A 50-year-old, homeless male presented to the Department of General Surgery with complaints of multiple discharging sinuses along the penis for 1 month. He also gave a history of gradually increasing swelling of the penis for 1 year and a purulent discharge per urethra for the last 6 months. At physical examination, there was an ulceroproliferative growth of the penis (Figure 1). The penis and the glans penis were tender, edematous and indurated. However, both the testes and the epididymis were normal. The vas deferens was normal on palpation. The prostate was normal on rectal examination. Preliminary laboratory investigations revealed high sedimentation, C-reactive protein (CRP) and leukocytosis. He was referred to our Radio-Diagnosis Department for Retrograde Urethrography - Voiding Cystourethrography (RGU-VCUG) evaluation.
RGU was performed through the distorted external urethral meatus which was first identified by asking the patient to micturate to observe the main stream of urine. RGU revealed multiple (around 15 to 20), contrast-filled, narrow, irregular, fistulous tracts (urethrocutaneous fistulas) arising from both the dorsal and ventral aspects of the pendulous (penile) part of the anterior urethra (Figure 2). This distal segment of the pendulous part of the anterior urethra also showed significant distortion and irregular, beaded narrowing. The proximal segment of the pendulous part of the anterior urethra showed smooth and regular dilation. The bulbous part of the anterior urethra as well as the prostatic and the membranous parts of the posterior urethra showed adequate filling of contrast and a regular outline with no evidence of communicating sinus/fistulous tracts. The VCUG showed a markedly-contracted and small-capacity urinary bladder with a thickened, irregular and edematous wall. There were multiple nodular densities in the bladder lumen suggestive of hypertrophied trabeculae along its anterior, posterior and lateral walls, representative of a 'thimble bladder' (Figure 3). There was no evidence of reflux into the ureters during micturition.
Chest radiograph (posteroanterior view) ruled out presence of pulmonary Koch's (both active as well as old, healed pulmonary Koch's). Scrotal ultrasound revealed normal testes and epididymis. Renal ultrasound showed no calyceal or papillary abnormality/hydronephrosis. Intravenous urography showed no evidence of renal or ureteric tuberculosis. Mantoux test was strongly positive while pathological examination of discharge per urethra revealed caseating granulomas. Gram stain and culture examinations for gonorrhea were negative while schistosomiasis was ruled out on the basis of microbiological studies of stool and urine samples. Pseudoepitheliomatous, Keratotic and Micaceous Balanitis (PKMB) was excluded as the patient had not undergone prior circumcision and also because histopathological examination after an incisional biopsy revealed no evidence of acanthosis, papillomatosis, elongated rete ridges or cellular atypia. Balanitis Xerotica Obliterans (BXO) was ruled out on the basis of a normal Tzanck smear test.
The patient was administered anti-tubercular treatment (Isoniazid 300 mg, Rifampicin 600 mg, Pyrazinamide 1500 mg, and Ethambutol 800 mg per day). The patient started to show signs of improvement by 6 weeks. There was partial obliteration of the sinus and fistulous tracts. Since the patient's symptoms regressed, he was discharged and is being currently followed up as an out-patient. At the end of this treatment regimen, a repeat RGU-VCUG will be performed and decision regarding urethroplasty and further management will be planned depending upon the presence of any remaining fistulas or strictures involving the urethra.