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Snapshot diagnosis - what's causing this man's swollen genitals?

Dr Mike Wyndham describes how a swollen penis and hardened scrotum led to a diagnosis usually made on GI symptoms

Dr Mike Wyndham describes how a swollen penis and hardened scrotum led to a diagnosis usually made on GI symptoms

The patient

This 18-year-old presented with a three-week history of a swollen penis. He had noticed his scrotum had started to feel hard too. Otherwise, he felt perfectly well and there was no significant medical history. He was not taking any medication.

First instinct

Certainly, this was the first time I had ever seen a problem like this. I had once seen someone in severe cardiac failure with generalised swelling. However, this swelling appeared to be localised to the penis and scrotum, with the soft tissues feeling ‘uncomfortably' hard. My working diagnosis was sarcoidosis as this can cause plaques in the skin.

Differential diagnosis

• Crohn's disease

• Acquired lymphoedema

Getting on the right track

There was no suggestion of abdominal malignancy and no international travel where he might have caught filariasis, which made lymphoedema unlikely. On the basis that this might be sarcoidosis, I arranged for a chest X-ray and blood tests including calcium and angiotensin converting enzyme – which is raised in 60% of cases of sarcoidosis. But I had some doubts about the diagnosis as the plaques of sarcoidosis are usually a red/ purple colour and this wasn't the case. All the tests were normal, so a referral was made for biopsy, which confirmed a granulomatous condition.

The hidden clue

With Crohn's disease in the differential, investigations of the GI tract were carried out. These confirmed the presence of Crohn's and he was started on azathioprine. This has not made an improvement to his condition and it is likely that he will need to be treated with infliximab. Crohn's rarely affects the penis and usually manifests as ulceration. Its appearance may precede the GI symptoms of the disease.

Dr Mike Wyndham is a GP in Edgware, north London

What's causing this man's swollen penis? What's causing this man's swollen penis?

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