Case of the Month

September 2010

A 34 year old man presented to Alexandra Men’s clinic, Gauteng with a ‘Water Can’ penis. He had a 3 year history of genital ulceration and purulent discharge per urethra, with multiple discharge sinuses around the shaft of the penis. His past medical history included confirmed pulmonary TB 2 years previously, treated for 6 months with regimen 1. On clinical examination inguinal glands and testes were normal, there was no urethral discharge, but he had multiple sinuses on the glans penis.

The case was thoroughly investigated to rule out STIs such as syphilis, chancroid and Donovanosis. M-PCR was done from the genital swab taken and all organisms (HSV, Haemophilus ducreyi and Treponema pallidum) were negative including LGV. Serological tests for HSV-2 serology were positive, as was Chlamydia pneumoniae IgG at a titre of 1:128. Syphilis serology was negative. All urethral discharge STI pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium) were negative except Trichomonas Vaginalis. He was treated with metronidazole 400mg bd and acyclovir 400mg tds for 7 days. Chlamydia pneumoniae titre may indicate previous exposure and was not treated.

At the time of presentation, sputum from the patient was smear-positive for acid-fast bacilli and despite regimen 2 TB treatment, he remained smear-positive after 2 months.

M. tuberculosis resistance testing was not performed. He developed persistent cough and marked weight loss. He eventually agreed to undergo HIV counselling and testing (HCT) and was found to be HIV-infected with a CD4 count of 181 cells/mL. Early initiation of ARV therapy was recommended and the patient referred to start ART.

Question 1: What is the causative organism of “Water Can” penis? Discuss the other clinical manifestations of the urogenital tract that this organism can produce and its pathogenesis.

Answer to Q1

‘Water can’ penis is a very rare manifestation of urethral tuberculosis with associated peri-urethral fistulae. It was first described by Karithikeyan and colleagues in 20041. Depigmentation of the glans penis may occur to give a ‘vitilgo-like’ appearance and painless, increased frequency may occur. Although genital involvement occurs in ~50% of male urogenital tuberculosis, penile involvement is rare, occuring in < 1% of all cases2.

More common manifestations of penile/urethral tuberculosis include:

  • Superficial solitary, painless ulcer of the glans penis3
  • Solid nodule4
  • Cavernositis with ulceration5
  • Papulonecrotic tuberculide; a papular skin eruption secondary to an immunological reaction to M. tuberculosis antigen, which may ulcerate6
  • Peri-urethral abscesses and strictures7
  • Fistulae involving the perineum may result in ‘Water Can perineum’

Urogenital tuberculosis may result from infection with M. tuberculosis via the following routes:

  • Haematogenous dissemination
  • Secondary to transmission from urinary tract tuberculosis via bacilluria Direct contact at the time of intercourse with a partner with urogenital tuberculosis. The bacilli are inoculated into abrasions. The normal mucosa is resistant to tuberculosis. Sometimes, a penile lesion maybe caused by re-inoculation of the male partner through his own infected ejaculate. Primary tuberculosis as a complication of ritual circumcision during which the operator with pulmonary tuberculosis sucks the circumcised penis. Sucking was employed as a haemostatic and styptic measure but after the turn of the century this act was practically eliminated from the ritual, resulting in a decreased incidence of penile tuberculosis.

The commonest manifestation of urogenital tuberculosis is renal involvement9,10(~60%), followed by ureteric, prostate, epididymis and bladder involvement. Obstruction of the ureteric system with stricture formation may lead to hydronephrosis and renal failure11. Less commonly, kidney destruction may be secondary to an enlarging focal lesion. Kidney and prostate tuberculous abscesses have been reported at increased frequency in AIDS patients12,13

Question 2: What is the main differential diagnosis in this case?

Answer to Q2

Water Can penis itself, is virtually pathognomonic of urethral tuberculosis complicated by urethral fistulae. It has not been reported secondary to other sexually transmitted infections to date. Neisseria gonorrhoeae has been reported as a cause of water can perineum8, but not water can penis.

Penile ulceration is commonly caused by:

  • Syphilis
  • Chancroid
  • Herpes simplex virus

Less common causes of penile ulceration include:

  • Penile cancer - hence any genital ulcer that does not respond to syndromic treatment should be biopsied for histological examination.
  • Non-tuberculous mycobacteria that may cause genital ulceration or nodules include:
    • M. avium-intrcellulare15
    • M.celatum15
  • Primary cases may occur as a complication of ritual circumcision

Question 3: How should this man be treated?

Answer to Q3

Urogenital tuberculosis should be treated with a minimum of 6 months anti-tuberculous therapy. There is no clear evidence to suggest higher relapse rates occur with short course therapy, but longer duration of treatment up to 12 months has been advocated for complicated urogenital tuberculosis14. As this was the patient’s second episode of tuberculosis, he would have been started on rifafour (rifampicin, isoniazid, pyrazinamide and ethambutol) for the first 3 months, plus 40 doses of streptomycin, pending the result of M. tuberculosis culture and sensitivity or HAIN test profile of the positive sputum sample. If sensitive to rifampicin and isoniazid, continuation phase treatment with 5 months of rifampicin, isoniazid and ethambutol should follow. The fact that his sputum smear was still positive at 2 months is cause for concern and a HAIN test should be performed if available to determine rifampicin and isoniazid sensitivity, if not done on the original sputum sample. The fact that he continued to clinically deteriorate on anti-tuberculous therapy may be due either to one or a combination of the following:

  • M. tuberculosis resistance to rifampicin, isoniazid, ethambutol or streptomycin
  • Non-compliance with anti-tuberculous therapy
  • Malabsorption of drugs
  • Comorbid opportunistic infections


  1. Karthikeyan K, Thappa DM, Shivaswamy. “Water can” penis caused by tubercuosis. Sex Transm Infect 2004; 80:75
  2. Elkin M. Urogenital tubercuolosis in atlas and textbook of urological imaging. 1990: 1030-52
  3. Venkataramaiah NR, van Roolte JA, Dutta SN. Tuberculosis ulcer of penis. Postgrad Med J 1982, 58: 59-60
  4. Baskin, L.S. and Mee, S.: Tuberculosis of the penis presenting as a subcutaneous nodule; J. Urol.; 1989, 141, 143
  5. Ramesh V, Vasanthi R. Tuberculous cavernositis of the penis. Genitourin Med 1989: 65:58-9
  6. Vijaikumar M, Thappa DM, Kaviarasan PK. Papulonecrotic tuberculid of the gland penis. Sex Transm Infect 2001; 77: 47
  7. Symes JM. Blandy JP. Tuberculosis of male urethra. Br J Urol 1973; 45:432-6
  8. Osoba AO, Alausa O. Gonococcal urethral stricture and watering-can perineum. Br J Vener Dis 1976; 52: 387-93
  9. Christensen WI. Genitourinary tuberculosis. Review of 102 cases. Medicine (Baltimore). 1974; 53: 377-90
  10. Garcia-Rodriguez JA, Carcia Sanchez JE, Munoz Belido JI. Genitourinary tuberculosis in Spain: review of 81 cases. Clin Infect Dis. 1994; 18: 557-61
  11. Figueiredo AA, Lucon AM. Urogenital Tuberculosis: Update and review of 8961 cases from the world literature. Reviews in Urology 2008; 10(3): 207-17
  12. Trauzzi SH, Kay CJ, Kaufman DG, Lowe FC. Management of prostatic abscess in paitents with human immunodeficiency syndrome. Urology 1994; 43: 629-33
  13. Marques LP, Rioja LS, Oliveira CA, Santo OD. AIDS-associated renal tuberculosis. Nephron 1996; 74: 701-4
  14. Cek M, Lenk S, Kurt G et al. EAU guidelines for the management of genitourinary tuberculosis. Eur Urology 2005; 40: 353-62.
  15. Dilip Kumar Pal, Anup Kumar Kundu, Subrata Chakraborty, Shlkha Das. Tuberculosis of penis. Report of two cases. Ind. J.Tub, 1996, 43: 203
Outcome of the case

The patient was transferred to Sizwe Fever Hospital, a specialist tuberculosis centre where despite attempts to treat his tuberculosis and convince him to start ART, he died without antiretroviral therapy.

Lesson learnt

The differential diagnosis of a chronic penile ulcer with histological features of granulomas is extensive. Consideration needs to be given to bacterial and fungal infections and parasitic infections. Because there is paucity of organisms present in most forms of cutaneous tuberculosis, results of both staining and culture are usually negative. To overcome this problem, PCR should be used to detect M. tuberculosis DNA in cutaneous lesions or in urine. It is also important to screen sex partners in high-risk groups for diseases that are not traditionally transmitted sexually.

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