The Aging Male

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Urethral stricture and scrotal abscess: a rare case

presentation of penile cancer and review of the
literature

Aldo Franco De Rose, Francesca Ambrosini, Laura Tomasello, Francesco

Boccardo & Carlo Terrone

To cite this article: Aldo Franco De Rose, Francesca Ambrosini, Laura Tomasello,
Francesco Boccardo & Carlo Terrone (2019): Urethral stricture and scrotal abscess: a
rare case presentation of penile cancer and review of the literature, The Aging Male, DOI:
10.1080/13685538.2019.1650017

To link to this article: https://doi.org/10.1080/13685538.2019.1650017

Published online: 09 Aug 2019.

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THE AGING MALE
https://doi.org/10.1080/13685538.2019.1650017

ORIGINAL ARTICLE

Urethral stricture and scrotal abscess: a rare case presentation of penile

cancer and review of the literature
Aldo Franco De Rosea, Francesca Ambrosinia, Laura Tomasellob, Francesco Boccardoa and Carlo Terronea
a
Department of Urology, San Martino University Hospital – IST National Cancer Research Institute, Genoa, Italy; bAcademic Unit of
Medical Oncology, San Martino University Hospital – IST National Cancer Research Institute, Genoa, Italy

ABSTRACT ARTICLE HISTORY

Penile cancer is a very rare malignancy and it is usually identified as a nodule or an ulceration. Received 22 June 2019
We report a case of locally advanced penile cancer presented as a urethral stricture and recur- Revised 21 July 2019
rent scrotal abscess. The patient had been treating for obstructive voiding symptoms and septic Accepted 26 July 2019
condition for 5 months. Because of persistent symptoms, a drainage of the abscess was per- Published online 8 August
2019
formed and the histopathological examination showed infiltrating moderately differentiated
squamous cell carcinoma of penis. He underwent a surgical Emasculation followed by the KEYWORDS
administration of a combination of chemotherapy (paclitaxel, ifosfamide, and cisplatin). We high- Penile cancer; scrotal
light the importance of including penile cancer in the differential diagnosis of scrotal abscess abscess; urethral stricture;
and urethral stricture. A multimodal approach is an effective strategy to manage the disease. TIP regimen

Introduction ulceration. Suppuration or hemorrhage is very uncom-

Primary penile cancer is a rare disease with an overall
incidence of around 1/100,000 males in Europe and in
the USA [1,2]. The incidence increases with age [2],
with a peak in the sixth decade [3] and varies region-
ally all around the world depending on socioeconomic
factors and religious habits.
Some risk factors have been identified such as
chronic penile inflammation and phimosis associated
with poor personal hygiene, lichen sclerosus, high-risk
human papillomaviruses (hrHPV) infection and smok-
ing [3]. On the other hand, circumcision in childhood
shows a protective effect [4].
The most frequent histotype of penile carcinoma is
the squamous cell carcinomas (SCC) with several sub-
types described including verrucous carcinoma, basa-
loid carcinoma, warty carcinoma (verruciform), and
sarcomatoid carcinoma. Malignant melanoma and
basal cell carcinoma account for the remainder of pen-
ile cancer cases. It usually originates from the epithe-
lium of the inner prepuce or from the glans.
Prognostic factors of penile cancer include tumor
stage, histologic grade and subtype, presence of peri-
neural and lymphatic infiltration, depth of infiltration
and lymph node involvement at the diagnosis [5].
Patients typically present with a solitary painless
lesion of the penis, sometimes associated with
mon signs and is usually related to an advanced dis-
ease or to nodal involvement [6].
We report a case of locally advanced penile SCC
presented with a 5-month history of obstructive void-
ing symptoms and purulent urethral discharge that
had been initially associated with urethral stricture. He
was treated with total penectomy and then he
received a combination chemotherapy with paclitaxel,
ifosfamide, and cisplatinum (TIP regimen). We high-
light the importance of considering scrotal symptoms
and obstructive voiding symptoms as one of the pos-
sible presentations of penile SCC. In addition, we
denote the effectiveness of multimodality approach
combining aggressive surgery and chemotherapy to
manage unresectable cancer.
Case report
A 67-year-old male presented to the Department of
Urology, San Martino Hospital (Genova) in December
2017 with high temperature and purulent urethral dis-
charge. He was cigarette smoker and suffered from
chronic obstructive pulmonary disease, but apart from
that the patient’s medical history was unremarkable.
The patient did not provide any history of urethral
trauma or sexually transmitted disease. In July 2017, a

CONTACT Francesca Ambrosini f.ambrosini1@gmail.com Department of Urology, San Martino University Hospital – IST National Cancer Research
Institute, University of Genova, Policlinico San Martino, L.go R. Benzi 10, Genova 16132, Italy
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 A. F. DE ROSE ET AL.
suprapubic cystostomy had been placed for the man-
agement of obstructive voiding symptoms, after failed
urethral catheterization in another Department. A
urethral stricture had been suspected. In September
2017, the patient had been admitted because of peno-
scrotal abscess extending to surrounding subcutaneous
tissue. A perineal urethrostomy had been performed
after several unsuccessful attempts of conservative
treatment. A malignant disease was not rule out.
After the procedure, the patient continued to suffer
from swelling, redness of scrotum and undulating
pain. In December 2017 symptoms got worse so he
went to our Emergency Room complaining of septic
fever, purulent urethral discharge, pain, and scrotal
swelling. The clinical examination showed a scrotal
abscess. Inguinal lymph nodes were not palpable. A
contrast-enhanced-computed tomography (CT) scan of
abdomen demonstrated an elongated midline abscess
with peripheral enhancement at the base of the penis
involving also the urethral sponge, measuring approxi-
mately 50 mm  40 mm. In the delayed phase, contrast
spread from the urethra to the fluid collection reaching
the contiguous thick perineal tissue. He was treated
with immediate surgical debridement and drainage of
the abscess. A suprapubic cystostomy was placed. The
margin of the perineal urethral meatus and a sample of
abscessualized and necrotic material were sent to the
Pathology Department. Unexpectedly, the histopatho-
logical examination showed infiltrating moderately dif-
ferentiated SCC with positive surgical resection margins.
The clinical condition of the patient got worse: he
developed pelvic, scrotal, and perineal pain and both
the scrotal volume and the purulent urethral discharge
increased. The patient received antibiotic treatment
without response. An abdominopelvic revaluation CT
showed a penile solid mass of 5 cm  8 cm  9 cm
extending from the glans to the root of the penis,
infiltrating the corpus cavernosum and the spermatic
funiculus. Enlarged bilateral inguinal lymph nodes
were identified measuring about 13 mm. Furthermore,
suspected small lymph nodes were detected along
the external iliac vessels. A surgical Emasculation was
performed in February 2018: penis in toto, urethra,
and both testicles were removed. Histopathologic
examination demonstrated a well-differentiated kerati-
nizing SCC of penis with positive margins of resection
(pT4/G1-2).
An abdominopelvic revaluation MRI after the surgical
procedure indicated a local residual disease of about
52 mm  38 mm and bilateral enlarged inguinal and
external iliac lymphadenomegaly. Bilateral inguinal and
pelvic lymphadenectomy had been planned as a
secondary procedure but after the first surgery the
patient refused any additional surgical treatment.
Based on the above information, the patient was
treated with a TIP regimen. After the first three cycles,
a follow-up thorax and abdomen CT scan indicated
significant shrinkage of the known perineal mass. The
patients received two additional cycles and success-
fully completed five cycles of TIP. Thorax and abdo-
men CT scan done 3 months after the last cycle
showed complete resolution of lymphadenomegaly. A
follow-up FDG PET/CT scan performed 1 year later the
surgery indicated no uptake. The patient remained dis-
ease-free at 18-month follow-up. The clinical course
was excellent and it was characterized by complete
regression of pain. He undergoes a monthly change of
the suprapubic cystostomy.
Discussion
Penile SCC is a rare malignancy. The usual presenta-
tion of penile cancer ranges from a small excrescence
or induration of any part of the penis to a large exo-
phytic lesion. It may be also identified as an extended
penile ulceration or a superficial erosion. Urethral stric-
ture and scrotal abscess are very uncommon presenta-
tions of penile SCC. Very few cases about patients
with urethral stricture that in a few months turned out
to be a penile SCC are reported.
Kathpalia et al. [7] described a case of a 76-year-old
man diagnosed with bulbar urethral stricture and
managed with urethral dilation. Four months later the
patient noticed an ulcerative lesion on over the glans
and its histological analysis revealed an SCC. A partial
penectomy was performed.
Two months later, the patient developed obstruct-
ive symptoms due to a peno-bulbar urethra mass, so
he underwent a wide excision of the mass with per-
manent perineal urethrostomy. The histopathological
examination confirmed an SCC. The authors concluded
that the urethral lesion is more likely to be a metasta-
sis from penile cancer.
Malik et al. [8] also reported a case of 55-year-old
man presented with a fungating growth on the shaft
of his penis which caused obstructive symptoms and
ultimately retention of urine. He was treated as a case
of urethral stricture, but the histological analysis of the
lesion revealed a penile SCC so a total penectomy
was performed.
Kotb et al. [9] described a case of a 55-year-old
man with a 5-year history of pluri-treated urethral
stricture presented with obstructive symptoms, scrotal
swelling and a penile lesion suspicious for malignancy.

The pathological analysis confirmed a penile SCC and
a total of penectomy and partial scrotectomy was car-
ried out.
The histopathological type of our patient’s penile
cancer was SCC with T4 as staging result.
This condition is commonly found in patients with
penile SCC, as also found in the research by Lynch
and Krush [10], which reported 15–50% patients
delayed up to 1 year before they finally received
the treatment.
The delayed diagnosis of penile SCC in our patient
and in these reports highlights the importance of
including malignancy in the differential diagnosis of
urethral stricture and scrotal abscess.
The goal of the treatment of penile cancer is com-
plete tumor removal with as much organ preservation
as possible, without compromising oncological con-
trol [11].
Aside from treating the primary tumor, the involve-
ment of lymph nodes is also an important prognosis
factor. Penile cancer in late stages accompanied by
the involvement of regional lymph nodes or distant
metastases is still considered as a challenging problem
for uro-oncologists. When metastases on regional
lymph nodes occur, administration of chemotherapy
combined with aggressive surgical management might
be effective, even though the recurrence rate and pro-
gressivity are still high [12].
In our case, according to the staging result, a multi-
modality approach combining aggressive surgery and
chemotherapy was recommended.
Most of the data related to chemotherapy for penile
cancer have been generated in the neoadjuvant setting
in attempt to downstage extensive regional disease.
Leijte et al. [13] evaluated five different chemother-
apeutic regimens, including bleomycin–methotrexate–-
cisplatin (BMP) and Fisplatin-5-FU (adopted from SCC
of the head and neck). Response rates were 33–63%;
however, Bleomycin-containing regimens were associ-
ated with severe toxicity and a high rate of treatment-
related deaths. Importantly, the authors found that
patients showing clinical response to chemotherapy
could benefit the most from surgery with a chance for
cure. More recently, the activity of Taxanes combining
with cisplatin has been evaluated with promis-
ing results.
Combination chemotherapy using paclitaxel has
been administered to treat penile SCC since early
2000. Bermejo et al. described a series of 10 patients
diagnosed with advanced penile SCC and treated
with a combination of Paclitaxel as neoadjuvant
chemotherapy before surgical consolidation. After
THE AGING MALE 3
chemotherapy four patients had a complete response,
one had a partial response and five had stable disease.
For all patients, the 5-year actuarial survival rate was
40% with a median survival of 26 months [14]. This
regimen has been also evaluated by Pagliaro et al. A
series of 30 regionally advanced patients (stage N2 or
N3) treated with neoadjuvant chemotherapy were
reported. TIP resulted in an objective response rate of
50% and 73.3% of patient underwent surgery. 30.0%
of patients remained alive and free of recurrence in a
median follow-up of 0.34 months. This represents a
significant improvement over historic controls of the
disease and suggests that TIP induced clinically mean-
ingful responses in patients with bulky regional lymph
node metastases [15]. Joerger et al. [16] reported sig-
nificant remission in a 62-year-old patient with
advanced disease after three cycles of Paclitaxel/
Carboplatin.
Sitompul et al. described a series of 17 patients diag-
nosed with penile SCC and lymphonodal involvement
who received the TIP regimen as neoadiuvant chemo-
therapy. Ten of them received the complete regimen
but complete response was not noted (six of them had
a partial response, three with a stable disease and one
with a progression of malignancy). Subgroup analysis
of patients who were responsive and unresponsive to
chemotherapy showed a statistically significantly higher
overall survival in patients who were responsive to
chemotherapy. The administration of paclitaxel, ifosfa-
mide, and cisplatin-based chemotherapy showed an
improvement in overall survival [17].
According to our results, we could state that we
have achieved an effective control of the disease for 18-
month follow-up with complete remission of the cancer,
although the regional lymph nodes were involved.
Conclusion
Penile SCC is a rare malignancy. In patients presenting
with persistent genital or urethral symptoms, we rec-
ommend including scrotal SCC in the differential diag-
nosis. Throughout the diagnostic process, a biopsy
could be suggested. A multimodal approach to treat-
ment is desirable for patients presenting with bulky
unresectable disease. The administration of TIP regi-
men combined with surgery is a valuable treatment
option for patient with advanced disease and com-
plete remission could be feasible.
Disclosure statement
No potential conflict of interest was reported by the authors.
4 A. F. DE ROSE ET AL.
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