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J R Soc Med. 2002 March; 95(3): 136–137.
PMCID: PMC1279483

Perineal necrotizing fasciitis with dilatation of Cowper's gland

D J Hodgson, MSc FRCSEd, J L Peters, FRCS, and P J R Shah, FRCS

In an immunocompromised patient, a urethral stricture can have life-threatening consequences.

CASE HISTORY

A man aged 35 was worried by a painless lump below his scrotum, present for some 6 months. He also complained of obstructive voiding symptoms but denied any history of trauma or urethritis. He had been diagnosed with HIV four years previously and was receiving triple therapy with a CD4 count of 150 × 109/L. On examination he had a lump in his perineum the size of a golf ball. An ultrasound scan suggested a urethral diverticulum. He did not attend for follow-up as requested but returned 5 months later with a large fluctuant perineal mass, with ischaemic changes to the overlying skin (Figure 1). An ultrasound and urethrogram showed a tight bulbar stricture with a track via Cowper's duct and gland into the perineum (Figure 2). Later that day he underwent urethroscopy, optical urethrotomy and debridement of necrotizing fasciitis. A large infected urinoma was drained and the track to Cowper's gland was curettaged. 4 months later he was well, with a normal urethrogram.

Figure 1
Perineal necrotizing fasciitis
Figure 2
Preoperative urethrogram

COMMENT

Cystic dilatation of the main duct of Cowper's bulbourethral gland is well documented1,2. This case, however, demonstrates not only dilatation of the duct and gland but also the development of a communication to the perineum and subsequent urinoma formation, seemingly not reported previously. A combination of a tight urethral stricture and the immunocompromised state of the patient led to the development of a life-threatening condition.

In his original description of infective necrotizing fasciitis Jean Alfred Fournier described a rapidly progressive genital gangrene that was idiopathic in origin3. This case reflects the emergence of HIV as a major risk factor in the development of the condition.

References

1. Redman JF, Rountree GA. Pronounced dilatation of Cowper's gland duct manifest as a perineal mass: a recommendation for management. J Urol 1988;139: 87-8 [PubMed]
2. Bevers RFM, Abbekerk AM, Boon TA. Cowper's syringocele: classification and treatment of an unappreciated problem. J Urol 2000;163: 782-4 [PubMed]
3. Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol 1998;81: 347-55 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press