PART III - Carcinoma of the Penis

Clinical Scenario

Q.11 - Four Most Common Differential Diagnoses (4 marks)

1. Carcinoma of the penis (squamous cell carcinoma hidden under non-retractile prepuce) - most likely
2. Chronic balanoposthitis with reactive lymphadenopathy - infection under phimotic prepuce causing secondary lymph node enlargement
3. Lymphoma (primary or secondary involving inguinal nodes) - non-tender, hard fixed nodes
4. Metastatic carcinoma from another primary (e.g., lower limb skin malignancy, perineal/anal carcinoma) presenting with fixed inguinal nodes

Q.12 - How to Establish the Diagnosis (3 marks)

1. Dorsal slit or circumcision - to expose the glans penis and prepuce so the primary lesion can be visualized
2. Biopsy of the lesion - incisional or punch biopsy of any suspicious area on the glans/prepuce for histopathological confirmation (this is the definitive step)
3. Assessment of inguinal nodes - ultrasound-guided fine-needle aspiration cytology (FNAC) of the enlarged inguinal node to confirm nodal metastasis
   • Additional: MRI of the penis for local staging; CT chest/abdomen/pelvis for distant staging

Q.13 - Three Definitive Precancerous Conditions of Carcinoma Penis (3 marks)

1. Penile Intraepithelial Neoplasia (PeIN) - includes:
   • Erythroplasia of Queyrat (PeIN on the glans - presents as a velvety, red, well-demarcated plaque)
   • Bowen's disease (PeIN on the shaft - presents as red cutaneous patch)
2. Leukoplakia of the glans - similar to the condition seen on the tongue; white plaque on glans
3. Lichen Sclerosus (LS) / Balanitis Xerotica Obliterans (BXO) - causes progressive scarring and is a well-recognized precancerous condition

Q.14 - Treatment Modalities for Primary Lesion and How to Choose (4 marks)

Treatment Options:

How to Choose:

• Tumor stage (T stage): Tis/T1 - laser/Mohs/local excision; T2 glans - glansectomy; T2 shaft - partial penectomy; T3/T4 - total penectomy
• Tumor grade: High-grade tumors require wider excision margins
• Location: Glans-confined vs. shaft vs. urethral involvement
• Patient preference and functional/cosmetic outcome: Organ-preserving surgery (excision with conservative 1-2 mm margins rather than the old 2 cm rule) is now preferred when oncologically safe

Q.15 - Most Common Cause of Death in Carcinoma Penis (1 mark)

• Alternatively stated as: Uncontrolled locoregional disease with secondary infection and hemorrhage from eroded inguinal nodes
• Distant metastases are relatively infrequent in carcinoma penis; death is predominantly from regional node disease eroding major vessels

PART II - Epididymo-Orchitis

Clinical Scenario

Q.7 - Four Common Causes of Acute Scrotum (2 marks)

1. Testicular torsion (torsion of the spermatic cord)
2. Acute epididymo-orchitis (infective/inflammatory)
3. Torsion of the appendix testis (torsion of the hydatid of Morgagni)
4. Strangulated inguinal hernia / Incarcerated hernia presenting as acute scrotum

Q.8 - Clinical Differentiation of Causes of Acute Scrotum (4 marks)

Q.9 - Correlation of Perineal Trauma History with Current Problem (2 marks)

• However, investigation shows the urethra is normal in caliber and distensible, which excludes urethral stricture
• The difficulty in passing urine is therefore more likely due to bladder outflow obstruction from prostatitis or a urethral problem proximal to the bulb
• Alternatively, this combination correlates with secondary bacterial epididymo-orchitis due to high-pressure voiding from any degree of outflow obstruction: infected urine refluxes retrogradely through the ejaculatory ducts and vas deferens to seed the epididymis (the Corriere mechanism)
• The perineal trauma may also have led to a periurethral fibrosis causing obstruction with the current infective epididymo-orchitis being a downstream consequence

Q.10 - Further Investigations to Establish Diagnosis (3 marks)

1. Urine routine examination and culture/sensitivity - look for pyuria, bacteriuria, identify the causative organism
2. Urethral swab + NAAT (Nucleic Acid Amplification Test) - for Chlamydia trachomatis and Neisseria gonorrhoeae (sent on a urine specimen or urethral swab)
3. Scrotal Doppler ultrasound - to confirm epididymo-orchitis (increased vascularity), exclude testicular torsion and tumors, identify abscess formation
4. Additional (if TB suspected): Urine for AFB (3 early morning specimens), chest X-ray, USG of renal tract; Serum markers (if tumor suspected)

Q.11 - Treatment (2 marks)

• Antibiotics - empiric therapy based on likely organism:
  • In older men (>35 yrs): Quinolones (ciprofloxacin) or co-amoxiclav targeting Gram-negative organisms/coliforms, for 4-6 weeks
  • If STI suspected: Doxycycline 100 mg BD + Ceftriaxone (covering Chlamydia + gonorrhea)
• Anti-inflammatory agents (NSAIDs) for pain/swelling
• Scrotal support and elevation (Prehn's position) - relieves pain
• Rest and adequate hydration
• If abscess forms: Surgical drainage
• Treat any underlying cause (BPH, urethral pathology)

Q.12 - Four Complications of Epididymo-Orchitis (2 marks)

1. Epididymal/testicular abscess - pus collection requiring surgical drainage
2. Testicular atrophy - due to ischemia/infarction from pressure and vascular compromise
3. Infertility - due to obstruction of the vas/epididymis by fibrosis (especially bilateral disease), or testicular damage
4. Chronic epididymo-orchitis - persistent pain, thickening and induration of the epididymis