screen for Campylobacter fetus venerialis, together with serial blood samples to assess their seroprevalence to Bovine Virus Diarrhoea virus (BVDv), Bovine Herpes Virus-1 (BHV-1), Leptospira hardjo and Bovine Herpes Virus-4 (BHV-4). The possible impact of natural mating on the epidemiology of these diseases is described. Evidence of infections with Campylobacter fetus and BVH-4 were not found in this sample. The overall seroprevalence to BVDv was 78%, for BHV-1 49%, and L. hardjo 27% at titres of > or = 1/400. This study shows that bulls may be responsible for the introduction and dissemination of these diseases when moved from farm to farm as part of normal cattle breeding in this area. Young unproven bulls may be particularly susceptible to endemic diseases associated with lowered reproductive performance.

Primary tuberculosis of the penis

We present a case of primary tuberculosis of the inner lining of the prepuce in a 63-year-old man. The condition resembled carcinoma. The diagnosis was based on histopathology and on M. tuberculosis culture. Successful treatment was by a combined medical and surgical approach. The rarity of the case is emphasized.

Pilonidal sinus of the penis. A report of two cases, one of them associated with actinomycosis

Pilonidal sinus is a long-standing chronic inflammatory condition which occurs most commonly in the sacrococcygeal area and it is rare in the penis. Two cases of penile pilonidal sinus in patients aged 25 and 28 years are reported and the literature is reviewed. The lesion is acquired and has to be distinguished from balanoposthitis, epidermal cyst and carcinoma. For pilonidal sinus to occur at this site, it is hypothesized that the coronal sulcus acts as a cleft where hair may accumulate and be driven into the shaft and prepuce by the natural movement between these two surfaces. One of our cases was associated with actinomycosis. Actinomycosis associated with pilonidal sinus of the penis is extremely rare and there are only two previous reports. It is suggested that pilonidal sinus may have been predisposed to the infection with the actinomyces organisms. Information stating that penile pilonidal sinus and actinomycosis may occur simultaneously is necessary to accomplish an early diagnosis.