Tuberculosis is a bacterial infectious disease in Mycobacterium tuberculosis .Genitourinary tuberculosis (TB) is a common site for extra pulmonary tuberculosis. But tuberculosis of the penis is an extremely rare entity with few cases described in the literature.

A 43-year-old man presented with complaint of painless and nonhealing lesion over his genitalia for last 13 months. He had no history of any loss of weight in the recent past and He denied extramarital sexual contact or dysuria.

The patient had tried different treatment modalities without any response.

Dermatological examination of the penis found multiple ulcers, some of them confluent, with jagged edges and indurated base.

The rest of the clinical examination objectified bilateral, sensitive and mobile inguinal lymph nodes. Haematological and biochemical examination did not reveal any abnormality.

A Laboratory test for syphilis, serology for HIV and Viral Hepatitis B and C were negative. The histological examination of the ulceration revealed intense granulomatous infiltrate with Langhans giant cells and caseation necrosis, first evoking tuberculosis. Radiological investigations including X-ray chest and ultrasound of the abdomen, to find any collateral evidence of TB, were normal. The patient was treated with anti-bacillary drugs: rifampicin (R), isoniazid (H), pyrazynamide (Z) and ethambutol (E) during two months relayed by a dual therapy combining R and H during four months (Figure 1). The healing of genital ulcer was complete.

Figure 1: Multiple ulcers with well-defined irregular margins present all around the glans penis

TB of the genitourinary tract is the most common site for extra pulmonary disease [1]. But TB of the penis is extremely rare. Very few cases have been described worldwide with less than 1% of all genital TB cases reported [2].

It is classically contracted during a traditional circumcision. Sexual intercourse with a partner with genital or pulmonary tuberculosis has been recently described. Inoculation from contaminated clothing is rare.

The main differential diagnosis is penile carcinoma should be removed by histological examination.

The diagnosis of tuberculosis is based on a bundle of clinical, histological, bacteriological and immunological arguments [3,4]. Localization far from the meatus eliminates an urogenital or periorifical form. Lupus vulgaris is evolving very slowly and is accompanied by progressive tissue destruction (Figure 2).

Figure 2: Cutaneous histology (HES, G x 100), epithelioid granuloma with central area of necrosis surrounded by lymphocytes.

Histologically, there is a tuberculoid granuloma but gaseous necrosis is rarely found. The treatment of cutaneous tuberculosis is the same as that of pulmonary tuberculosis using the RHZE association for two months then RH for four months.

Any chronic non-healing ulcer over the penis should arouse a suspicion of tuberculosis, especially in an endemic country like Morocco.