Dorsal perforation of prepuce due to squamous cell carcinoma

M Bhallal, S Kaur, AK Attri, GP Thami

 Department of Dermatology and Venereology and Department of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India

Correspondence Address:
G P Thami
Department of Dermatology and Venereology and Department of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh
India

Introduction

The prepuce, a pentalaminar specialized junctional tissue with mucosa on its inner surface and skin on its outer surface, is an important part of the human anatomy. Dorsal perforation of the prepuce is a presentation which is common to a variety of conditions of different aetiologies. It has usually been reported as a sequelae of severe, infective genital ulcer disease causing rapid destruction of the glans and prepuce.[1],[2] Non-infectious causes, though infrequently reported may also lead to dorsal perforation of prepuce. A patient with squamous cell carcinoma of the penis leading to dorsal perforation of prepuce is reported.

Case Report

A 45-year-old sexually active male presented with genital ulcer disease of six months′ duration. Despite history of exposure to commercial sex workers the disease had not responded to treatment for various sexually transmitted genital ulcer diseases which the patient had taken elsewhere.

On examination, penis showed diffuse enlargement with phimosis. There was a 3-4 cm sized nodulo-ulcerative lesion with irregular margins over the ventral aspect of penis invading the urethra. The base of the ulcer was greyish yellow with a foul smelling mucopurulent discharge. Another 1.5cm diameter hole was present over dorsum of penis with floor showing similar ulceration [Figure - 1]. Regional lymph nodes were not enlarged. A clinical diagnosis of Donovanosis was considered and patient was investigated. Biopsy form both ulcers was taken and he was empirically treated with doxycycline (100 mg twice daily) for two weeks to which he did not respond.

Cultures and smears from mucopurulent material showed no infective organism. Tissue smears for Donovan bodies was negative. Serology for syphilis and HIV was negative. Histopathology from both the ulcers at dorsal and ventral aspect showed a well differentiated squamous cell carcinoma. Fine needle aspiration of inguinal lymph nodes showed lymphatic metastases. Patient was explained about the disease, its prognosis and management. He was counselled and managed with penectomy and regional lymph node dissection.

Discussion

Dorsal perforation of prepuce (holey prepuce) is known to complicate phage-denic sexually transmitted infection causing genital ulcer diseases like chancroid, Donovanosis and herpes genitalis as well as non-ulcerative infections like condyloma acuminata.[1],[2],[3],[4] Hidradenitis suppurative and podophyllin application[3] has also led to dorsal perforation of prepuce. The dorsal portion of the prepuce has been considered vulnerable due to a relatively deficient vascular supply in comparison to ventral portion. The prepuce is supplied by the blood vessels originating from its proximal attachment with the skin of the penile shaft and not distally from the corona.[5] These superficial penile arteries on reaching the preputial ring become branched, tortuous and minute while the ventral aspect of preputial skin is richly supplied separately by the frenular branch of dorsal artery of penis.1,6 As the areas with relatively less blood supply are more prone to ischaemic necrosis, so any insult in the form of infection or trauma is likely to cause destruction and necrosis of dorsal portion of prepuce.[1] Similarly the ulcers of non-infectious aetiology are more likely to perforate the prepuce dorsally rather than ventrally, even though they may be present on both surfaces as was observed in this patient. In the present patient, initially, a sexually transmitted genital ulcer disease was considered to be the cause of dorsal perforation of prepuce, but it was proved otherwise. Although dorsal perforation of prepuce is a rare complication of genital ulcer disease, it amy also result from invasive carcinomatous disease of penis as in this patient. Thus, though the site of the defect makes one think initially of a sexually transmitted ulcer as the underlying cause but it should be remembered that other non-ulcerative and non-infective causes like trauma, podophyllin application and squamous cell carcinoma, as in our case, are also known to present a similar picture.

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