Periurethral abscess complicating gonococcal urethritis: case report and literature review

Abstract

Periurethral abscess formation secondary to urethritis has become an atypical and rare urological complication. We report here a case of penile gonococcal periurethral abscess and review the literature. Chart review and writing of the manuscript have been approved by the Ethical Committee of the Faculty of Biology and Medicine of Lausanne University, Switzerland. In February 2007, a 46-year-old HIV-positive homosexual man was admitted to the Urology Clinic of the University Hospital of Lausanne for a painful cherry-sized mass of the distal penis. One week before the admission, he had consulted the outpatient emergency unit with a history of urethral discharge which was diagnosed clinically as gonococcal urethritis and treated with 400 mg of ofloxacin, single dose. On physical examination, the patient presented a good general status and was afebrile. Examination of the external genitalia revealed a tender mass 2 cm in diameter affecting the ventral aspect of the penis, close to the balano-preputial separation (Fig. 1a). The overlying skin was intact. There was no discharge, no ulceration, and no palpable lymphadenopathy. The C-reactive protein value and blood leucocytes count were within normal limits. Syphilis serology was positive with a VDRL titer of 2 and a TPHA titer of 1,280. Blood and urine cultures were negative. Penile ultrasound scan showed a hypo-echogenic collection adjacent to the distal penile urethra and spongy urethra measuring 20 9 15 9 10 mm (Fig. 1b). Retrograde urography and urethroscopy demonstrated normal urethral mucosa. The urethral lumen was narrowed by a bulging mass originating from outside the urinary tract. There was no communication between the mass and the urinary tract. Regarding the HIV infection, the CD4 lymphocyte count was 91 cells/mm (18%) and the HIV viral load was 2,300 copies/ml. (The patient had recently stopped his antiretroviral treatment.) A combined medical and surgical approach was required. Following a 5-day course of ceftriaxone 2 g once daily intravenously, the abscess did not decrease in size. The abscess was, thus, incised and drained completely by performing a transurethral endoscopic incision of the abscess using the Collins loop of a 24 French resectoscope. A urethral Foley catheter was then inserted and kept in place for 3 days. Gram stain and culture of the pus failed to identify any germ. A real-time in-house polymerase chain P. Jichlinski and M. Cavassini contributed equally to this work.