A 63 year-old man presented for a milky penile discharge. He was hemodialysis dependent and recently discharged from the hospital following bilateral renal embolization for persistence of blood clots in his bladder and incontinence. He also had a history of radiation cystitis after salvage therapy following prostatectomy. He was not sexually active and had not been for several years prior to presentation. He was afebrile and had a milky white discharge at his penile orifice. A Crede maneuver did not yield urethral discharge. CBC showed leukocytosis (16.5) with a neutrophil predominance. Swab culture of the penile discharge yielded many epithelial cells and grew Klebsiella oxytoca and Enteroccoccus species. Abdominal CT of the abdomen showed persistent bladder wall thickening with increased density material in the bladder lumen.
Penile discharge is a problem commonly encountered by the Hospitalist. The overwhelming majority of times, the problem is infectious urethritis due to a sexually transmitted infection, specifically due to one or both N. gonorrhoeae and C. trachomatis. A methodical approach to penile discharge is necessary in order to diagnose less common causes of the problem. The most common cause of penile discharge is going to be infectious urethritis with the above organisms, but it is also worth considering Mycoplasma genitalium, Trichomonas vaginalis, Treponema pallidum, Neisseria meningitidis, Ureaplasma species, herpes simplex virus, and adenovirus. If infectious urethritis is unlikely, evaluating for epididymitis, prostatits, and cystitis is warranted. These conditions frequently coexist with infectious urethritis but can also exist in isolation. Noninfectious conditions are also a consideration if infectious etiologies have been ruled out and the history supports irritation of the urethra that would precipitate inflammation in the urethra.
In our patient, his history led to cystitis as the cause of his penile discharge and was confirmed by cross sectional imaging. Pyocystitis, also called vesical empyema, is an infection of the bladder that is a common, under recognized complication in anuric end stage renal disease patients. The diagnosis often requires a high index of suspicion because pyocystitis can often present without fever, leukocytosis, or typical symptomatology as was the case for our patient. It is also often made more difficult by the inability to obtain a urine sample for analysis due to anuria. The physiology behind the development of bladder complications in anuric patients is likely due to inadequate washout of the urinary bladder. Other risk factors include patients with a suprapubic catheter, worsening uremia, urinary diversion surgery without cystectomy, and causes of visceral neuropathy, such as long standing diabetes mellitus.
Pyocystitis and other lower genitourinary tract bacterial infections can be a cause of penile discharge that needs to be considered in the right clinical setting. As the incidence of ESRD patients on dialysis continues to increase, the number of patients with anuria continues to increase. The Hospitalist should keep a high index of suspicion for pyocystitis in anuric patients to avoid a delay in recognition of the disease, in order to prevent major complications.
1) Recognize the clinical presentation of lower genitourinary tract bacterial infections in anuric patients.
2) Identify the differential diagnosis of penile discharge
To cite this abstract:Smith MP, Wunschel J. Penile Discharge: Not Just for the Young and Sexually Active. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 885. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/penile-discharge-not-just-for-the-young-and-sexually-active/. Accessed November 18, 2019.