Urology Journal UNRC/IUA Vol. 1, No. 4, 278-279 Autumn 2004 Printed in IRAN 278 Primary Tuberculosis of Glans Penis: a Case Report AMIR-ZARGAR MA*1, YAVANGI M2, JA'FARI M3, MOHSENI MJ 1Department of Urology, Ekbatan Hospital, Hamedan University of Medical Sciences, Hamedan, Iran 2Department of Obstetrics, Ekbatan Hospital, Hamedan University of Medical Sciences, Hamedan, Iran 3Department of Pathology, Ekbatan Hospital, Hamedan University of Medical Sciences, Hamedan, Iran KEY WORDS: primary tuberculosis, tuberculosis of glans, diagnosis Introduction An extremely rare form of genitourinary tract tuberculosis (TB) is TB of glans, being reported in 139 cases up to 1971.(1-4) Penile glans may be affected through different mechanisms(1,2,4,5): pri- mary, as an ulcerative lesion of glans; secondary, which is due to TB of other parts in urinary tract system--usually extended through urethra; and finally, hematogenous. Long ago, circumcision was a risk factor when mycobacterium could enter the wounded glans from affected circumci- sion operators.(3,6) At present, TB of glans in adults is usually a primary or secondary form. Primary glans TB can be acquired by either inter- course with a patient suffering from genital TB, or contact with contaminated fabric. The second- ary form is the subsequent complication of lung tuberculosis or other organs involvement.(3) We report a case of primary glans TB, which is, to our best knowledge, the first report in Iran. Case Report A 48-year-old blind man was referred with an ulcerative burgeon (granulated) lesion on his glans. Physical examination revealed the involve- ment of the entire glans tissue (fig. 1), but no other sign or symptom in the genitourinary sys- tem. The patient had received different antibiotic therapies in the last two years, without a desir- able response. According to a positive culture for staphylococcus aureus, the patient was started on gentamicin and cephalexin, but no improvement yielded. Direct examination of the lesion dis- charge was negative for mycobacterium tubercu- losis. Also, VDRL test was negative, but a posi- tive tuberculin test was reported. Eventually, since the lesion had a tumor mimicking feature, frozen section biopsy was performed and the pri- mary report showed tuberculosis, confirmed by repeated biopsies (fig. 2). Further assessments for TB with intravenous pyelography and chest x- ray were normal. Subsequently, anti-TB treatment was initiated, using pyrazinamide, 2mg/kg/day, isoniazid, 300 mg/day, refampin, 450 mg/day, for two months, and isoniazid, 500 mg, 3 times per week, rifampin, 900 mg, 3 times per week, for another additional two months. Complete improvement was achieved following the treatment and reconstructive surgery was done on the glans. Also, the spouse of the patient was evaluated and genital tuberculosis was detected by physical examination and paraclinical Received January 2001 Accepted April 2001 *Corresponding author: Tel: +98 918 111 7950, E-mail: dr_amirzargar@yahoo.com FIG. 1. Involvement of the entire glans by an ulcerative lesion Amir-Zargar et al 279 and imaging assessments. She was referred to a gynecologist and treated successfully. Discussion Recently, the prevalence of TB in developing countries has had a declining trend(7) and multi- ple-organ involvement with TB is hardly seen.(4,8) However, Afghanistan wars in the last decade has led to immigration of the Afghans to Iran, result- ed in re-development of TB in the country and subsequently various forms of TB were found again. Involvement of glans of penis was first described by Hellerstrom and later by Bafverstedt and Hagemen.(9) The prevalence is higher in Japan and has been termed as penile tuberculo- sis.(10) TB of glans presents as a superficial lesion,(6,10) which is difficult to differentiate from malignant tumors.(3,7,10) The lesion can be exten- sive, with the involvement of urethra and corpus cavernosum.(3) Rarely it may present as a hard- ened nodule or even cavernositis accompanied with ulcer.(3) Biopsy must be done to confirm diagnosis, in which tuberculide granuloma with giant cells and caseous foci can be seen.(3,7,11) To determine whether a TB of glans is a primary or a secondary disease, intravenous pyelography and chest x-ray must be taken.(3,8,12,13) TB of glans usually responds to short-term anti-tubeculosis triple-drug chemotherapy.(4,11,14,15) References 1. Sekhon GS, Lal MM, Dhall JC. Tuberculosis of the penis. J Indian Med Assoc. 1971;56:316-8. 2. Lewis EL. Tuberculosis of the penis. A report of 5 new cases and complete review of literature. J Urol. 1946;56:737. 3. Johnson WD Jr, Johnson CW, Lowe FC. Tuberculosis and parasitic diseases of the genitourinary system. In: Walsh PC, Retik AB, Vaughan ED Jr, et al, editors. Campbell's urology. 8th ed. Philadelphia: WB Saunders; 2002. p.750-1. 4. Guy M, Eisenkraft S, Eliraz A. Primary tuberculosis of the glans penis. Harefuah. 1993;125:260-1, 328. 5. Narayana AS, Kelly DG, Duff FA. Tuberculosis of the penis. Br J Urol. 1976;48:274. 6. Venkataramaiah NR, van Raalte JA, Dutta SN. Tuberculous ulcer of the penis. Postgrad Med J. 1982;58:59-60. 7. Ueda H, Ohara H, Sakakibara T, et al. Tuberculosis of the contralateral adrenal gland: a case report. Hinyokika Kiyo. 1985;31:449-56. 8. Sah SP, AshokRaj G, Joshi A. Primary tuberculosis of the glans penis. Australas J Dermatol. 1999;40:106-7. 9. Jeyakumar W, Ganesh R, Mohanram MS, Shanmugasundararaj A. Papulonecrotic tuberculids of the glans penis: case report. Genitourin Med. 1988;64:130-2. 10. Nishigori C, Taniguchi S, Hayakawa M, Imamura S. Penis tuberculides: papulonecrotic tuberculides on the glans penis. Dermatologica. 1986;172:93-7. 11. Tanikawa K, Matsushita K, Ohkoshi M. Tuberculosis of the penis: report of a case and review of the literature. Hinyokika Kiyo. 1985;31:1065-70. 12. Agarwalla B, Mohanty GP, Sahu LK, Rath RC. Tuberculosis of the penis: report of 2 cases. J Urol. 1980;124:927. 13. Antonio D, Gow JG. Renal calcification in genito-urinary tuberculosis a clinical study. Int Urol Nephrol. 1975;7:289-95. 14. Fox W. Short course chemotherapy for tuberculosis. In: Fleneley DC, editor. Recent advances in respiratory Medicine. 2nd ed. Edinburgh: Churchill Livingstone; 1980. p.83. 15. Nakamura S, Aoki M, Nakayama K, Kanamori S, Onda S. Penis tuberculid (papulonecrotic tuberculid of the glans penis): treatment with a combination of rifampicin and an extract from tubercle bacilli (T.B. vaccine). J Dermatol. 1989;16:150-3. FIG. 2. Multiple granulomas in the epithelium of glans mucosa, containing epithelioid and giant granulomatous cells. Caseous necrosis is seen in the center of one of the granulomas. Hyperplasia of superficial epithelium has occurred. No malignancy was detected.