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• September 2007
• April 2007
• February 2007
• November 2006
• September 2006
• May 2006
• March 2006
• January 2006
• December 2005

The case of the month

February 2007 case of the month

A 26-year-old man presents to the emergency room with a complaint of penile pain, difficulty in urination and high temperature (38.3º). He has history of penile dysmorphophobia and physical examination revealed his penis to be swallowed, with penile skin irregularity, multiple hard subcutaneal conglomerates, areas of discoloration, and purulent secretion from the subcoronal area on the dorsal surface of the penile shaft.
(Case provided by Dr Juza Chen, Tel Aviv, Israel, chenv@bezeqint.net)

Question 1
What will be your working diagnosis?

1. Infection after intracavernosal injection: 11%
2. Infection after penile augmentation: 34%
3. Infection after penile bite: 23%
4. Infected oil granulomas (Paraffinoma): 28%
5. Subcutaneal fungal infection: 4%

Comments:

Penile paraffinoma is the result of subcutaneal injection of mineral-oil for the purpose of penile enlargement. It may occur months or many years following the injection of the oil, and is characterized with single or multiple irregular masses with painful or painless ulcer, skin indurations and penile edema. Usually patients are febrile but in acute fazes some patients may suffer from high temperature and have problems in sexual function. Most patients have a history of penile dysmorphophobia and some of them have problems in urination.

Infection after penile augmentation usually occurs close to the operation, associated with significant local pain, fluctuation and purulent discharges from the operation scar.

Infection after penile bite is a localized infection associated with limited penile edema, pain and high temperature.

Question 2
How do you treat this patient?

1. Treat with antibiotics and derange: 28%
2. Treat with antibiotics followed excision of all infected granulomas: 30%
3. Treat with antibiotics followed wide excision of all involved skin and skin graft: 13%
4. Treat with antibiotics followed wide excision and delayed skin graft: 9%
5. Perform two stage operation: wide excision of all involved skin and skin graft: 20%

Comments:

The treatment of choice for paraffinoma is aggressive excision of all effected areas and of the scrotal skin flap or skin mesh graft in one stage. Pre and post operative antibiotic therapy is essential. Once a patient is treated with the appropriate antibacterial therapy and all effected areas are excised, the chances of infection are insignificant.

A two-stage operation and or delay grafting is not recommended by most authors.

Treatment with antibiotics and drainage is not sufficient.

Treatment with antibiotics following the excision of all granulomas is related with significant morbidity.