Genital tuberculosis

Introduction

Tuberculosis of the penis is extremely rare even in developing countries where the prevalence of tuberculous infection is high. Recently, we had 3 cases of penile ulcers due to tuberculosis.

Case 1

A 35 - year -old unmarried man presented with multiple ulcers over the glans penis. For 4 months, he was having fever, weight loss and painful papules over the glans penis which ulcerated. He denied history of recent sexual exposures. The ulcers were of 0.5 - 1 cm in size, with irregular punched out edges. The floor was covered with crust and the ulcers were tender and non-indurated. The superficial inguinal lymph nodes on both sides were enlarged, firm and non - tender. Dark ground examination for Treponema pallidum, gram stain for H. ducreyi and tissue smear for Donovan bodies were negative. Blood VDRL was non reactive and screening test for HIV was negative. Mantoux test was positive 15 mm. Chest x -ray and ultrasound abdomen were normal. No focus of tuberculosis could be found out. Biopsy from the ulcer showed tuberculoid granuloma and features of vasculitis. A diagnosis of papulonecrotic tuberculid over the glans penis was made. He was treated with INH 300 mg daily, rifampicin 600mg daily, ethambutol 800mg daily and pyrazinamide 1500mg daily for 2 months, followed by INH 300mg daily and rifampicin 600mg daily for 4 months as per the WHO recommendation. The ulcers healed with treatment leaving thin depressed circular scars.

Case 2

A 60-year-old unmarried man who had no history of sexual exposures presented with multiple papules and ulcers over the glans penis of 8 months duration. The ulcers were 2-5mm in size, had punched out edges, and were tender and non-indurated. They were covered with brownish crust, removal of which revealed underlying pale granulation tissue. The inguinal lymph nodes on both sides were enlarged, non tender. Dark ground examination, gram stain and tissue smear showed no organism. Blood VDRL test and ELISA test for HIV were negative. Mantoux test was positive 15mm. Chest X-ray and ultrasound abdomen were normal. No focus of tuberculous infection could be detected. Histopathology showed tuberculoid granuloma and features of vasculitis [Figure - 1]. A diagnosis of papulonecrotic tuberculid of glans penis was made. The ulcers healed on treatment with antituberculosis drugs.

Case 3

A 55- year-old man presented with an ulcer over the glans penis of 5 months duration. It was 1.5x1 cm in size, indurated, nontender, was covered with red granulation tissue and had undermined edges [Figure - 2]. The inguina l lymph nodes were enlarged on both sides and were nontender. The dark ground microscopy for Treponema pallidum and smears for H. ducreyi and Donovan bodies were negative. Blood VDRL and ELISA test for HIV were negative. Chest X-ray showed cavitary lesions right apex suggestive of tuberculosis. Histology from the ulcer showed tuberculoid granuloma. A diagnosis of tuberculous ulcer over the penis was made and he was treated with antituberculosis drugs. The ulcer healed completely on treatment.

Discussion

Although any organ or system can be affected by tuberculosis, penis is an uncommon site for its involvement. Tuberculosis affecting the penis can be tuberculous chancre, papulonecrotic tuberculid, tuberculosis cutis orificialis or tuberculous gumma. Tuberculous chancre has been reported following ritual circumcision and sexual contact.[1] The possibility of tuberculous chancre is very unlikely in our case since there was no associated suppurative lymhadenopathy. Several cases of papulonecrotic tuberculids over the glans penis have been reported previously.[2],[3],[5],[6] The first six cases were reported from Japan.[5] Papulonecrotic tuberculid is considered to be due to a hypersensitivity reaction of fragments of tubercle bacilli. It occurs in patients with a moderate or high degree of immunity to tubercle bacilli. It occurs in patients with a moderate or high degree of immunity to tubercle bacilli. The focus of tuberculosis infection is found in 30-40% of cases. The condition promptly responds to antituberculosis drugs but relapses have been reported.[4] When lesions are limited to glans penis, diagnosis can be difficult. All our cases were thoroughly investigated to rule out sexually transmitted diseases such as syphilis, chancroid and Donovanosis. A diagnosis of tuberculosis was made by clinical, laboratory and histological features. Unless the possibility of tuberculosis is considered, the diagnosis can be missed in these cases. All our patients responded to treatment.