Penile Atrophy and Urethral Stricture Following Pyoderma Gangrenosum: A Case Report and Review of the Literature

Penile Atrophy and Urethral Stricture Following Pyoderma Gangrenosum: A Case Report and Review of the Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Penile Atrophy and Urethral Stricture Following Pyoderma Gangrenosum: A Case Report and Review of the Literature Xiao Luo, Hongsun Lu, Yaojun Li, Shoulei Liu, Yifeng Yao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8606784/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Pyoderma gangrenosum (PG) is a rare, chronic, neutrophilic dermatosis. Penile involvement is exceptionally uncommon and can lead to severe complications if not managed appropriately. Case Presentation We report a case of a 59-year-old man with a six-month history of dysuria and urinary incontinence. Seven years prior, he was diagnosed with penile PG based on clinical and histopathological findings and treated with oral methylprednisolone. The initial skin lesions improved rapidly, and the dose was tapered to a long-term maintenance dose. However, the patient subsequently developed progressive penile atrophy. Upon current presentation, physical examination and imaging studies revealed complete absence of the pendulous penis, severe atrophy of the remaining penile structures, bilateral hydronephrosis, and a panurethral stricture. The patient underwent total penectomy and urethrectomy. Postoperative pathology surprisingly revealed massive neutrophilic infiltration in the penile urethra, indicating ongoing inflammatory activity despite long-term corticosteroid therapy. Following surgery, therapy was transitioned to adalimumab (a TNF-alpha inhibitor), with no recurrence after one year of follow-up. Conclusion This case highlights that long-term corticosteroid therapy for penile PG may not suppress the underlying destructive inflammatory process in deeper tissues, potentially leading to catastrophic complications such as penile atrophy and panurethral stricture. It underscores the critical need for vigilant, long-term urological monitoring and early consideration of alternative or adjunctive steroid-sparing agents in the management of this condition. Figures Figure 1 Figure 2 Introduction Pyoderma gangrenosum (PG) is a rare, chronic, recurrent neutrophilic dermatosis characterized by painful, progressive ulcerations 1 . While it can affect any part of the body, penile involvement is particularly rare and can lead to significant complications if not managed appropriately 2 . We report on a case presenting a unique instance of severe penile atrophy and panurethral stricture following long-term corticosteroid treatment for penile PG. Case presentation A 59-year-old man presented to our center with a 6-month history of dysuria and urinary incontinence. Seven years earlier, the patient had developed recalcitrant ulcerative lesions on his glans (Fig. 1 A). He underwent a skin biopsy in another hospital, and based on the clinical presentation and histopathological findings, a diagnosis of penile pyoderma gangrenosum was established. Treatment with oral methylprednisolone was initiated at a dose of 24 mg daily, which rapid improved the skin lesion. The dose was gradually tapered to a long-term maintenance dose of 4 mg daily. However, the patient reported a gradual atrophy of his penis over the subsequent years. At the current presentation, physical examination revealed complete absence of the pendulous penis (Fig. 1 B). Ultrasound showed bilateral hydronephrosis with a post-void residual volume of 500 ml. Magnetic resonance imaging demonstrated severe atrophy of the remaining penis (Fig. 2 A). Urethrography revealed panurethral stricture (Fig. 2 B). The patient underwent total penectomy and urethrectomy with suprapubic cystostomy. Postoperative pathology revealed massive neutrophilic infiltration in the penile urethra, consistent with ongoing inflammatory activity despite long-term corticosteroid therapy (Fig. 2 C). Following surgery, the patient was started on biweekly injections of adalimumab, a tumor necrosis factor (TNF) inhibitor, to better control the underlying inflammatory process. The patient was follow-up for one year with no sign of recurrence. Discussion PG is a rare, noninfectious neutrophilic dermatosis that can affect various parts of the body, including the genitalia 3 . The pathogenesis of PG involves a dysregulation of the innate immune system, leading to neutrophil-mediated inflammation and tissue destruction. While the exact trigger for this dysregulation remains unclear, genetic factors and associated systemic diseases are thought to play a role 2 . A total of 31 cases have been reported in English-language published works since 1979, which were summarized in Table 1 4–18 . Clinical features of penile PG often include painful, rapidly progressing ulcers on the penis, often accompanied by purulent discharge. These ulcers can be extensive, sometimes involving the scrotum or perineum, and may mimic other conditions such as infections (e.g., Fournier’s gangrene) or malignancies. While Penile PG can occur in isolation, it may associate with systemic diseases. In our review, cases were linked to conditions such as chronic lymphocytic leukemia 4 , myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) 2 , HIV/AIDS, ulcerative colitis 5 , 15 , renal cell carcinoma 11 , and diabetes mellitus 14 . However, a significant number of cases had no identifiable associated diseases, suggesting that Penile PG can also present as an idiopathic condition. This variability underscores the heterogeneous nature of Penile PG’s etiology. Our review of 31 cases reveals a spectrum of associated conditions and treatment outcomes. Approximately 45% of cases were idiopathic, with no underlying systemic disease identified 6 , 8 , 10 , 12 , 17 , 18 . Others were linked to systemic conditions, including ulcerative colitis (4 cases) 5 , 13 , 15 , diabetes mellitus (3 cases) 14 , chronic lymphocytic leukemia 4 , renal cell carcinoma 11 , T-cell large granular lymphocyte leukemia, myelodysplastic syndrome, acute myeloid leukemia, and HIV/AIDS. This variability underscores the diverse etiology of penile PG, which may occur in isolation or as a manifestation of systemic disease. Diagnosing penile PG can be challenging due to its rarity and the need to exclude other causes of genital ulceration, including infections (e.g., herpes simplex virus, syphilis), malignancy, and other inflammatory conditions (e.g., Behçet's disease) 19 . Histopathological examination typically reveals a dense neutrophilic infiltrate without evidence of infection or vasculitis. In our case, the initial diagnosis was based on the characteristic clinical appearance of the penile lesions and confirmatory biopsy findings. The development of penile atrophy and panurethral stricture, leading to urinary retention and bilateral hydronephrosis, as observed in our patient, represents rare complications of penile PG that had not been previously reported in the literature. These complications may have resulted from a combination of factors: 1. Chronic inflammation leading to tissue destruction and fibrosis; 2. Long-term corticosteroid use potentially affecting tissue integrity; 3. Reduced blood flow due to vascular changes associated with chronic inflammation. The management of penile PG primarily involves immunosuppression to control the underlying inflammatory process. Systemic corticosteroids are typically the first-line treatment, often leading to rapid improvement in acute lesions 2 . Topical corticosteroids or calcineurin inhibitors may be used for limited disease 9 . Systemic immunosuppressants including cyclosporine, mycophenolate mofetil, and methotrexate have shown efficacy in some cases 9 , 10 , 16 . In our patient, initial treatment with high-dose oral methylprednisolone (24 mg daily) resulted in improvement of the ulcerative lesions. However, the gradual tapering to a maintenance dose of 4 mg daily may have been insufficient to completely suppress the inflammatory process, potentially contributing to the development of long-term complications. Management of penile PG primarily focuses on immunosuppression to control inflammation. Systemic corticosteroids, typically prednisolone or methylprednisolone, remain the first-line therapy, with doses ranging from 0.5 to 2 mg/kg/day, often leading to rapid lesion improvement 2 , 4 – 8 , 11 , 13 – 15 , 17 , 18 . Topical therapies, such as corticosteroids or tacrolimus, have been effective in milder cases or as adjuncts 9 . Other systemic agents, including cyclosporine 13 , 16 , azathioprine 17 , colchicine 10 , dapsone 14 , thalidomide 8 , 12 , and methotrexate, have shown efficacy in specific cases. Tumor necrosis factor (TNF) inhibitors, such as adalimumab, have emerged as promising options for refractory cases, as utilized in our patient post-surgery to prevent recurrence 13 , 20 , 21 . In our case, initial high-dose methylprednisolone (24 mg/day) improved ulcerative lesions, but long-term low-dose maintenance (4 mg/day) may have been insufficient to suppress ongoing inflammation, contributing to complications. In recent years, TNF inhibitors (e.g., infliximab, adalimumab) have shown promise in the treatment of refractory PG 20, 21 . The use of adalimumab in our patient aimed to better control the underlying inflammatory process and potentially prevent further complication. Surgical interventions, such as debridement or reconstructive procedures, were reported in several cases but carry a risk of pathergy, where trauma exacerbates PG lesions 22 . In our patient, the severity of penile atrophy and panurethral stricture necessitated total penectomy and suprapubic cystostomy, highlighting the potential for extreme outcomes in poorly controlled disease. Less invasive options, such as urethral dilation or urethroplasty, may suffice for milder strictures but were not feasible here due to extensive tissue destruction. Less severe cases of urethral stricture might be managed with less invasive approaches such as urethral dilation or urethroplasty. However, the risk of pathergy in PG patients must be carefully considered when planning any surgical intervention 22 . In our case, the severity of penile atrophy and urethral stricture, duo to the tissue destruction and fibrosis, necessitated radical surgical intervention with total penectomy and suprapubic cystostomy. Conclusion This case presents a rare and severe complication of penile pyoderma gangrenosum, highlighting the potential for significant urological sequelae even with standard corticosteroid therapy. The development of penile atrophy and panureathral stricture in this patient underscores the need for careful long-term follow-up and management of patients with penile PG. Declarations Funding This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests The authors declare that they have no competing interests. Clinical trial number Not applicable. Ethics approval This retrospective case report was conducted in accordance with the Declaration of Helsinki. Ethical approval was waived by the Institutional Review Board of [The First People's Hospital of Tongxiang City] as it involved the retrospective analysis of existing clinical data. Consent for publication Written informed consent was obtained from the patient for both the use of his clinical data and the publication of this report, including all accompanying images. Declaration of generative AI and AI-assisted technologies in the writing process. During the preparation of this work the authors used Deepseek in order to improve the language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. Author Contribution Conceptualization: [Xiao Luo], [Hongsun Lu]Patient Management and Investigation: [Hongsun Lu], [Yifeng Yao ]Data Curation and Formal Analysis: [Yaojun Li, Shoulei Liu]Writing – Original Draft Preparation: [Xiao Luo]Writing – Review & Editing: [ All Authors]Supervision: [Hongsun Lu]Approval of Final Manuscript: All Authors References Park AN, Raj A, Bajda J, et al. Narrative Review: Pyoderma Gangrenosum Cureus. 2024;16:e51805. Ahronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol. 2012;13:191. Toussi A, Le ST, Barton VR, et al. Successful Management of Anti-TNF-Induced Psoriasis Despite Continuation of Therapy in a Pyoderma Gangrenosum Patient. J Drugs Dermatol. 2020;19:199. Wahba A, Cohen HA. Herpes simplex virus isolation from pyoderma gangrenosum lesions in a patient with chronic lymphatic leukemia. Dermatologica. 1979;158:373. Sanusi ID, Gonzalez E, Venable DD. Pyoderma gangrenosum of penile and scrotal skin. J Urol. 1982;127:547. Harto A, Sanz-Gadea G, Vives C. [Pyoderma gangrenosum of the penis]. Actas Urol Esp. 1985;9:263. Baskin LS, Dixon C, Stoller ML, et al. Pyoderma gangrenosum presenting as Fournier's gangrene. J Urol. 1990;144:984. Farrell AM, Black MM, Bracka A, et al. Pyoderma gangrenosum of the penis. Br J Dermatol. 1998;138:337. Gopi SS, Evans AT, Raza A, et al. Superficial granulomatous pyoderma gangrenosum of the penis: a case report. ScientificWorldJournal. 2007;7:2426. Parren LJ, Nellen RG, van Marion AM, et al. Penile pyoderma gangrenosum: successful treatment with colchicine. Int J Dermatol. 2008;47(Suppl 1):7. Usui S, Otsuka A, Kaku Y, et al. Pyoderma gangrenosum of the penis possibly associated with pazopanib treatment. J Eur Acad Dermatol Venereol. 2016;30:1222. Hu YQ, Yao XX, Zhang JZ, et al. Penile pyoderma gangrenosum: Successful treatment with thalidomide. Dermatol Ther. 2019;32:e12952. Curtin PO, Sweeney T, Rogers MJ. Broadening the differential: A case of penile pyoderma gangrenosum. Urol Case Rep. 2020;33:101344. Garg T, Himadri H, Meena AK, et al. Pyoderma gangrenosum: An uncommon cause of nonsexually acquired genital ulcer disease. Indian J Sex Transm Dis AIDS. 2022;43:66. Thomas MJ, Segal E, Levy L, et al. Penile Pyoderma Gangrenosum in Pediatric Ulcerative Colitis. JPGN Rep. 2023;4:e281. Georgala S, Georgala C, Nicolaidou E. Pyoderma gangrenosum of the penis: a potentially dramatic skin disease. Urology, 72: 1185 e9, 2008. Gisondi P, Pizzolato M, Galvan A, et al. Image Gallery: Pyoderma gangrenosum of the penis. Br J Dermatol. 2018;178:e62. Watanabe Y, Nobeyama Y, Asahina A. A case of postoperative pyoderma gangrenosum on penis caused by patient himself. J Dermatol. 2024;51:e154. Philip M, Samson JF, Simi PS, et al. Penile pyoderma gangrenosum. Indian J Sex Transm Dis AIDS. 2013;34:138. Romagnuolo M, Moltrasio C, Iannone C, et al. Pyoderma gangrenosum following anti-TNF therapy in chronic recurrent multifocal osteomyelitis: drug reaction or cutaneous manifestation of the disease? A critical review on the topic with an emblematic case report. Front Med (Lausanne). 2023;10:1197273. Hakami S, Alharthi Y, Alanazi AMM. Refractory Pyoderma Gangrenosum: Stabilized on Colchicine and Tumor Necrosis Factor (TNF) Inhibitor. Cureus. 2022;14:e30419. Slocum AMY. A surgeon's nightmare: pyoderma gangrenosum with pathergy effect mimicking necrotising fasciitis. BMJ Case Rep, 2017, 2017. Tables Table 1 Reported Cases of Penile Pyoderma Gangrenosum Author(s) Publication Year Clinical Manifestation Associated Diseases Management Outcomes Wahba and Cohen 4 1979 Penile and scrotal ulcers with purulent discharge Chronic lymphocytic leukemia Prednisolone 30 mg daily Patient died before clinical improvement Sanusi et al. 5 1982 Penile and scrotal ulcers with purulent discharge Ulcerative colitis Total colectomy after corticosteroid failure Complete healing of cutaneous lesions Harto et al. 6 1985 Penile ulcers None discovered Prednisolone 1 mg/kg per day followed by trunk and limb treatment Responded to treatment Baskin et al. 7 1990 Penile and scrotal ulcers presenting as Fournier's gangrene None discovered Systemic administration of methylprednisolone 60 mg twice daily after surgical debridement Wound healed with skin grafts Farrell et al. 8 1998 Deep, almost circumferential purulent ulceration involving the upper shaft of the penis and corpora cavernosa None discovered Prednisolone 80 mg twice daily, minocycline 100 mg twice daily, thalidomide 100 mg once daily followed by surgical treatment Significant improvement, no recurrence Gopi et al. 9 2007 Recalcitrant penile ulceration with sinus tract formation Postoperative urethral fistula Topical steroids + tacrolimus Near-complete healing Georgala et al. 16 2008 Circumferential purulent ulceration involving the glans penis, neck of the glans, and adjacent prepuce and shaft of the penis None discovered Cyclosporine 250 mg and methylprednisolone 16 mg Improvement in lesion, urethral fistula remained Parren et al. 10 2008 Painful penile ulceration that had developed spontaneously None Colchicine 0.6 mg three times daily Marked clinical improvement within 2 months Usui et al. 11 2016 Painful ulcers on the glans and penis Recurrent renal cell carcinoma possibly associated with pazopanib treatment Systemic corticosteroids 50 mg daily Rapid improvement, no recurrence Gisondi et al. 17 2018 Acute-onset painful ulcer with a purulent base and soft undetermined edges on the frenulum None Oral therapy with azathioprine (2.5 mg/kg) and prednisone (0.5 mg/kg) Complete clinical remission after 3 months Hu et al. 12 2019 Progressive genital ulceration in a 16-year-old male None Thalidomide (50 mg/d) and minocycline (100 mg twice a day). Ulcer healed within 6 weeks Curtin et al. 13 2020 Penile ulceration with delayed wound healing and multiple unsuccessful urologic surgeries Ulcerative colitis Prednisolone, adalimumab, and cyclosporine Lesion healed, no recurrence Garg et al. 14 2022 Two ulcers on the glans penis Diabetes mellitus Prednisolone, dapsone, and colchicine Rapid response to treatment Thomas et al. 15 2023 Penile ulceration associated with pediatric ulcerative colitis Ulcerative colitis Systemic corticosteroids and antibiotics Rapid therapeutic response, no recurrence Watanabe et al. 18 2024 Postoperative PG on the penis caused by the patient himself None Oral prednisolone 20 mg/day Ulcer rapidly decreased in size, healed with healthy granulation tissue Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 25 Feb, 2026 Reviews received at journal 15 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor invited by journal 22 Jan, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 14 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8606784","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":592411803,"identity":"a5cff06c-3515-4466-9d46-41e7e460ddc0","order_by":0,"name":"Xiao 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City","correspondingAuthor":false,"prefix":"","firstName":"Hongsun","middleName":"","lastName":"Lu","suffix":""},{"id":592411807,"identity":"0901d1dc-2dc3-4d64-97b9-d7bc10510f9c","order_by":2,"name":"Yaojun Li","email":"","orcid":"","institution":"The First People's Hospital of Tongxiang City","correspondingAuthor":false,"prefix":"","firstName":"Yaojun","middleName":"","lastName":"Li","suffix":""},{"id":592411808,"identity":"eca26274-fd31-43e0-ae1c-7cccb50cffad","order_by":3,"name":"Shoulei Liu","email":"","orcid":"","institution":"The First People's Hospital of Tongxiang City","correspondingAuthor":false,"prefix":"","firstName":"Shoulei","middleName":"","lastName":"Liu","suffix":""},{"id":592411809,"identity":"d8445c4b-5e64-41bb-9ef4-d31ae9473cbd","order_by":4,"name":"Yifeng Yao","email":"","orcid":"","institution":"The First People's Hospital of Tongxiang City","correspondingAuthor":false,"prefix":"","firstName":"Yifeng","middleName":"","lastName":"Yao","suffix":""}],"badges":[],"createdAt":"2026-01-15 04:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8606784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8606784/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103049925,"identity":"2157add0-2ad0-4d5a-893c-720ff4ce8bde","added_by":"auto","created_at":"2026-02-20 07:47:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1165243,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Initial presentation of recalcitrant ulcerative lesions on the glans penis in a 59-year-old man diagnosed with penile pyoderma gangrenosum.\u003c/p\u003e\n\u003cp\u003e(B) Clinical appearance at the time of current presentation, showing complete absence of the pendulous penis due to severe atrophy.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8606784/v1/72ef368ac5af154092c2b932.png"},{"id":102991189,"identity":"9b731c41-fb55-4655-8176-5e63d05965e3","added_by":"auto","created_at":"2026-02-19 11:31:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":613261,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Magnetic resonance imaging (MRI) demonstrating severe atrophy of the remaining penile tissue, highlighting the extent of tissue destruction and fibrosis associated with chronic inflammation.\u003c/p\u003e\n\u003cp\u003e(B) Urethrography revealing panurethral stricture, indicative of significant urethral involvement and contributing to the patient’s urinary retention and bilateral hydronephrosis.\u003c/p\u003e\n\u003cp\u003e(C) Postoperative histopathological findings from the penectomy specimen showing massive neutrophilic infiltration.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8606784/v1/faf708563fe9f441f54582ad.png"},{"id":103051713,"identity":"7cf7075e-8dd5-40d5-a2c4-25f291cdc9ae","added_by":"auto","created_at":"2026-02-20 08:02:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2793665,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8606784/v1/52c260e3-7210-4c56-ae9f-e40afdc0aa9c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Penile Atrophy and Urethral Stricture Following Pyoderma Gangrenosum: A Case Report and Review of the Literature","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePyoderma gangrenosum (PG) is a rare, chronic, recurrent neutrophilic dermatosis characterized by painful, progressive ulcerations\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. While it can affect any part of the body, penile involvement is particularly rare and can lead to significant complications if not managed appropriately\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. We report on a case presenting a unique instance of severe penile atrophy and panurethral stricture following long-term corticosteroid treatment for penile PG.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 59-year-old man presented to our center with a 6-month history of dysuria and urinary incontinence. Seven years earlier, the patient had developed recalcitrant ulcerative lesions on his glans (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). He underwent a skin biopsy in another hospital, and based on the clinical presentation and histopathological findings, a diagnosis of penile pyoderma gangrenosum was established. Treatment with oral methylprednisolone was initiated at a dose of 24 mg daily, which rapid improved the skin lesion. The dose was gradually tapered to a long-term maintenance dose of 4 mg daily. However, the patient reported a gradual atrophy of his penis over the subsequent years. At the current presentation, physical examination revealed complete absence of the pendulous penis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Ultrasound showed bilateral hydronephrosis with a post-void residual volume of 500 ml. Magnetic resonance imaging demonstrated severe atrophy of the remaining penis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Urethrography revealed panurethral stricture (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The patient underwent total penectomy and urethrectomy with suprapubic cystostomy. Postoperative pathology revealed massive neutrophilic infiltration in the penile urethra, consistent with ongoing inflammatory activity despite long-term corticosteroid therapy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Following surgery, the patient was started on biweekly injections of adalimumab, a tumor necrosis factor (TNF) inhibitor, to better control the underlying inflammatory process. The patient was follow-up for one year with no sign of recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePG is a rare, noninfectious neutrophilic dermatosis that can affect various parts of the body, including the genitalia\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The pathogenesis of PG involves a dysregulation of the innate immune system, leading to neutrophil-mediated inflammation and tissue destruction. While the exact trigger for this dysregulation remains unclear, genetic factors and associated systemic diseases are thought to play a role\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA total of 31 cases have been reported in English-language published works since 1979, which were summarized in Table\u0026nbsp;1\u003csup\u003e4\u0026ndash;18\u003c/sup\u003e. Clinical features of penile PG often include painful, rapidly progressing ulcers on the penis, often accompanied by purulent discharge. These ulcers can be extensive, sometimes involving the scrotum or perineum, and may mimic other conditions such as infections (e.g., Fournier\u0026rsquo;s gangrene) or malignancies.\u003c/p\u003e \u003cp\u003eWhile Penile PG can occur in isolation, it may associate with systemic diseases. In our review, cases were linked to conditions such as chronic lymphocytic leukemia\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, HIV/AIDS, ulcerative colitis\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, renal cell carcinoma\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, and diabetes mellitus\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, a significant number of cases had no identifiable associated diseases, suggesting that Penile PG can also present as an idiopathic condition. This variability underscores the heterogeneous nature of Penile PG\u0026rsquo;s etiology.\u003c/p\u003e \u003cp\u003eOur review of 31 cases reveals a spectrum of associated conditions and treatment outcomes. Approximately 45% of cases were idiopathic, with no underlying systemic disease identified\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Others were linked to systemic conditions, including ulcerative colitis (4 cases)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, diabetes mellitus (3 cases)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, chronic lymphocytic leukemia\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, renal cell carcinoma\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, T-cell large granular lymphocyte leukemia, myelodysplastic syndrome, acute myeloid leukemia, and HIV/AIDS. This variability underscores the diverse etiology of penile PG, which may occur in isolation or as a manifestation of systemic disease.\u003c/p\u003e \u003cp\u003eDiagnosing penile PG can be challenging due to its rarity and the need to exclude other causes of genital ulceration, including infections (e.g., herpes simplex virus, syphilis), malignancy, and other inflammatory conditions (e.g., Beh\u0026ccedil;et's disease) \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Histopathological examination typically reveals a dense neutrophilic infiltrate without evidence of infection or vasculitis. In our case, the initial diagnosis was based on the characteristic clinical appearance of the penile lesions and confirmatory biopsy findings.\u003c/p\u003e \u003cp\u003eThe development of penile atrophy and panurethral stricture, leading to urinary retention and bilateral hydronephrosis, as observed in our patient, represents rare complications of penile PG that had not been previously reported in the literature. These complications may have resulted from a combination of factors: 1. Chronic inflammation leading to tissue destruction and fibrosis; 2. Long-term corticosteroid use potentially affecting tissue integrity; 3. Reduced blood flow due to vascular changes associated with chronic inflammation.\u003c/p\u003e \u003cp\u003eThe management of penile PG primarily involves immunosuppression to control the underlying inflammatory process. Systemic corticosteroids are typically the first-line treatment, often leading to rapid improvement in acute lesions\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Topical corticosteroids or calcineurin inhibitors may be used for limited disease\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Systemic immunosuppressants including cyclosporine, mycophenolate mofetil, and methotrexate have shown efficacy in some cases\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. In our patient, initial treatment with high-dose oral methylprednisolone (24 mg daily) resulted in improvement of the ulcerative lesions. However, the gradual tapering to a maintenance dose of 4 mg daily may have been insufficient to completely suppress the inflammatory process, potentially contributing to the development of long-term complications.\u003c/p\u003e \u003cp\u003eManagement of penile PG primarily focuses on immunosuppression to control inflammation. Systemic corticosteroids, typically prednisolone or methylprednisolone, remain the first-line therapy, with doses ranging from 0.5 to 2 mg/kg/day, often leading to rapid lesion improvement \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Topical therapies, such as corticosteroids or tacrolimus, have been effective in milder cases or as adjuncts\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Other systemic agents, including cyclosporine\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, azathioprine\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, colchicine\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, dapsone\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, thalidomide\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, and methotrexate, have shown efficacy in specific cases. Tumor necrosis factor (TNF) inhibitors, such as adalimumab, have emerged as promising options for refractory cases, as utilized in our patient post-surgery to prevent recurrence\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. In our case, initial high-dose methylprednisolone (24 mg/day) improved ulcerative lesions, but long-term low-dose maintenance (4 mg/day) may have been insufficient to suppress ongoing inflammation, contributing to complications. In recent years, TNF inhibitors (e.g., infliximab, adalimumab) have shown promise in the treatment of refractory PG\u003csup\u003e20, 21\u003c/sup\u003e. The use of adalimumab in our patient aimed to better control the underlying inflammatory process and potentially prevent further complication.\u003c/p\u003e \u003cp\u003eSurgical interventions, such as debridement or reconstructive procedures, were reported in several cases but carry a risk of pathergy, where trauma exacerbates PG lesions\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. In our patient, the severity of penile atrophy and panurethral stricture necessitated total penectomy and suprapubic cystostomy, highlighting the potential for extreme outcomes in poorly controlled disease. Less invasive options, such as urethral dilation or urethroplasty, may suffice for milder strictures but were not feasible here due to extensive tissue destruction.\u003c/p\u003e \u003cp\u003eLess severe cases of urethral stricture might be managed with less invasive approaches such as urethral dilation or urethroplasty. However, the risk of pathergy in PG patients must be carefully considered when planning any surgical intervention\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. In our case, the severity of penile atrophy and urethral stricture, duo to the tissue destruction and fibrosis, necessitated radical surgical intervention with total penectomy and suprapubic cystostomy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case presents a rare and severe complication of penile pyoderma gangrenosum, highlighting the potential for significant urological sequelae even with standard corticosteroid therapy. The development of penile atrophy and panureathral stricture in this patient underscores the need for careful long-term follow-up and management of patients with penile PG.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eThis retrospective case report was conducted in accordance with the Declaration of Helsinki. Ethical approval was waived by the Institutional Review Board of [The First People\u0026apos;s Hospital of Tongxiang City] as it involved the retrospective analysis of existing clinical data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for both the use of his clinical data and the publication of this report, including all accompanying images.\u003c/p\u003e\n\u003cp\u003eDeclaration of generative AI and AI-assisted technologies in the writing process.\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the authors used Deepseek in order to improve the language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\n\u003cp\u003eConceptualization: [Xiao Luo], [Hongsun Lu]Patient Management and Investigation: [Hongsun Lu], [Yifeng Yao ]Data Curation and Formal Analysis: [Yaojun Li, Shoulei Liu]Writing \u0026ndash; Original Draft Preparation: [Xiao Luo]Writing \u0026ndash; Review \u0026amp;amp; Editing: [ All Authors]Supervision: [Hongsun Lu]Approval of Final Manuscript: All Authors\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePark AN, Raj A, Bajda J, et al. Narrative Review: Pyoderma Gangrenosum Cureus. 2024;16:e51805.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol. 2012;13:191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToussi A, Le ST, Barton VR, et al. Successful Management of Anti-TNF-Induced Psoriasis Despite Continuation of Therapy in a Pyoderma Gangrenosum Patient. J Drugs Dermatol. 2020;19:199.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWahba A, Cohen HA. Herpes simplex virus isolation from pyoderma gangrenosum lesions in a patient with chronic lymphatic leukemia. Dermatologica. 1979;158:373.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanusi ID, Gonzalez E, Venable DD. Pyoderma gangrenosum of penile and scrotal skin. J Urol. 1982;127:547.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarto A, Sanz-Gadea G, Vives C. [Pyoderma gangrenosum of the penis]. Actas Urol Esp. 1985;9:263.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaskin LS, Dixon C, Stoller ML, et al. Pyoderma gangrenosum presenting as Fournier's gangrene. J Urol. 1990;144:984.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarrell AM, Black MM, Bracka A, et al. Pyoderma gangrenosum of the penis. Br J Dermatol. 1998;138:337.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGopi SS, Evans AT, Raza A, et al. Superficial granulomatous pyoderma gangrenosum of the penis: a case report. ScientificWorldJournal. 2007;7:2426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParren LJ, Nellen RG, van Marion AM, et al. Penile pyoderma gangrenosum: successful treatment with colchicine. Int J Dermatol. 2008;47(Suppl 1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUsui S, Otsuka A, Kaku Y, et al. Pyoderma gangrenosum of the penis possibly associated with pazopanib treatment. J Eur Acad Dermatol Venereol. 2016;30:1222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu YQ, Yao XX, Zhang JZ, et al. Penile pyoderma gangrenosum: Successful treatment with thalidomide. Dermatol Ther. 2019;32:e12952.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurtin PO, Sweeney T, Rogers MJ. Broadening the differential: A case of penile pyoderma gangrenosum. Urol Case Rep. 2020;33:101344.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg T, Himadri H, Meena AK, et al. Pyoderma gangrenosum: An uncommon cause of nonsexually acquired genital ulcer disease. Indian J Sex Transm Dis AIDS. 2022;43:66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas MJ, Segal E, Levy L, et al. Penile Pyoderma Gangrenosum in Pediatric Ulcerative Colitis. JPGN Rep. 2023;4:e281.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgala S, Georgala C, Nicolaidou E. Pyoderma gangrenosum of the penis: a potentially dramatic skin disease. Urology, 72: 1185 e9, 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGisondi P, Pizzolato M, Galvan A, et al. Image Gallery: Pyoderma gangrenosum of the penis. Br J Dermatol. 2018;178:e62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe Y, Nobeyama Y, Asahina A. A case of postoperative pyoderma gangrenosum on penis caused by patient himself. J Dermatol. 2024;51:e154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhilip M, Samson JF, Simi PS, et al. Penile pyoderma gangrenosum. Indian J Sex Transm Dis AIDS. 2013;34:138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomagnuolo M, Moltrasio C, Iannone C, et al. Pyoderma gangrenosum following anti-TNF therapy in chronic recurrent multifocal osteomyelitis: drug reaction or cutaneous manifestation of the disease? A critical review on the topic with an emblematic case report. Front Med (Lausanne). 2023;10:1197273.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHakami S, Alharthi Y, Alanazi AMM. Refractory Pyoderma Gangrenosum: Stabilized on Colchicine and Tumor Necrosis Factor (TNF) Inhibitor. Cureus. 2022;14:e30419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlocum AMY. A surgeon's nightmare: pyoderma gangrenosum with pathergy effect mimicking necrotising fasciitis. BMJ Case Rep, 2017, 2017.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReported Cases of Penile Pyoderma Gangrenosum\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAuthor(s)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePublication Year\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eClinical Manifestation\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAssociated Diseases\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eManagement\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOutcomes\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWahba and Cohen\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1979\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile and scrotal ulcers with purulent discharge\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChronic lymphocytic leukemia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrednisolone 30 mg daily\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePatient died before clinical improvement\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSanusi et al.\u003csup\u003e5\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1982\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile and scrotal ulcers with purulent discharge\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUlcerative colitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTotal colectomy after corticosteroid failure\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComplete healing of cutaneous lesions\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHarto et al.\u003csup\u003e6\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1985\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile ulcers\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone discovered\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrednisolone 1 mg/kg per day followed by trunk and limb treatment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eResponded to treatment\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBaskin et al.\u003csup\u003e7\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1990\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile and scrotal ulcers presenting as Fournier\u0026apos;s gangrene\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone discovered\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSystemic administration of methylprednisolone 60 mg twice daily after surgical debridement\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWound healed with skin grafts\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFarrell et al.\u003csup\u003e8\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1998\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDeep, almost circumferential purulent ulceration involving the upper shaft of the penis and corpora cavernosa\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone discovered\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrednisolone 80 mg twice daily, minocycline 100 mg twice daily, thalidomide 100 mg once daily followed by surgical treatment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSignificant improvement, no recurrence\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGopi et al.\u003csup\u003e9\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2007\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRecalcitrant penile ulceration with sinus tract formation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePostoperative urethral fistula\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTopical steroids\u0026thinsp;+\u0026thinsp;tacrolimus\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNear-complete healing\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGeorgala et al.\u003csup\u003e16\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2008\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCircumferential purulent ulceration involving the glans penis, neck of the glans, and adjacent prepuce and shaft of the penis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone discovered\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCyclosporine 250 mg and methylprednisolone 16 mg\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eImprovement in lesion, urethral fistula remained\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParren et al.\u003csup\u003e10\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2008\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePainful penile ulceration that had developed spontaneously\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eColchicine 0.6 mg three times daily\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMarked clinical improvement within 2 months\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUsui et al.\u003csup\u003e11\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2016\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePainful ulcers on the glans and penis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRecurrent renal cell carcinoma possibly associated with pazopanib treatment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSystemic corticosteroids 50 mg daily\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRapid improvement, no recurrence\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGisondi et al.\u003csup\u003e17\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2018\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAcute-onset painful ulcer with a purulent base and soft undetermined edges on the frenulum\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOral therapy with azathioprine (2.5 mg/kg) and prednisone (0.5 mg/kg)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComplete clinical remission after 3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHu et al.\u003csup\u003e12\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2019\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eProgressive genital ulceration in a 16-year-old male\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThalidomide (50 mg/d) and minocycline (100 mg twice a day).\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUlcer healed within 6 weeks\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCurtin et al.\u003csup\u003e13\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2020\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile ulceration with delayed wound healing and multiple unsuccessful urologic surgeries\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUlcerative colitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrednisolone, adalimumab, and cyclosporine\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLesion healed, no recurrence\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGarg et al.\u003csup\u003e14\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2022\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTwo ulcers on the glans penis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDiabetes mellitus\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrednisolone, dapsone, and colchicine\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRapid response to treatment\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThomas et al.\u003csup\u003e15\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2023\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePenile ulceration associated with pediatric ulcerative colitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUlcerative colitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSystemic corticosteroids and antibiotics\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRapid therapeutic response, no recurrence\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWatanabe et al.\u003csup\u003e18\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2024\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePostoperative PG on the penis caused by the patient himself\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOral prednisolone 20 mg/day\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUlcer rapidly decreased in size, healed with healthy granulation tissue\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8606784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8606784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePyoderma gangrenosum (PG) is a rare, chronic, neutrophilic dermatosis. Penile involvement is exceptionally uncommon and can lead to severe complications if not managed appropriately.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report a case of a 59-year-old man with a six-month history of dysuria and urinary incontinence. Seven years prior, he was diagnosed with penile PG based on clinical and histopathological findings and treated with oral methylprednisolone. The initial skin lesions improved rapidly, and the dose was tapered to a long-term maintenance dose. However, the patient subsequently developed progressive penile atrophy. Upon current presentation, physical examination and imaging studies revealed complete absence of the pendulous penis, severe atrophy of the remaining penile structures, bilateral hydronephrosis, and a panurethral stricture. The patient underwent total penectomy and urethrectomy. Postoperative pathology surprisingly revealed massive neutrophilic infiltration in the penile urethra, indicating ongoing inflammatory activity despite long-term corticosteroid therapy. Following surgery, therapy was transitioned to adalimumab (a TNF-alpha inhibitor), with no recurrence after one year of follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights that long-term corticosteroid therapy for penile PG may not suppress the underlying destructive inflammatory process in deeper tissues, potentially leading to catastrophic complications such as penile atrophy and panurethral stricture. It underscores the critical need for vigilant, long-term urological monitoring and early consideration of alternative or adjunctive steroid-sparing agents in the management of this condition.\u003c/p\u003e","manuscriptTitle":"Penile Atrophy and Urethral Stricture Following Pyoderma Gangrenosum: A Case Report and Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 11:31:03","doi":"10.21203/rs.3.rs-8606784/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"238278535119520437219976320689734067624","date":"2026-02-25T14:39:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T11:27:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80756344894443625115416481708491304750","date":"2026-02-15T10:58:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T09:59:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-22T09:41:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T15:47:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T15:44:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2026-01-15T04:19:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf97e15f-75a7-4785-9faf-696c69c779b7","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-19T11:31:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 11:31:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8606784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8606784","identity":"rs-8606784","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}