Mpox (monkeypox) causing penile lesions and acute urinary retention

Background

Amidst the current pandemic, the WHO declared another Global Health emergency in July 2022 following an mpox (monkeypox) outbreak which resulted in 16 000 cases across 75 countries and included five deaths.1 The spread of mpox (monkeypox) occurs when a person comes into close contact with an infected animal, rodents in particular, human, or materials contaminated with the virus which enters the body through broken skin, the respiratory tract, or the mucous membranes. By the end of May 2022 there were 320 reported confirmed cases of mpox (monkeypox). Of these 99% were male, and 99% of cases who completed more detailed questionnaires by the UK Health Security Agency identified as gay, bisexual and other men who have sex with men (MSM), or reported same sex contact.2 In this case we describe a patient with mpox (monkeypox) who was admitted with AUR as the chief complaint and was managed conservatively.

Case presentation

A usually fit and well man in his 20s was travelling to the UK, when he initially presented to a UK sexual health clinic 3 days postunprotected oral and anal intercourse with a Caucasian man from the UK. He presented with a 1 day history of pustular penile discharge, penile pain, and white pustular lesions under the foreskin and on the shaft of the penis. This patient’s sexual contact was confirmed mpox (monkeypox) positive. Two days prior to admission (day 7 postexposure) he developed severe influenza-like symptoms and multiple penile (figure 1) and anal lesions (figure 2) developed overnight with associated proctitis and purulent anal discharge.

Admission was prompted by severe penile swelling, unretractable foreskin and secondary urinary retention. The original white spots were now black and had spread to elsewhere on his body, such as the arms, face, back, feet and shoulders. Mpox (monkeypox) swabs were sent for testing at the Public health england rare and imported pathogen laboratory. A digital rectal exam was performed but assessment of the entire gland was not possible due to pain secondary to proctitis and perianal lesions. The patient was catheterised to relieve his symptoms; 250 mL of clear urine was passed. He was isolated and managed in a side room. On examination he had several well circumscribed umbilicated lesions on the penile shaft and scrotum with diffuse penile oedema without any signs of necrosis. There were also several pustular lesions over the face, back, legs and perianal region.

Investigations

The vitals were stable and the patient was afebrile throughout admission. Full blood count, blood urea and electrolytes were both within normal range. C-reactive protein (CRP) was mildly raised to 55.

Syphilis negative—HIV negative

Mpox (monkeypox) positive—Gonorrhoea and Chlamydia negative

Herpes simplex virus 1 and 2 negative—Urine culture negative

Treatment

Prior to admission, 5 days postexposure he presented to a sexual health clinic and received the smallpox vaccine, intramuscular ceftriaxone 1 g and was given 100 mg doxycycline orally for sexually transmittted infection (STI) cover. This was stopped when he was admitted to hospital 9 days postexposure. He was catheterised with a simple two-way catheter (figure 3). A suprapubic catheter was not used as it would have been more invasive and pustular discharge per urethra is not a contraindication for urethral catheterisation. He was given co-amoxiclav as per microbiology advice to cover for SSI. He was also given tamsulosin until he was TWOCd to ensure success as a full prostate assessment had not been possible. Regular non-steroidal anti-inflammatory drugs (NSAIDs) were used which helped him with his pain and inflammation. Lignocaine jelly was used for painful scabs around the anus to very good effect.

Outcome and follow-up

He was successfully TWOCd alongside tamsulosin 2 days after catheter insertion. The patient became comfortable, his penile swelling reduced 3 days after admission and he was deemed medically fit for discharge. On discharge, follow-up was arranged with the local sexual health clinic to review swab results. We intend to carry out flow rate, PVR, IPSS and pain scores in 4–6 weeks time.