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Penoscrotal oedema is an extremely rare presentation of metastatic urothelial bladder cancer.1 The limited number of published cases refer to patients with a history of transitional bladder cancer or cutaneous metastases.1 2 To our knowledge, this is the first reported case of urothelial bladder cancer with penoscrotal oedema as the first sign due to compressive adenopathies. Bladder cancer is the seventh most commonly diagnosed cancer among men and it is related to tobacco use.3 When interviewing a patient with this genital presentation, the urological malignancies, such as bladder or prostate cancer, should be excluded.4
We report a case of a man in his early 60s who presented to the emergency department with 2 weeks of progressive penoscrotal oedema. He denied genital trauma or prolonged erection. He smoked 20 cigarettes a day.
On physical examination, oedema of the penoscrotal area and cutaneous fibroma were seen. Enlarged bilateral inguinal adenopathies were palpable.
He was investigated with contrast-enhanced thorax, abdomen and pelvis CT scan. The CT scan showed multiple retroperitoneal, axillary, pelvic, inguinal and iliac adenopathies (figure 1, arrow). An infiltrative vesical mass (figure 1, arrowhead) obstructing the left ureter caused marked dilation and chronic atrophy of the left kidney. Also, a defect of repletion in the left calyceal system suggested ureteral tumour dissemination. An omental cake, which is an extensive peritoneal dissemination with omental metastasis, and hepatic metastasis were described. Although the left kidney was atrophic, his blood analyses showed preserved renal function with creatinine 0.75 mg/dL.
Transurethral resection of the bladder tumour (TURBT) was debated in a tumour board. The TURBT is not a curable approach in a metastatic or unresectable stage. In order to obtain a pathology sample to confirm the diagnosis, we decided to perform an ultrasound-guided core needle biopsy of an inguinal adenopathy due to its availability and quick results. The sample was obtained in the pathologist’s office the same day with no admission.
Pathology reported a high-grade urothelial carcinoma. After multidisciplinary discussion, a palliative platinum-based chemotherapy of cisplatin and gemcitabine was started for metastatic urothelial carcinoma. At 6 months, ureteral disease progressed and the patient was accepted at a clinical trial (NCT03390504) with erdafitinib for FGFR mutated progression on platinum-based chemotherapy. The lymphadenopathies reduced its size in the 3-month review of the CT scan and the penoscrotal oedema showed partial improvement. The patient is alive after 12 months of follow-up.
Bladder cancer spreads first to perivesical nodes and then to the presacral nodes, followed by the internal iliac, obturator and external iliac nodes.5 The penis lymphatic drainage drains to superficial and then deep inguinal lymphatic nodes and later to the iliac nodes.6 So, neoplastic enlargement of the inguinal or iliac lymphatics can cause drainage obstruction that expresses as secondarily painless penoscrotal oedema. The idiopathic penoscrotal oedema can be also caused by an infectious genital disease, injury after trauma, lymphadenectomy, radiation or underlying malignancy.2 4 7
Translated to English from native language.
When I visited the emergency room twelve doctors came to see my problem and no one thought it would be this serious. I was suffering from internal pain and swelling of my genitals… I had to wait for a month to get the scan done and meanwhile the disease was spreading. I knew something was going on. The moment the scan was done, I received a call from the hospital and then they told me the diagnosis. It was shocking to hear that I had a spread disease. I was upset that none of the doctors that I visited thought that my inflammation could be something severe. I knew that the treatment was being delayed… Now I am alive and my cancer is regressing but this drug has severe effects on my eyes and nails, I cannot drive anymore. But it works well.
Penoscrotal oedema can be caused by malignant compression of inguinal nodes.
Persistent penoscrotal oedema should be studied with imaging techniques.
Bladder cancer is a very prevalent disease.
Patient consent for publication
Contributors MPM-F collected the data, edited the figures, drafted and revised the draft paper. IP-R drafted and revised the paper. PG-A revised the draft paper.
Funding This study was funded by Universidad Francisco de Vitoria (SF00525889).
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.