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Dysphasia – dysuria – disaster

01 September 2009

Mr W, a 70-year-old retired shoe mender, went to his GP surgery because he was experiencing difficulty passing urine. He had previously suffered a stroke leaving him with marked speech difficulty, so verbal communication was not easy. His main complaints were of dysuria, bouts of urinary incontinence and a split urinary stream. His symptoms had come on gradually and worsened over the course of a year.

He saw four different doctors at the practice over a period of three months. He was treated with antibiotics for a presumed urinary tract infection on four occasions. This was on the basis of urine dipstick tests which were positive for nitrites, leucocytes, blood and protein. No definitive infecting organism was ever cultured from MSU samples.

On one occasion he mentioned that the tip of his penis had been sore, and this led one of the doctors to make a non-urgent referral to a urology clinic. At no point during his attendance with this problem is there any record of a physical examination.

About four months after his last attendance at the surgery, Mr W attended the urology clinic. Examination of the penis showed an ulcerated, erythematous mass close to the external urethral meatus which was causing partial obstruction and division of the urinary stream.

Biopsy of the lesion showed it to be an invasive, moderately differentiated keratinising squamous carcinoma. Mr W underwent partial penectomy. However, metastatic spread had already occurred and he died two years after his initial diagnosis.

Mr W’s wife sued the doctors at his GP practice, alleging negligence in their handling of his case, leading to a delay in diagnosis which contributed to Mr W’s death.

Expert opinion

The main failing in this case was considered to be the omission of examination of Mr W’s external genitalia, given that he had a persistent split urinary stream and at one point complained of penile soreness. Blindly continuing to treat for urinary tract infection without any confirmatory evidence was felt to be poor practice. The claim was settled for a moderate sum.

Learning points

  • When obtaining a detailed history is made difficult by communication issues, detailed physical examination and appropriate investigation is the best route to a correct diagnosis. 
  • Treating a man of this age with such symptoms it would be prudent to examine the patient’s prostate.
  • Patients may be reluctant to mention that they have problems “down below” so have a low threshold for directly asking about penile lesions and examining the external genitalia, where there are distal urinary tract symptoms. It may be that the use of slang or euphemisms may aid communication.
  • Any complaint of itching, burning sensation, soreness or bleeding affecting the glans or prepuce should prompt consideration of the diagnosis of carcinoma of the penis, requiring examination of the external genitalia and inguinal lymph fields.
  • It is important to carry out investigation before referral and make use of available outpatient investigations.
  • Differential diagnosis of penile lesions is fraught with difficulty. Where there is any doubt, you should refer the patient to a urologist or dermatologist for an opinion and consideration of biopsy.
  • Any lesion of the penis that is potentially compatible with penile carcinoma should be referred urgently to a urologist.
  • Female practitioners should offer to have a male colleague examine the area if embarrassment is a bar to this.
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