Carcinoma presenting as urethrocutaneous fistula: BMJ case r
A 65-year-old man was referred with non-healing wound in the perineum and passage of urine from wound for last 3 months. He initially presented with voiding lower urinary tract symptoms (LUTS) and perineoscrotal swelling to a local practitioner 3 months ago. The discharge card given to the patient mentioned that he underwent incision and drainage of the swelling under anaesthesia with suprapubic catheter placement.

He also revealed history of two sessions of endoscopic dilatation performed 1 year ago. On local examination, there was normal external urethral meatus, presence of partially healed wound in the hemiscrotum with a hard indurated round partially healed wound at penoscrotal junction. The inguinal lymph nodes were palpable and enlarged. History including local trauma, sexually transmitted diseases were unremarkable. His routine blood/urine examination was unremarkable.

Further evaluation with retrograde urethrogram/micturating cystourethrogram showed evidence of urethrocutaneous fistula in the region of penobulbar urethra (figure 2). After proper counselling and consent, patient underwent biopsy of wound under anaesthesia. The histopathology was suggestive of squamous cell carcinoma (SCC) of male urethra.

The patient further underwent MRI of the pelvis which revealed tumour arising from bulbar urethra and invading corpus spongiosum. The patient was advised en bloc resection which he refused. The patient then received combination of chemoradiotherapy in radiation oncology.

Learning points
• Primary urethral carcinomas of male urethra is very rare.

• In men, it mostly presents with obstructive/irritative lower urinary tract symptoms or haematuria.

• In locally advanced squamous cell carcinoma of urethra, combination of chemoradiotherapy offers an effective alternative and improves survival compared with surgery alone.

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