0022-5347/90/1442-0351$02.00/0
THEJOURNAL OF UROLOGY Copyright 0 1990 by AMERICAN UROLOGICAL ASSOCIATION,INC
Voi. 144. August Printed in U.S.A.
TUBERCULOUS COLD ABSCESS OF THE CORPUS CAVERNOSUM: A CASE REPORT DANIEL YACHIA, MARC FRIEDMAN
AND
LYA AUSLAENDER
From the Departments of Urology and Pathology, Hillel Yaffe Medical Center, Hadera, Israel
ABSTRACT
A rare case of tuberculous cold abscess of t h e corpus cavernosum is presented. T h e only presenting symptom was obstructive urinary symptoms caused by external compression of t h e urethra by t h e abscess. Diagnosis was reached after surgical drainage a n d specific antituberculosis therapy led to a satisfactory conclusion. ( J . Urol., 144: 351-352, 1990) Tuberculosis is a multisystem infection that has almost dis- surface of both corpora appeared to be entirely normal. The appeared from hospitals of developed countries. However, oc- tunica at the puncture site was opened longitudinally and the casionally, patients with old urogenital tuberculosis are de- necrotic material was found in a pouch of fibrotic tissue. The walls of the pouch were cleaned by curettage, and the specimen tected. Abscesses of the corpora cavernosa are uncommon findings.' was sent for histological and bacteriological examination. Since They can develop as an unusual presentation of gonorrhea2 or no significant bleeding occurred the crater was irrigated with from t r a ~ m aor, ~they can be iatrogenic after cavern~sography,~diluted povidone-iodine solution and the tunica was left open, intracorporeal papaverine injections5 or penile prosthesis im- covered only by the penile skin. A small Penrose drain was left p l a n t a t i ~ n They .~ may also develop spontaneously.' Although for 48 hours. Histological examination revealed Langerhans no part of the genital system is immune to tuberculosis, we giant cells and necrotizing granulomatous inflammation. Culcould locate no case in the literature during the last 2 decades ture of the necrotic material remained sterile for bacteria but in which the corpus cavernosum was involved. We report a case Ziehl-Neelsen staining showed acid-fast bacteria and culture in which the only affected organ with active tuberculosis was for mycobacterium yielded massive tuberculous mycobacterium. Further examination of other organs for tuberculosis the corpus cavernosum. involvement did not yield any information. Antituberculosis C A S E REPORT treatment was begun immediately after Ziehl-Neelsen staining A 73-year-old man was referred to our outpatient clinic results were received. The multiple drug treatment consisted of because of a weak urinary stream that had developed during isoniazid, rifampicin, myambutol and pyridoxine, and was conthe last year. Physical examination of this healthy-appearing tinued for 1 year. When the patient was discharged from the man revealed only 1 testicle in the right scrotum. The testicle hospital he was able to urinate without difficulty. Urethroscopy and the vas deferens were normal to palpation. According to 2 years later was normal. the patient the left testicle had been removed elsewhere when DISCUSSION he was 26 years old because of a swelling. He could not recall whether he received any treatment postoperatively. According Tuberculosis of the urogenital system is an important but to his recollection no one in his immediate family had tuber- rare specific infection that may easily be missed, especially in culosis but he related that he had been hospitalized in his early countries where this infection is not endemic. The disease almost always is secondary to pulmonary tuberculosis and the twenties during military service because of a lung infection. Upon rectal examination the prostate was noted to be small, urogenital infection usually occurs via the hematogenous route. smooth and elastic. A slightly painful thickening was palpated The lupoid genital form (skin lesions) is believed to be primary on the dorsal side of the penis. Despite his age this finding was and acquired by sexual c o n t a ~ tSince . ~ our patient was a widbelieved to be a recent Peyronie's disease plaque. Urinalysis ower for 20 years and he had not had any sexual relations was normal. Excretory urography (IVP) showed marked resid- during this time no local contact could be suspected in this ual urine but a normal urinary tract without signs of prostatic enlargement. A chest x-ray revealed a calcified p ~ i m a r ~ c o m p l e x in the right upper pole. Cystoscopic examination failed initially because of obstruction of t h e penile urethra. At urethroscopy a narrowing of the penile urethra caused by external compression was detected. After dilation a 17F cystoscope could be passed. The external compression was 3 cm. long, the urethral lining was normal and no other pathological condition was noted in the prostate or bladder. Ultrasonography of the penis revealed fibrous thickening of the dorsal tunica albuginea and a hypoechoic area in the center of the left corpus cavernosum (fig. 1). Ultrasonography of the upper and lower urinary tract was normal. Computerized tomography (CT) of the penis confirmed the ultrasound findings that was suggestive of an old abscess formation (fig. 2). Blood counts revealed leukocytosis of 10,800 and renal function tests were within normal limits. Needle aspiration yielded 2 ml. whitish necrotic material. The site was explored through a circumcisional incision. Except FIG. 1. Ultrasonography of penile shaft shows fibrous thickening of for an indurated area in the left dorsal corpus cavernosum the Accepted for publication March 7, 1990.
dorsal tunica albuginea and hypoechoic area in center of left corpus cavernosum.
352
YACHIA, FRIEDMAN AND AUSLAENDER
and scars. When the lesion is in the penile skin the diagnosis is made by biopsy.lO," In our case despite the initial diagnosis of abscess of the corpus cavernosum made by ultrasound and CT, the final diagnosis could be reached only after histological and bacteriological examination of the necrotic material obtained by surgical drainage. REFERENCES
1. Sater, A. A. and Vandendris, M.: Abscess of corpus cavernosum. J. Urol., 141: 949, 1989. 2. Rosen, T.: Unusual presentations of gonorrhea. J. Amer. Acad. Dermatol., 6: 369, 1982. 3. Niedrach, W. L., Lerner, R. M. and Linke, C. A,: Penile abscess involving the corpus cavernosum; a case report. J. Urol., 141: 374, 1989. 4. Velcek, D. and Evans, J. A.: Cavernosography. Radiology, 144: 781, 1982. 5 . Orvis, B. R. and Lue, T. I?.: New therapies for impotence. Urol. Clin. N. Amer., 14: 569, 1987. 6. Peppas, D. S., Moul, 3. W. and McLeod, D. G.: Candida albicans coruora abscess followina- penile prosthesis placement. J. Urol., 140: 1541,1988. 7. Agarwalla, B., Mohanty, G. P., Sahu, L. K. and Rath, R. C.: Tuberculosis of the penis: reoort of 2 cases. J. Urol., 124: 927, 1980. 8. Symes, J. M. and Blandy, J. P.: Tuberculosis of the male urethra. Brit. J. Urol.. 45: 432. 1973. 9. Lewis, E. L.: Tuberculosis of the penis: a report of 5 new cases and a complete review of the literature. J. Urol., 56: 737, 1946. 10. Kaufman, J. J. and Silver, B. B.: Tuberculous ulcer of the penis: primary surgical excision. J. Urol., 72: 226, 1954. 11. Baskin, L. S. and Mee, S.: Tuberculosis of the penis presenting as a subcutaneous nodule. J. Urol., 141: 1430, 1989. A
FIG. 2. CT scan of penile shaft shows thickened left dorsal tunica. Catheter is in urethra.
case. Tuberculous cavernositis undoubtedly is hematogenic but by contiguous extension, tuberculous urethritis can become periurethritis, and invade the corpora and Tuberculosis causes a specific pathological tissue reaction, generally starting as a tuberculoma that gradually enlarges, and then caseates
THEJOURNAL OF UROLOGY Copyright 0 1990 by AMERICAN UROLOGICAL ASSOCIATION,INC
Voi. 144. August Printed in U.S.A.
TUBERCULOUS COLD ABSCESS OF THE CORPUS CAVERNOSUM: A CASE REPORT DANIEL YACHIA, MARC FRIEDMAN
AND
LYA AUSLAENDER
From the Departments of Urology and Pathology, Hillel Yaffe Medical Center, Hadera, Israel
ABSTRACT
A rare case of tuberculous cold abscess of t h e corpus cavernosum is presented. T h e only presenting symptom was obstructive urinary symptoms caused by external compression of t h e urethra by t h e abscess. Diagnosis was reached after surgical drainage a n d specific antituberculosis therapy led to a satisfactory conclusion. ( J . Urol., 144: 351-352, 1990) Tuberculosis is a multisystem infection that has almost dis- surface of both corpora appeared to be entirely normal. The appeared from hospitals of developed countries. However, oc- tunica at the puncture site was opened longitudinally and the casionally, patients with old urogenital tuberculosis are de- necrotic material was found in a pouch of fibrotic tissue. The walls of the pouch were cleaned by curettage, and the specimen tected. Abscesses of the corpora cavernosa are uncommon findings.' was sent for histological and bacteriological examination. Since They can develop as an unusual presentation of gonorrhea2 or no significant bleeding occurred the crater was irrigated with from t r a ~ m aor, ~they can be iatrogenic after cavern~sography,~diluted povidone-iodine solution and the tunica was left open, intracorporeal papaverine injections5 or penile prosthesis im- covered only by the penile skin. A small Penrose drain was left p l a n t a t i ~ n They .~ may also develop spontaneously.' Although for 48 hours. Histological examination revealed Langerhans no part of the genital system is immune to tuberculosis, we giant cells and necrotizing granulomatous inflammation. Culcould locate no case in the literature during the last 2 decades ture of the necrotic material remained sterile for bacteria but in which the corpus cavernosum was involved. We report a case Ziehl-Neelsen staining showed acid-fast bacteria and culture in which the only affected organ with active tuberculosis was for mycobacterium yielded massive tuberculous mycobacterium. Further examination of other organs for tuberculosis the corpus cavernosum. involvement did not yield any information. Antituberculosis C A S E REPORT treatment was begun immediately after Ziehl-Neelsen staining A 73-year-old man was referred to our outpatient clinic results were received. The multiple drug treatment consisted of because of a weak urinary stream that had developed during isoniazid, rifampicin, myambutol and pyridoxine, and was conthe last year. Physical examination of this healthy-appearing tinued for 1 year. When the patient was discharged from the man revealed only 1 testicle in the right scrotum. The testicle hospital he was able to urinate without difficulty. Urethroscopy and the vas deferens were normal to palpation. According to 2 years later was normal. the patient the left testicle had been removed elsewhere when DISCUSSION he was 26 years old because of a swelling. He could not recall whether he received any treatment postoperatively. According Tuberculosis of the urogenital system is an important but to his recollection no one in his immediate family had tuber- rare specific infection that may easily be missed, especially in culosis but he related that he had been hospitalized in his early countries where this infection is not endemic. The disease almost always is secondary to pulmonary tuberculosis and the twenties during military service because of a lung infection. Upon rectal examination the prostate was noted to be small, urogenital infection usually occurs via the hematogenous route. smooth and elastic. A slightly painful thickening was palpated The lupoid genital form (skin lesions) is believed to be primary on the dorsal side of the penis. Despite his age this finding was and acquired by sexual c o n t a ~ tSince . ~ our patient was a widbelieved to be a recent Peyronie's disease plaque. Urinalysis ower for 20 years and he had not had any sexual relations was normal. Excretory urography (IVP) showed marked resid- during this time no local contact could be suspected in this ual urine but a normal urinary tract without signs of prostatic enlargement. A chest x-ray revealed a calcified p ~ i m a r ~ c o m p l e x in the right upper pole. Cystoscopic examination failed initially because of obstruction of t h e penile urethra. At urethroscopy a narrowing of the penile urethra caused by external compression was detected. After dilation a 17F cystoscope could be passed. The external compression was 3 cm. long, the urethral lining was normal and no other pathological condition was noted in the prostate or bladder. Ultrasonography of the penis revealed fibrous thickening of the dorsal tunica albuginea and a hypoechoic area in the center of the left corpus cavernosum (fig. 1). Ultrasonography of the upper and lower urinary tract was normal. Computerized tomography (CT) of the penis confirmed the ultrasound findings that was suggestive of an old abscess formation (fig. 2). Blood counts revealed leukocytosis of 10,800 and renal function tests were within normal limits. Needle aspiration yielded 2 ml. whitish necrotic material. The site was explored through a circumcisional incision. Except FIG. 1. Ultrasonography of penile shaft shows fibrous thickening of for an indurated area in the left dorsal corpus cavernosum the Accepted for publication March 7, 1990.
dorsal tunica albuginea and hypoechoic area in center of left corpus cavernosum.
352
YACHIA, FRIEDMAN AND AUSLAENDER
and scars. When the lesion is in the penile skin the diagnosis is made by biopsy.lO," In our case despite the initial diagnosis of abscess of the corpus cavernosum made by ultrasound and CT, the final diagnosis could be reached only after histological and bacteriological examination of the necrotic material obtained by surgical drainage. REFERENCES
1. Sater, A. A. and Vandendris, M.: Abscess of corpus cavernosum. J. Urol., 141: 949, 1989. 2. Rosen, T.: Unusual presentations of gonorrhea. J. Amer. Acad. Dermatol., 6: 369, 1982. 3. Niedrach, W. L., Lerner, R. M. and Linke, C. A,: Penile abscess involving the corpus cavernosum; a case report. J. Urol., 141: 374, 1989. 4. Velcek, D. and Evans, J. A.: Cavernosography. Radiology, 144: 781, 1982. 5 . Orvis, B. R. and Lue, T. I?.: New therapies for impotence. Urol. Clin. N. Amer., 14: 569, 1987. 6. Peppas, D. S., Moul, 3. W. and McLeod, D. G.: Candida albicans coruora abscess followina- penile prosthesis placement. J. Urol., 140: 1541,1988. 7. Agarwalla, B., Mohanty, G. P., Sahu, L. K. and Rath, R. C.: Tuberculosis of the penis: reoort of 2 cases. J. Urol., 124: 927, 1980. 8. Symes, J. M. and Blandy, J. P.: Tuberculosis of the male urethra. Brit. J. Urol.. 45: 432. 1973. 9. Lewis, E. L.: Tuberculosis of the penis: a report of 5 new cases and a complete review of the literature. J. Urol., 56: 737, 1946. 10. Kaufman, J. J. and Silver, B. B.: Tuberculous ulcer of the penis: primary surgical excision. J. Urol., 72: 226, 1954. 11. Baskin, L. S. and Mee, S.: Tuberculosis of the penis presenting as a subcutaneous nodule. J. Urol., 141: 1430, 1989. A
FIG. 2. CT scan of penile shaft shows thickened left dorsal tunica. Catheter is in urethra.
case. Tuberculous cavernositis undoubtedly is hematogenic but by contiguous extension, tuberculous urethritis can become periurethritis, and invade the corpora and Tuberculosis causes a specific pathological tissue reaction, generally starting as a tuberculoma that gradually enlarges, and then caseates
