Quiz: Young male with scrotal ulcers

A 24-year-old male is seen in the emergency room for complaints of bilateral testicular pain for the past several weeks. He admitted that he recently shaved his scrotum with a razor a few weeks ago. The patient immigrated to the U.S. from Pakistan 3 months ago and has a history of contact with his uncle, who has tuberculosis. Other notable past medical history is uveitis causing partial blindness and a history of recurrent epididymo-orchitis for several months.

On physical exam, the patient has multiple, superficial, tender scrotal ulcers that appear chronic as well as an oral ulcer. No inguinal lymphadenopathy is present. He underwent a scrotal biopsy (figure) that revealed inflammation and disruption of elastic fibers in the venules and arteries at the base of the ulcer.

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Answer

C. Behçet’s disease

Discussion

Behçet’s disease is a rare disorder that causes blood vessel inflammation throughout the body. The disease can lead to numerous symptoms that may seem unrelated at first. The etiology of Behçet’s is uncertain but occurs mostly in the HLA-B51 phenotype. Behçet’s disease is a triad of recurrent oral ulcers, recurrent genital ulcers, and uveitis. The diagnosis is essentially clinical, but confirmatory biopsy of the ulcers would reveal inflammation of the blood vessels and disruption of elastic fibers in the vessels. Oftentimes, patients will present with recurrent epididymo-orchitis that is inflammatory in nature and non-infectious.

It is treated with anti-inflammatory medications and typically resolves without sequelae. Genitourinary TB may also rarely present with non-healing scrotal ulcers, epididymo-orchitis, and uveitis but the vasculitis present in this case is more characteristic of Behçet’s disease. The genital ulcers that present with both syphilis and granuloma inguinale are painless and would not account for all his other findings.

Suggested reading

Urologic screening for men with Behçet’s syndrome. Urology 1998; 52:863-5.

https://rarediseases.info.nih.gov/diseases/848/behcet-disease

Igor Sorokin, MD, Assistant Professor at the University of Massachusetts, Worcester, MA, is section editor for Urology Times Clinical Quiz.