CASE R E P O R T

ELSEVIER

AMEBIASIS OF THE PENIS

MOHAMED J. HEJASE, RICHARD BIHRLE, GILBERTO CASTILLO, AND CHRISTOPHER L. COOGAN

ABSTRACT
Penile amebiasis is rarely a recognized entity because the penis is not the usual site of presentation for
amebiasis. Homosexual men have a higher risk of acquiring the lesion. Amebic ulcers resemble cutaneous
lesions arising from squamous cell carcinoma, chancroid, primary syphilis, granuloma inguinale, and many
other causes. An amebic ulcer should be suspected in a patient with balanoposthitis that resists antibiotic
therapy. Biopsy is fundamental to isolate the trophozoites to confirm the diagnosis. Metronidazole and hy-
drochloric emetine are still the treatment of choice. This diagnosis should especially be considered in cases
of lesions detected in patients who practice anogenital sex or who are immunocompromised. UROLOGY 48:
151-154, 1996.

mebiasis of the penis is a rare disease. About
A 20 cases have been reported in the world lit-
erature to date. 1-11 However, many cases are still
unpublished. Entamoeba histolytica is the etiologic
agent of h u m a n amebiasis. 8'12'13 Enteric infections,
which have traditionally been associated with con-
taminated food or water, are now being found in
patients without such exposure. Transmission
might be achieved by direct inoculation or
through anal intercourse with a person suffering
from amebic dysentery. 8'9 It has been reported as
the result of coitus with a woman who had vul-
vovaginal amebiasis. 2'8
We present four cases of amebiasis, emphasizing
the importance of a high index of suspicion for ac-
curate clinical diagnosis. The epidemiology, evalua-
tion, and treatment are all discussed. Urologists
should consider amebiasis in the differential diagnosis
of patients with penile lesions, especially those pa-
tients who are at high risk of acquiring such lesions.
CASE REPORTS
CASE 1
A 39-year-old uncircumcised man presented
with a history of foul-smelling exudate and tender
From the Department of Urology, Hospital General de Zona
IMSS No. 33, Monterrey, Nuevo Leon, Mexico, and the Indiana
University Medical Center, Indianapolis, Indiana
Reprint requests: Richard Bihrle, M.D., Department of Urol-
ogy, Indiana University Medical Center, University Hospital,
Suite 1725, 550 North University Blvd., Indianapolis, IN 46202-
5250
Submitted: October 26, 1995, accepted (with revisions): Jan-
uary 4, 1996
ulceration on the ventral surface of his foreskin
(Fig. 1 ). On physical examination, a 2-cm irreg-
ular ulcer with a nonraised border covered by a
serous exudate was evident. The patient also dem-
onstrated bilateral inguinal adenopathy. Serologic
testing for syphilis, h u m a n immunodeficiency vi-
rus (HIV), and hepatitis B surface antigen was
negative. Microscopic evaluation of the exudate
revealed numerous E. histolytica trophozoites. Se-
rologic titers were elevated, and examination of
stool samples revealed the presence of trophozo-
ites. The treatment of the ulcer included local ap-
plication of nitrofurazone for 10 days with each
dressing change. In addition to local care, a 10-day
course of oral metronidazole (800 mg three times
daily) was administered. Two-week follow-up ex-
amination of the penis demonstrated complete
healing of the ulcer.
CASE 2
A 15-year-old uncircumcised man with a history
of active homosexuality presented with a 0.5-cm
necrotic ulceration on his distal foreskin. A mal-
odorous serous exudate was noted. Edema of the
foreskin prevented adequate retraction. Painless
bilateral inguinal adenopathy was found. Light mi-
croscopy in dark field for Treponema was negative,
as were serologic syphilis and gonorrhea tests. No
HIV studies were performed at that time (1983).
Microscopic examination of the exudate showed
abundant E. histolytica trophozoites. Biopsy of the
lesion demonstrated a chronic inflammatory pro-
cess with infiltration of polymorphonucleated cells
and abundant eosinophils. Hydrochloric emetine
(1 m g / k g / d a y intramuscularly) and ampicillin

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ALL RIGHTS RESERVED PII S 0 0 9 0 - 4 2 9 5 ( 9 6 ) 0 0 1 0 8 - 2 1 S1
FIGURE 1. Penile amebiasis lesion shown on admis-
sion.
(500 mg orally four times daily) for a total of 10
days were initiated. Because of incomplete reso-
lution of the lesion, the patient then received 10
days of oral metronidazole ( 1000 mg three times
a day). Two weeks following commencement of
therapy, the ulceration was completely healed. The
final scarring resulted in phimosis, which was later
treated by circumcision.
CASE 3
A 26-year-old man presented with a 15-day his-
tory of painful swelling of the penile foreskin and
a foul-smelling and blood-stained preputial dis-
charge. The foreskin could not be retracted. A bi-
opsy was obtained because a neoplasm was sus-
pected. Within a week, the entire foreskin had
been destroyed by an ulcer. The entire penis was
edematous with no significant regional lymphad-
enopathy. Syphilis, gonorrhea, Chlamydia, and
HIV tests were negative. Histologically, biopsy
demonstrated a granuloma rich in trophozoites
(Fig. 2). Treatment consisted of hydrochloric em-
etine ( 1 m g / k g / d a y intramuscularly) and metron-
idazole (1000 mg orally three times a day) for 2
weeks. He was examined 30 days later and found
to be completely asymptomatic with a normal
phallus.
CASE 4
A 52-year-old man was admitted with a 3-week
history of a painful, exudative, and foul-smelling
ulceration on the ventral aspect of his foreskin that
grew rapidly, destroying his glans (Fig. 3 ). He had
already failed a 2-week course of oral tetracycline
(500 mg four times daily). Test results for syph-
ilis, gonorrhea, and HIV were negative. Biopsy of
the ulcer revealed the presence of trophozoites and
an inflammatory process. Oral metronidazole ( 750
mg three times per day) and hydrochloric emetine
(1 m g / k g / d a y intramuscularly) were adminis-
1 52
FIGURE 2. Photomicrograph shows granular tissue,
light epithelial hyperplasia, cytolysis, and the tropho-
zoites. Arrow marks trophozoite (hematoxglin and eosin
100).
FIGURE 3. Lesion detected upon admission prior to
treatment.
tered for 10 days. The patient was discharged
when he was asymptomatic. One month later, no
ulcers were detected on his penis.
COMMENT
Within the last two decades, the sexual trans-
mission of protozoal pathogens generally acquired
by the fecal-oral route, such as Giardia lamblia
and E. histolytica, has become apparent in the ur-
ban homosexual community. 14-16 E. histolytica is
endemic in Africa, South America, Mexico, and In-
dia. In the United States, the prevalence is lower,
but several groups are at high risk of acquiring
amebiasis. 8'17-19 Humans are the only known res-
ervoir for E. histolytica.
E. histolytica is a parasite that exists in two
forms, cyst and trophozoite. The cyst is the infec-
tious form and may yield up to eight trophozo-
ites. 2 It is estimated that as many as 10% of the
world's population is infected with E. histolytica,
and this organism is responsible for as many as
100,000 deaths per year worldwide. 2 The incu-
UROLOGY 48 (1), 1996
bation period for amebiasis varies from a few days
to several months, but it is usually 2 to 4 weeks, t6
Penile amebiasis starts as pruriginous hyperemic
zone on the foreskin that evolves into a vesicle.
Several days later, this vesicle will evolve into a
painful, irregular ulcer with a viscous exudate that
is often foul smelling. The ulcer spreads rapidly
and may surround the entire penile shaft. If mis-
diagnosed and mistreated, this ulcerative process
may cause significant penile deformity or even
penile loss. 8-1 Previous studies in the United
States and elsewhere have demonstrated that a his-
tory of syphilis a n d / o r gonorrhea is highly corre-
lated with sexually transmitted amebiasis. 13'17-19
Genital primary l e s i o n s - - w h e t h e r papular, ve-
sicular; or p u s t u l a r - - q u i c k l y erode to an ulcera-
tive phase. Ulcer characteristics can be valuable in
formulating a differential diagnosis (Table I).21 A
deep genital ulcer suggests chancroid, whereas the
ulcers of syphilis, herpes, and lymphogranuloma
venereum are more superficial. Primary penile
squamous cell carcinoma may occur at any ana-
tomic location of the penis. The fiat variety typi-
cally appears as a superficial round ulcer on a
slightly elevated base, and it grows laterally and
infiltrates deeply. A high index of suspicion for
penile cancer and a low threshold for biopsy of all
penile lesions--including balanoposthitis--that
do not respond to a short trial of conservative an-
timicrobial therapy are the primary requirements
for early diagnosis and treatment of patients with
penile cancer. 22 The histologic picture confirms
the acute and chronic inflammatory processes. It
shows abundant granular tissue, light epithelial
hyperplasia, and a superficial band of necrosis in
which trophozoites are encountered. These organ-
isms are n u m e r o u s and easy to identify by routine
staining procedures, s-n
The clinical presentation of a penile ulcer shows
great variability; a study by Chapel et al. 23 has
demonstrated that even an experienced clinician
can misdiagnose 40% of genital ulcers. The differ-
ential diagnosis of an acute genital ulcer can be a
difficult problem for physicians working in the
sexually transmitted disease field. Although each
etiology has its typical symptoms and signs, there
is tremendous overlap in clinical presentation.
What appears to be a classic picture may actually
be another infectious process. 22 As a result of the
nonspecificity of the clinical findings, the etiologic
diagnosis of genital ulcer disease requires labora-
tory confirmation.
The diagnosis of intestinal amebiasis is made by
identifying E. histolytica cysts or trophozoites in
stool. A single stool specimen will usually detect
one third of infected patients, and it is usually rec-
o m m e n d e d that three separate stool specimens be
examined to rule out amebiasis. Trophozoites rap-
UROLOGY 48 (1), 1996
TABLE I. Classical presentation of
genital ulcer
Classical Presentation Disease
Painless superficial round Squamous cell carcinoma
ulcer with elevated
base and mildly rolled
edges
Grouped vesicles* Genital herpes
Traumatic ulcer
Onset during sexual
activity*
Recurrences associated Fixed drug reaction
with the same systemic
medicine*
Painful deep ulcer with Chancroid
undermined border
Painless, firm, rolled, and Granuloma inguinale
elevated ulcer border
Painless, firm, indurated Primary syphilis
ulcer
* Pathognomonic.
idly die after passage; therefore, stool samples
must be examined within 20 minutes of collection.
Serologic studies are also used in the diagnosis of
invasive amebiasis. Asymptomatic cyst passers will
usually have serologically low titers, but patients
with invasive disease will have elevated titers. 2
The necessity of treating asymptomatic cyst pass-
ers is controversial. In a controlled study in To-
ronto, Canada, E. histolytica was isolated in stool
samples from 27% of the homosexual and 1% of
the heterosexual men, and G. lamblia was isolated
from 13% of the homosexual and 3% of the het-
erosexual men. 24 Most E. histolytica infections in
homosexual men are believed to be asympto-
matic. 24
Genital ulcer disease is a risk factor for the
transmission of h u m a n retroviral infection. An
u n d e r s t a n d i n g of this interaction is emerging
and will have an impact on the treatment and
control programs for the agents causing genital
ulcer disease. 25 The increased risk of contracting
acquired i m m u n o d e f i c i e n c y s y n d r o m e (AIDS)
with increasing age appears to be greater than
that associated with acquiring syphilis or ame-
biasis, a finding that suggests a true increase in
susceptibility. However, it is also possible that
the apparent difference between the age distri-
bution of reported cases of AIDS and reported
cases of syphilis and amebiasis is the result of
the long latency believed to be associated with
AIDS. 26 Moreover, because the risk factors for
a m e b i a s i s - - i n c l u d i n g multiple sexual partners,
poor hygiene, and anogenital s e x - - i s similar to
those for AIDS, declining sexual transmission of
amebiasis might be used to predict decreasing
1 53
t r a n s m i s s i o n of HIV a n d l o w e r e d i n c i d e n c e of
AIDS a m o n g h o m o s e x u a l a n d b i s e x u a l men.
G i v e n the l o n g i n c u b a t i o n of AIDS, s u c h a de-
cline in i n c i d e n c e s h o u l d follow the initial de-
crease in amebiasis rates b y several years.12 This
is p r o b a b l y d u e to the i n c r e a s i n g use of c o n d o m s
a n d i m p r o v e d s e x u a l e d u c a t i o n in the p o p u l a -
tion.
Patients presenting with a penile ulcer of enteric
etiology, w i t h o u t a history of the classic m e a n s of
transmission, have m o s t likely been infected sex-
ually. These patients s h o u l d be advised that their
sexual contacts are p r o b a b l y infected as well. All
sexually active individuals w h o p e r f o r m anilingus
and fellatio, especially male h o m o s e x u a l s a n d their
contacts, are at high risk for their infections. 16'27
In the evaluation of patients with a genital ulcer,
one s h o u l d suspect an amebic ulcer w h e n e v e r a
patient presents with balanoposthitis or a penile
ulcer that resists antibiotics. Biopsy or scrapings
from freshly collected necrotic exudate are fun-
d a m e n t a l in isolating the t r o p h o z o i t e s to confirm
the diagnosis. Metronidazole and h y d r o c h l o r i c
emetine offer an excellent regression and fast-heal-
ing process of these ulcers.
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