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The Cases of the month (CoM) have been introduced by Christoph F. Dietrich as first Editor from 2008 to 2009 followed by Paul S. Sidhu from 2010 to 2015, with Maija Radzina taking over in 2016. The earliest case of the month went online in March 2008. The Publication Committee envisaged regular contributions to include artefact of the month, tip of the month in addition to cases that would be of interest. Topics have ranged from Focal liver lesions (FLL), Crohn's disease, Echoscopy, to a rare double gallbladder. All these cases are listed on the EFSUMB website under Case Archive

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27-04-2015
Case of the Month - APRIL (Russian, Chinese & Latvian Translation Available)
Penile abscess recurrence ultrasound evaluation and guided treatment.






RUSSIAN VERSION - Click Here

LATVIAN VERSION - Click Here

CHINESE VERSION - Click Here

Jakob Fink Topsøe, MD 

Department of Radiology,
Copenhagen University Hospital Herlev,
Herlev Ringvej 75,
2730 Herlev, Denmark
e-mail: jakobfink@gmail.com



Caroline Ewertsen, MD, PhD
Department of Radiology, Copenhagen University Hospital Rigshospitalet, Denmark

 

Summary

We report a case of a recurrent penile abscess located within the corpus spongiosum. This rare urological condition was diagnosed and evaluated by contrast enhanced ultrasound (CEUS) and treated by ultrasound (US) guided intervention.


Case report

A 55-year-old patient presented with a painful mass on the ventral part of the penis. He gave history of a similar episode seven years earlier, where an abscess in the corpus spongiosum had been found and treated with percutaneous US guided drainage without any complications. The patient had noticed the slowly growing painful tumour for a week, and had been taking antibiotics four days prior to presentation, without symptomatic resolution. Clinical examination revealed an approximately 2 x 2 cm, tender mass with evident fluctuation on palpation. The attending urologist requested an US evaluation, and also, if possible, a percutaneous drainage, as the patient had declined to undergo surgery. B-mode US showed a well-delineated, homogeneous and hypo-echoic lesion measuring 2 x 3 cm (Figure 1). In order to further characterize these findings, a CEUS was performed with an intravenous injection of 1.4 ml of SonoVueTM (Bracco SpA, Milan), which demonstrated an avascular cavity Figure 2). A dorsal penile nerve block was performed, and the abscess cavity was punctured using a 1.2 mm (18 gauge) needle. Four ml of pus was aspirated and the cavity flushed with saline. After repeated flushing with saline, a few drops of SonoVue was added to 100 mL 0.9 % saline and a few millilitres were injected into the cavity. This allowed the demonstration of a small communicating fistula between the abscess cavity and the urethra (Video 1). The patient was treated with antibiotics for a further five days, and the fistula was managed and treated in the urology department following remission of the abscess.

Discussion
A penile abscess is a rare urologic abnormality. Primary symptoms are penile swelling and pain. Pyrexia, dysuria or urethral discharge may be seen. In the majority of reported cases the abscess is located in the corpus cavernosum and related to and intra-cavernosal injection, perianal/perineal/intra-abdominal abscess, penile trauma and instrumentation (1). Other conditions that predispose to an abscess include any cause of immunosuppression, particularly diabetes mellitus. The clinical diagnosis is usually obvious, but in difficult cases with possible widespread infection in the perineal area, further imaging with computed tomography (CT) or magnetic resonance (MR) is helpful. Surgery is the treatment of choice in most reported cases, but with an increase in post-operative complications, with penile curvature and erectile dysfunction known to occur. Percutaneous drainage guided by CT has been reported (2), but US guided drainage is convenient for operator as well as the patient and without ionizing radiation, a concern in younger patients. As described in the non-hepatic EFSUMB guidelines on the use of CEUS in clinical practice, CEUS for intra-cavitary use is effective in detection and evaluation of a cavity, and in this case demonstrated a communicating fistula to the urethra, the potential reason for abscess recurrance (3). Alternative diagnostic imaging to visualize the fistula would have been either an MR examination or retrograde urethrography.

Conclusion
Percutaneous US guided drainage followed by systemic antibiotics is a feasible treatment of penile abscesses. CEUS may help visualizing the extent of the abscess and possible fistulae.

References
1. Dugdale CM, Tomkins AJ, Reece RM, Gardner AF. Cavernosal Abscess due to Streptococcus Anginosus: A Case report and Comprehensive Review of the Literature. Curr Urol 2013;7: 51-56.

2. Thanos L, Tsagouli P, Eukarpidis T, Mpouhra K, Kelekis D. Computed tomography-guided drainage of a corpus cavernosum abscess: a minimally invasive successful treatment. Cardiovasc Intervent Radiol 2011;34:217-9.

3. Piscaglia F, Nolsøe C, Dietrich CF, Cosgrove DO et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med. 2012;33:33-59.


Figure Legends

Figure 1
The hypo-echoic cavity in the corpus spongiosum.

Figure 2
Following the administration of contrast, the abscess cavity is well demonstrated.



Video 1.
After instillation of saline with the added SonoVue contrast agent, a small fistula from the abscess cavity running to the urethra is shown. Artifacts from the SonoVue are seen on B-mode in the urethra and in the abscess cavity located to the right, inferior to the urethra. The proximal part of the penis is located to the right.

             
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