Cavassini, M.

Darling, K.

Jaton-Ogay, K.

Jichlinski, P.

Kenfak-Foguena, A.

Praz, V.

Wisard, M.

Zarkik, Y.

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CORRESPONDENCEPeriurethral abscess complicating gonococcal urethritis:case report and literature reviewA. Kenfak-Foguena • Y. Zarkik • M. Wisard •V. Praz • K. E. A. Darling • K. Jaton-Ogay •P. Jichlinski • M. CavassiniReceived: 17 May 2010 / Accepted: 3 August 2010 / Published online: 3 September 2010 Urban & Vogel 2010Periurethral abscess formation secondary to urethritis hasbecome an atypical and rare urological complication. Wereport here a case of penile gonococcal periurethral abscessand review the literature. Chart review and writing of themanuscript have been approved by the Ethical Committeeof the Faculty of Biology and Medicine of LausanneUniversity, Switzerland.In February 2007, a 46-year-old HIV-positive homo-sexual man was admitted to the Urology Clinic of theUniversity Hospital of Lausanne for a painful cherry-sizedmass of the distal penis. One week before the admission, hehad consulted the outpatient emergency unit with a historyof urethral discharge which was diagnosed clinically asgonococcal urethritis and treated with 400 mg of ofloxacin,single dose.On physical examination, the patient presented a goodgeneral status and was afebrile. Examination of the exter-nal genitalia revealed a tender mass 2 cm in diameteraffecting the ventral aspect of the penis, close to thebalano-preputial separation (Fig. 1a). The overlying skinwas intact. There was no discharge, no ulceration, and nopalpable lymphadenopathy. The C-reactive protein valueand blood leucocytes count were within normal limits.Syphilis serology was positive with a VDRL titer of 2 and aTPHA titer of 1,280. Blood and urine cultures were neg-ative. Penile ultrasound scan showed a hypo-echogeniccollection adjacent to the distal penile urethra and spongyurethra measuring 20 9 15 9 10 mm (Fig. 1b). Retro-grade urography and urethroscopy demonstrated normalurethral mucosa. The urethral lumen was narrowed by abulging mass originating from outside the urinary tract.There was no communication between the mass and theurinary tract. Regarding the HIV infection, the CD4 lym-phocyte count was 91 cells/mm3 (18%) and the HIV viralload was 2,300 copies/ml. (The patient had recently stop-ped his antiretroviral treatment.)A combined medical and surgical approach wasrequired. Following a 5-day course of ceftriaxone 2 g oncedaily intravenously, the abscess did not decrease in size.The abscess was, thus, incised and drained completely byperforming a transurethral endoscopic incision of theabscess using the Collins loop of a 24 French resectoscope.A urethral Foley catheter was then inserted and kept inplace for 3 days. Gram stain and culture of the pus failed toidentify any germ. A real-time in-house polymerase chainP. Jichlinski and M. Cavassini contributed equally to this work.A. Kenfak-Foguena  K. E. A. Darling  M. Cavassini (&)Infectious Diseases Service, Centre Hospitalier UniversitaireVaudois and Lausanne University, 1011 Lausanne, Switzerlande-mail: matthias.cavassini@chuv.chA. Kenfak-Foguenae-mail: alain.kenfak-foguena@chuv.chK. E. A. Darlinge-mail: katharine.darling@chuv.chY. Zarkik  M. Wisard  V. Praz  P. JichlinskiDepartment of Urology, Centre Hospitalier UniversitaireVaudois and Lausanne University, Lausanne, Switzerlande-mail: yassine.zarkik@chuv.chM. Wisarde-mail: marc.wisard@chuv.chV. Praze-mail: valentin.praz@chuv.chP. Jichlinskie-mail: patrice.jichlinski@chuv.chK. Jaton-OgayInstitute of Microbiology, Centre Hospitalier UniversitaireVaudois and Lausanne University, Lausanne, Switzerlande-mail: katia.jaton-ogay@chuv.chInfection (2010) 38:497–500DOI 10.1007/s15010-010-0050-zreaction (PCR) assay specific for Neisseria gonorrhoeae,targeting the porA gene (with sensitivity and specificitycomparable to Amplicor), was performed on the pus andgave a positive result (342 copies/mm3). PCR analysisspecific for Chlamydia trachomatis was negative.The patient developed a generalized erythrodermia withpalpebral and facial edema on ceftriaxone and this treat-ment was changed to imipenem to complete a 10-dayantibiotic course. His HIV antiretroviral therapy wasresumed during hospitalization.During a 2-year followup period post-treatment, thepatient has remained well, with no abscess recurrence andno symptoms of urethral obstruction or stricture.Gonococcal infection remains the second most commonsexually transmitted infection (STI) worldwide after chla-mydia [1]. Major risk groups are young people, females,men who have sex with men (MSM), and low socioeco-nomic populations [2]. Our patient’s risk behavior foracquiring another STI was unprotected oral sex with othermen. Gonococcal infection is more frequent in the HIV-positive population, but it is not clear whether HIV per seincreases the risk of infection or if other factors such ashigh risk behavior act as confounders [2, 3].The clinical presentation of gonorrhoea depends on theinvolved mucosa. Some patients may not developsymptoms, while others will present with complications,according to the degree of virulence of the infecting strains[4] and the involved mucosa (rectum and pharynx are lesssymptomatic than urogenital mucosa) [5]. Recurrentinfections also increase the risk of complications such aspelvic inflammatory diseases (PID), tubal scarring, orperiurethral abscesses.Before the use of adequate antibiotic treatment, theformation of periurethral abscesses was a typical ascendingcomplication of gonococcal urethritis in men. It hasbecome rare in the past three decades [6] and, nowadays, isusually described in case reports or small series (Table 1)[7–14]. In the study conducted by Sanders and Mulder [14],N. gonorrhoeae accounted for 3/20 culture-confirmedperiurethral abscesses. Abscess formation is usually asso-ciated with a delay in the diagnosis of gonococcal urethritisor the presence of a urethral stricture. Periurethral abscessusually develops when a Littre´ gland (and rarely a Tysongland) becomes obstructed by thickened pus or by fibrosis.However, it may also occur through urethral crypts orthrough the balano-preputial separation. Another risk factorfor gonococcal abscess may be a cutaneous traumaallowing direct inoculation of the bacteria [7].Gonococcus can be detected in biological samples byseveral methods. The Gram stain is a sensitive and specifictest for diagnosing symptomatic male urethral gonorrhea.However, the gold standard for the diagnosis is growth ofthe organism on chocolate agar or on Thayer–Martin agarand confirmatory tests include carbohydrate acidificationtests, chromogenic enzyme substrate tests, and immuno-logic tests [15]. Nucleic acid amplification tests (NAATs)are more sensitive and faster than culture, and are, nowa-days, commonly used [16], but they do not provide infor-mation on bacterial susceptibility to antibiotics. Whenavailable, the NAATs have largely replaced culture. Othermethods of diagnosis are point-of-care testing (POC), suchas immuno-chromatographic strip tests or optical immu-noassays performed on urine, endocervical, and vaginalswabs, which allow diagnosis and treatment in a singlevisit. These tests have a high specificity but lower sensi-tivity compared to NAATs [17]. Medical imaging is usefulto delineate and confirm the diagnosis of periurethralabscesses. Penile ultrasonography is usually sufficient;computed tomography (CT) and magnetic resonanceimaging (MRI) add no significant information and are,therefore, of little use.There are no randomized trials evaluating the manage-ment of periurethral abscesses. Treatment approaches tendto be based on surgeons’ experience and abscess location.Recommended management include antibiotic therapy anddrainage, the latter being performed by needle aspiration,open surgery, or endoscopic transurethral incision. In ourpatient, the location of the abscess in the periurethral distalFig. 1 Penile abscess: a physical examination, b ultrasonography;circle corpus cavernosum, star urethra, arrows periurethral abscess498 A. Kenfak-Foguena et al.penis made it easily accessible to endoscopic transurethralincision. Antibiotic coverage is important to prevent septi-cemia [18]. Recommended antibiotics for the treatment ofuncomplicated gonococcal urethritis are third-generationcephalosporins which can be given as a single dose (forexample, ceftriaxone and cefixime) [19]. In the case ofabscess formation, antibiotic treatment is generally contin-ued for at least 7 days. With the increased prevalence ofresistant strains, fluoroquinolones are no longer recom-mended as the first-line treatment [20]. In our patient, theprogression of urethritis to an abscess may have been dueeither to delay prior to consultation or to ofloxacin resistancein the infecting strain. As the detection of gonococcus wasperformed by PCR following a 5-day course of ceftriaxone,we do not have the data regarding the strain’s sensitivity.After appropriate treatment, outcome is usually good.However, abscess recurrence can occur, as can othercomplications, such as urethral stricture, urethrocutaneousfistula, or urethral diverticulum [6, 14]. To date, our patienthas not presented any sequelae following the treatment ofhis abscess.Conflict of interest None declared.References1. Centers for Disease Control and Prevention (CDC). Sexuallytransmitted disease surveillance, 2006. Atlanta, GA: US Depart-ment of Health and Human Services, CDC 2007. Available onlineat: http://www.cdc.gov/std/stats06/toc2006.htm. Accessed 11 Jun2009.2. Delpech V, Martin IM, Hughes G, et al. Epidemiology andclinical presentation of gonorrhoea in England and Wales:findings from the Gonococcal Resistance to AntimicrobialsTable 1 Periurethral gonococcal abscess in the literature (1980–2009)Reference Numberof casesClinical presentation Diagnostic procedure TreatmentKraus et al. [7] 1 Bagatelle penile traumaNo voiding dysfunction, no hematuria, nourethral dischargePus analysis: Gram stain and ELISAPenile ultrasonographySono-urethrography with retrogradesaline infusion to the distal urethraSurgical incision using aTurner-WarwickCephalosporin—aminoglycoside bolus,then cefuroxim for 7 daysKomolafe et al.[8]1 Urethral dischargePainful lump in the penis with a strikingerythema of the penile shaftUrethral smear and culture Surgical drainage of pusCiprofloxacin andamoxicillin-clavulanicacid (?metronidazole)Yamada and Ito[9]1 Mass of the prepuce not accompaniedwith urethritisNot available in the abstract (article inJapanese)Cefodizime IVNeubert et al.[10]3 Pus-filled nodule in the dorso-regionalregion of the prepuceNo urethral discharge or burningGram stain of a smear from theabscess and urethra and culture onmodified Thayer–Martin agarPenicillin bolus andprobenecid per osSurgical drainage ofabscessPainful preputial nodule with ulcerationof the prepuceNo discharge, no painPus culture on modified Thayer–Martin plateSpectinomycin 2 g singledosePreputial nodule without discharge orburningExamination of pus and urethra smear Cefotiam 1 g single doseFiumara andEisen [11]1 8-mm inflammatory mass of the prepuce.No discharge, no dysuriaGram stain and culture on Thayer–Martin agarProcaine penicillin G singledose IMClifford et al.[12]1 Discharge from a mass of the medianraphe, associated to urethritisCulture of the discharge Amoxicillin and probenecidbolus then amoxicillin perosSubramanian[13]1 Urethral dischargeTender swelling of 1 cm on each side ofthe frenum and another swelling at theinferior aspect of the penisMicroscopy of Gram-stained urethralmaterialAmpicillin and probenecidfor 10 daysSanders andMulder [14]3/16 Consecutive series of patients with aclinical diagnosis of periurethral abscessUrethral and endo-urethral swabsPus cultureNeedle aspiration of pusKanamycin single dose anddoxycycline for 1 weekArticles retrieved from PubMed on 1st December 2009. Search words: periurethral abscess or urethritis and gonorrhoeaPeriurethral abscess complicating gonococcal urethritis 499Surveillance Programme 2001–2006. Sex Transm Infect.2009;85(5):317–21.3. Zetola NM, Bernstein KT, Wong E, et al. Exploring the rela-tionship between sexually transmitted diseases and HIV acqui-sition by using different study designs. J Acquir Immune DeficSyndr. 2009;50(5):546–51.4. Edwards JL, Apicella MA. The molecular mechanisms used byNeisseria gonorrhoeae to initiate infection differ between menand women. Clin Microbiol Rev. 2004;17(4):965–81.5. Kent CK, Chaw JK, Wong W, et al. Prevalence of rectal, urethral,and pharyngeal chlamydia and gonorrhea detected in 2 clinicalsettings among men who have sex with men: San Francisco,California, 2003. Clin Infect Dis. 2005;41(1):67–74.6. Walther MM, Mann BB, Finnerty DP. Periurethral abscess.J Urol. 1987;138(5):1167–70.7. Kraus S, Luedecke G, Ludwig M, et al. Periurethral abscessformation due to Neisseria gonorrhoeae. Urol Int. 2004;73(4):358–60.8. Komolafe AJ, Cornford PA, Fordham MV, et al. Periurethralabscess complicating male gonococcal urethritis treated by sur-gical incision and drainage. Int J STD AIDS. 2002;13(12):857–8.9. Yamada Y, Ito K. Gonococcal abscess in the prepuce: a casereport. Kansenshogaku Zasshi. 2001;75(9):819–21.10. Neubert U, Korting HC, Luderschmidt C, et al. Preputialabscesses caused by beta-lactamase-producing gonococci. Cutis.1985;36(2):161–3.11. Fiumara NJ, Eisen R. Cutaneous gonococcal abscess: a casereport. Sex Transm Dis. 1984;11(1):34–5.12. Clifford GR, Krieger JN, Rein MF. Gonococcal infection of themedian penile raphe. J Urol. 1983;130(1):138–9.13. Subramanian S. Gonococcal urethritis with bilateral tysonitis andperiurethral abscess. Sex Transm Dis. 1981;8(2):77–8.14. Sanders CJ, Mulder MM. Periurethral gland abscess: aetiologyand treatment. Sex Transm Infect. 1998;74(4):276–8.15. Workowski KA, Berman SM. Sexually transmitted diseasestreatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1–94.16. Cook RL, Hutchison SL, Ostergaard L, et al. Systematic review:noninvasive testing for Chlamydia trachomatis and Neisseriagonorrhoeae. Ann Intern Med. 2005;142(11):914–25.17. Greer L, Wendel GD Jr. Rapid diagnostic methods in sexuallytransmitted infections. Infect Dis Clin North Am. 2008;22(4):601–17.18. Malatinsky E. Sepsis caused by periurethral abscess. Int UrolNephrol. 1991;23(5):485–8.19. Bignell C. 2009 European (IUSTI/WHO) guideline on the diag-nosis and treatment of gonorrhoea in adults. Int J STD AIDS.2009;20(7):453–7.20. Centers for Disease Control and Prevention (CDC). Update toCDC’s sexually transmitted diseases treatment guidelines, 2006:fluoroquinolones no longer recommended for treatment of gono-coccal infections. MMWR Morb Mortal Wkly Rep. 2007;56:332–6.500 A. Kenfak-Foguena et al.

Periurethral abscess complicating gonococcal urethritis: case report and literature review

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Periurethral abscess complicating gonococcal urethritis: case report and literature review

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