Case Report

A 45 year old uncircumcised man came to the out patient department with a painful ulcer over his glands penis for the last two months. It had initially started as a small nodule which ruptured forming the ulcer and grew to its present size. (Figure 1) He had no history of trauma or any other systemic illness.

Figure 1

Figure 1: Ulcer over the glans penis with unhealthy granulation

Physical examination revealed an ulcer of about 2 X 2 centimeter (cm) over his glands penis mainly towards the right side. It was irregular in shape, had undermined edges with unhealthy granulation tissue at its floor. The lesion was mildly tender and was surrounded with minimal induration. The external urethral meatus was spared from the lesion and there were no evidence of inguinal lymphadenopathy. His laboratory tests and chest x-ray were unremarkable. A provisional diagnosis of carcinoma of the penis was made and a biopsy was taken from the edge of the ulcer. It revealed tuberculuos granulation tissue with evidence of caeseation (Figure 2)

Figure 2

Figure 2: Epitheloid granuloma with caseous necrosis. Langhan's giant cells also seen at the periphery (Hematoxylin and eosin x 100)

The patient was put on oral four drug regime of Rifampicin(R), Isoniazid(H), Ethambutol(E) and pyrazinamide(Z) and was followed up every 15days. He responded well to his treatment and the ulcer showed significant evidence of healing at 2 months (Figure 3). At the end of treatment at 6 months the ulcer had completely disappeared with a very little residual scarring of the glands.

Figure 3

Figure 3: Healed Ulcer after 60 days of anti tubercular treatment.

Discussion

Penile tuberculosis is an extremely rare form of genitourinary tract tuberculosis even in developing countries where the prevalence of tuberculosis is high₁. Penile tuberculosis was first described by Hellerstrom and later by Bafverstedt and Hageman₂. In 1896, Darier put forward the concept of tuberculids whereby penile tuberculosis was explained as being the result of a cutaneous hypersensitive response to an underlying focus of tuberculosis.

So far, three forms of penile tuberculosis have been identified₁. The primary form is caused by direct inoculation of mycobacterium in the glands during coitus with a patient of genital tuberculosis₃, oral intercourse with an active pulmonary koch's patient, wearing of contaminated fabric or at the time of circumcision. The secondary form, also called as tuberculid occurs as a result of either hematogenous spread from a primary focus (commonly lungs) or as a cutaneous hypersensitive response to an underlying focus₄. The third variety is the result of direct extension through urethra into penile shaft from neighbouring genitourinary tubercular foci (prostate, seminal vesicle). An isolated case of penile tuberculosis has been reported as a complication of intravesical BCG therapy in superficial bladder carcinoma, probably due to traumatic catheterization₅.

The causative agents are Mycobacterium tuberculosis, Mycobacterium Bovis and Mycobacterium Celatum₆. The lesion presents commonly as a painful ulcer over glans penis. However it may present as an superficial ulcer over the inner lining of prepuce, as a subcutaneous nodule or cold abscess in the corpora cavernosa (Corpora cavernositis)₄.

Oral doses of Isoniazide 300mg/day, Rifampicin 600mg/day, Etambutol 800mg/day along with Pyrazinamide 1500/day for 2months followed by only HR for next four months₇ is the standard recommended treatment. Patients generally show good recovery within 2 months. Occasionally residual scar is seen for which plastic reconstruction may be needed₇. In cases with concomitant urethral stricture, surgical reconstruction is done first followed by Anti tubercular treatment₈. However in cases with severe obstructive uropathy, immediate urinary diversion is always the rule to prevent renal loss₈. Prognosis is usually very good with remission within a couple of months and no recurrence after 1 year of follow-up. The excellent response to SCC is probably due to the fact that mycobacteriums are intermittently excreted in urine from the genitourinary tract and hence cannot achieve infective load in genitourinary tissue. Also, the high concentration of HRZE that pass out in urine partly explains the effectiveness of SCC.

Correspondence to

Dr. Deborshi Sharma Department General Surgery Institute of Medical Sciences Banaras Hindu University Varanasi – 221 005, India Tel. No. : 91-542-2307507, 2307510 Fax : 91-542-2368163 E-mail : deborshi_sh@yahoo.com