Case Presentation

Age: 55 years Sex: Male Address: Chipalli, East Godavari district Marital status : married Occupation: Driver Socioeconomic status: Upper lower

Socioeconomic class (IV) [Modified Kuppuswamy]

Religion: Hindu

Personal information

Ulcer on Penis since 1 year. Bilateral Swelling and pain in groin region

since 8 months Enlargement of scrotum since 6 months.

Chief complaint (c/o) :-

Patient was apparently normal 1 year ago when he developed ulcer on Penis.

H/o on & off fever present. No H/o Trauma. No H/o discharge. No H/o associated diseases. Later he developed B/L swellings in groin

associated with pain 8 months ago.

History of present illness:-

The pain originated in groin. Insidious in origin, continuous, non

progressive and moderate severity. the patient was unable to describe the

nature of pain, relieved on self-medication. swelling was noticed due to pain. No aggravating factors, periodicity, special

times of occurrence and associated symptoms.

I&D by local surgeon. swellings recurred.

2 swellings –B/L and inguinal. recurred swellings associated with similar pain & scrotal enlargement. They were ulcerated in the due course.

No H/o other lumps, weight loss. No H/o sudden increase in size of swellings

2 ulcers developed over swellings 5 months ago in addition to previous ulcer on Penis.

No H/o Trauma. Ulcers associated with similar pain and foul smelling, Greenish, discharge.

No H/o associated diseases.

No similar complaints in the past. No H/o T.B., Filariasis, STDs. No H/o any surgeries in the past. No H/o

Circumcision. No H/o Phimosis ,balanoposthitis.

History of Past illness

Married mixed diet non-smoker and non-alcoholic. Chews

Tobacco. Bladder and bowel habits are normal. Sleep

pattern and appetite are normal. No weight loss.

No H/o D.M.,HTN,CVD. H/o multiple sexual partners & unsafe sex

present.

Personal History

No relevant drug history No similar complaints in family No H/o allergies.

Conscious, coherent and well oriented with time and place.

Moderately built and mild pallor is present Right pedal oedema of pitting type is present. B/L Inguinal Lymphadenopathy is present.

No Lymphadenopathy in other regions

General physical examination

No Icterus ,Koilonychia No evidence of Syphilitic stigmas. No palpable Parotid & Lacrimal glands

Pulse : 78 beats/min , with regular rhythm, normal flow. Arterial wall just palpable, no Radio-radial & Radio-femoral delay.

B.P: 120/80 mm of Hg at right Brachial artery in supine position.

Temperature: 99*F Respiration : 18 breaths/min, abdomino-thoracic type

Vital data

INSPECTION : One ulcer on Penis. oval in shape and approximately 2-3cm*1

cm in size rolled out edge and floor is sloughy. Discharge Green and the surrounding area

Red and oedematous.

Local examination

2 swellings B/L in groin. Red colour, oval shape. 7-8 cm horizontally

and 3-4 cm vertically with clearly defined edges.

Skin over the swollen lymph nodes is oedematous, reddish and ulcerated.

Ulcers-2, B/L, Oval in shape, 5-7*2-3cm in size, 1 on each swelling, Rolled out edges, sloughy floors, Purulent, Foul smelling, Greenish discharge, Surrounding areas red & oedematous.

Oedema and thickening of scrotal skin . Scrotal rugae absent. Scrotum swollen, extends up to 2/3rds of

thigh.

PALPATION : Ulcer is tender. Edge rolled out, indurated. Base markedly indurated. No bleeding on touch.

Local rise of temperature on all swellings. swellings tender and oval in shape. Swelling on right groin 7.5*4 cm*1mm , left

groin is 8*5cm*2mm. swellings have nodular surface, well-

defined edges, indistinct margins and stony hard consistency and ulcerated.

negative for fluctuation, reducibility, fluid thrill, compressibility and pulsatility.

negative for translucency and impulse on coughing.

Not fixed to surrounding structures Pitting right pedal oedema and thickened

scrotal skin Epididymis and Spermatic cord normal Testis not palpable Translucency of scrotum negative

Non-metastatic Jacksonian stage III, TNM stage T4 N2 M0 primary ulcerative carcinoma of penis(suspected to be of Squamous cell origin)complicated with secondary infection and scrotal elephantiasis.

PROVISIONAL DIAGNOSIS

Lymphogranuloma Venerum. Filariasis Tuberculosis Syphilis Chromoblastomycosis Co-existing Lymphogranuloma Venerum and

HPV infection leading to carcinoma penis complicated by secondary infection(suspected to be by Pseudomonas sp) and scrotal elephantiasis.

DIFFERENTIAL DIAGNOSIS

GENERAL INVESTIGATIONS The general investigations to help in planning therapy.

BIOCHEMISTRY : Random blood sugar(RBS),blood urea, Creatinine,

Sodium and Potassium levels normal.PATHOLOGY : Bleeding time(B.T) and Clotting time(C.T) normal. Haemoglobin concentration low(6.3 g/dl)-Anaemia. Total Leucocyte count(T.L.C) elevated (19,200

cells/cu.mm) - immune response to secondary infection and malignancy.

Blood group-B +.

Investigations

SPECIAL INVESTIGATIONS :PATHOLOGY The investigation of choice in a suspected

case of Penile carcinoma is Histopathological examination of edge biopsy specimen of ulcer.

RESULT :Well differentiated squamous cell carcinoma

RADIOLOGY : The other investigation is ultrasonography. This is done to assess the condition of Testis

and to confirm Scrotal elephantiasis.

RESULT : Normal Testis with bilateral Hydrocele and

thickened scrotal skin(Scrotal Elephantiasis).

MICROBIOLOGY The discharge from ulcer was sent to

Culture and sensitivity test.

Tests for Syphilis, Hepatitis and H.I.V were negative.

RESULT : secondary infection organism- Pseudomonas sp. sensitive to

1. Amikacin2. Piperacillin3. Gentamycin4. Imipinem5. Levofloxacin6. Tobramycin7. Azetreonam8. Mefzocillin

Advanced well differentiated non-metastatic Jacksonian stage III, TNM stage T4 N2 M0 ulcerative primary Squamous cell carcinoma of Penis complicated with secondary Pseudomonas infection and scrotal elephantiasis.

CLINICAL DIAGNOSIS

MANAGEMENT OF PRIMARY TUMOUR : As tumour involves entire shaft of the penis,

total penectomy must be done with perineal urethrostomy.

COMPLICATIONS : Scrotal Ammonical dermatitis. Stricture at urethrostomy site. Ammonical dermatitis can be prevented by

asking the patient to urinate in sitting position.

Management

Alternatively Total scrotectomy with orchidectomy can be done along with total amputation of penis (Sir Piersey Gold operation).

This procedure also reduces sexual desire.

MANAGEMENT OF SWOLLEN LYMPH NODES : Swelling of lymph nodes due to secondary

carcinomatous deposits . However as the tumour is of T4 stage prophylactic

inguinal block dissection can be done.COMPLICATIONS : Flap necrosis is the most common complication.

Other complications are :1. Haemorrhage2. Lymphorrhea3. Lymphoedema4. Infection.

THANKS TODr.Swaroop sir

ANDDr.DILIP sir

Of Department of SurgeryAnd to

My friends

THANKYOU