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Mpox (monkeypox) causing penile lesions and acute urinary retention
  1. Natalia Hackett,
  2. Prabhat Narayan and
  3. Simon Huf
  1. Royal Berkshire NHS Foundation Trust, Reading, UK
  1. Correspondence to Dr Natalia Hackett; natalia.hackett{at}


This is the first ever reported case of mpox (monkeypox) causing penile lesions and acute urinary retention (AUR) in a homosexual man, who had intercourse with his confirmed positive mpox (monkeypox) partner. The patient did not have any significant comorbidities and was managed conservatively with an urgent urethral catheter and co-amoxiclav as per the microbiologist’s advice to cover for his skin soft tissue infection (SSI). His blood parameters, urine and blood cultures were all normal. He was successfully trialled without a catheter (TWOCd) in a few days and was discharged home with an outpatient follow-up plan in Andrology Clinic with a flow rate, postvoid residual (PVR), International Prostate Symptoms Score (IPSS) and pain score. He was also planned to be contacted by the sexual health team to ensure a holistic follow-up.

  • Public health
  • Sexual health
  • Catheterisation / catheter care
  • Urinary and genital tract disorders
  • Global Health

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Amidst the current pandemic, the WHO declared another Global Health emergency in July 2022 following an mpox (monkeypox) outbreak which resulted in 16 000 cases across 75 countries and included five deaths.1 The spread of mpox (monkeypox) occurs when a person comes into close contact with an infected animal, rodents in particular, human, or materials contaminated with the virus which enters the body through broken skin, the respiratory tract, or the mucous membranes. By the end of May 2022 there were 320 reported confirmed cases of mpox (monkeypox). Of these 99% were male, and 99% of cases who completed more detailed questionnaires by the UK Health Security Agency identified as gay, bisexual and other men who have sex with men (MSM), or reported same sex contact.2 In this case we describe a patient with mpox (monkeypox) who was admitted with AUR as the chief complaint and was managed conservatively.

Case presentation

A usually fit and well man in his 20s was travelling to the UK, when he initially presented to a UK sexual health clinic 3 days postunprotected oral and anal intercourse with a Caucasian man from the UK. He presented with a 1 day history of pustular penile discharge, penile pain, and white pustular lesions under the foreskin and on the shaft of the penis. This patient’s sexual contact was confirmed mpox (monkeypox) positive. Two days prior to admission (day 7 postexposure) he developed severe influenza-like symptoms and multiple penile (figure 1) and anal lesions (figure 2) developed overnight with associated proctitis and purulent anal discharge.

Figure 1

Penis with early penile lesions.

Admission was prompted by severe penile swelling, unretractable foreskin and secondary urinary retention. The original white spots were now black and had spread to elsewhere on his body, such as the arms, face, back, feet and shoulders. Mpox (monkeypox) swabs were sent for testing at the Public health england rare and imported pathogen laboratory. A digital rectal exam was performed but assessment of the entire gland was not possible due to pain secondary to proctitis and perianal lesions. The patient was catheterised to relieve his symptoms; 250 mL of clear urine was passed. He was isolated and managed in a side room. On examination he had several well circumscribed umbilicated lesions on the penile shaft and scrotum with diffuse penile oedema without any signs of necrosis. There were also several pustular lesions over the face, back, legs and perianal region.


The vitals were stable and the patient was afebrile throughout admission. Full blood count, blood urea and electrolytes were both within normal range. C-reactive protein (CRP) was mildly raised to 55.

Syphilis negative—HIV negative

Mpox (monkeypox) positive—Gonorrhoea and Chlamydia negative

Herpes simplex virus 1 and 2 negative—Urine culture negative


Prior to admission, 5 days postexposure he presented to a sexual health clinic and received the smallpox vaccine, intramuscular ceftriaxone 1 g and was given 100 mg doxycycline orally for sexually transmittted infection (STI) cover. This was stopped when he was admitted to hospital 9 days postexposure. He was catheterised with a simple two-way catheter (figure 3). A suprapubic catheter was not used as it would have been more invasive and pustular discharge per urethra is not a contraindication for urethral catheterisation. He was given co-amoxiclav as per microbiology advice to cover for SSI. He was also given tamsulosin until he was TWOCd to ensure success as a full prostate assessment had not been possible. Regular non-steroidal anti-inflammatory drugs (NSAIDs) were used which helped him with his pain and inflammation. Lignocaine jelly was used for painful scabs around the anus to very good effect.

Figure 3

Penis with late crusted penile lesions and catheter in situ.

Outcome and follow-up

He was successfully TWOCd alongside tamsulosin 2 days after catheter insertion. The patient became comfortable, his penile swelling reduced 3 days after admission and he was deemed medically fit for discharge. On discharge, follow-up was arranged with the local sexual health clinic to review swab results. We intend to carry out flow rate, PVR, IPSS and pain scores in 4–6 weeks time.


This case is unique as it is the first ever presentation of an mpox (monkeypox) subject with typical genital skin lesions who also had AUR. This is intriguing for any urological service around the globe. Penile lesions have been reported previously and conservative management has been the mainstay of treatment. But AUR prompted the patient to be referred to Urology, which was managed with a temporary catheter.

A case series from Italy describes four patients with mpox (monkeypox), all young adult MSM, with symptoms and clinical features similar to our patient. In keeping with other reported cases in Europe, they also had mpox (monkeypox) positive seminal fluid. However, researchers have determined close contact during sexual intercourse to be most vital for transmission, declaring mpox (monkeypox) as not primarily a sexually transmitted disease.3 3

The incubation period for mpox (monkeypox) is between 5 days and 21 days. Mpox (monkeypox) infection is usually a self-limiting illness, and most people recover within several weeks. However, severe illness can occur in individuals. The course of the illness typically begins with systemic influenza-like symptoms, followed by a facial rash within 1 day to 5 days which spreads to other parts of the body. An individual is contagious until all the scabs have fallen off and there is intact skin underneath.

Mpox (monkeypox) definitive diagnosis requires lab testing using a PCR test on a viral swab taken from one or more vesicles or ulcers. Treatment is supportive. The smallpox vaccine can be used to control outbreaks and be used as pre-exposure and postexposure prophylaxis.

Learning points

  • Mpox (monkeypox) cases need a focused sexual history with a precise timeline. The skin lesions are self-limiting and can be managed conservatively under any medical team (does not necessitate a urology service) or even at home if the patient is not too unwell.

  • If there is any suspicion of gangrene/fasciitis around the urogenital region, appropriate specialities should be included urgently.

  • UK health security has released a case definition of possible and probable mpox (monkeypox) infection—they clearly illustrate the signs and symptoms and classify them in to possible and probable case groups.4

Ethics statements

Patient consent for publication


The authors thank Dr Jessica Daniel from Great Western Hospital Sexual Health Department for her contribution including preliminary testing and diagnosis.



  • NH and PN are joint first authors.

  • Twitter @nataliahackett, @Prabhat30181608

  • Contributors NH conceived of the presented idea, wrote the initial manuscript and made the editorial suggested edits with support from PN who re-formatted, added updated data and contributed urological expertise. SH helped supervise the project.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.