Summary: Mondor’s disease of the penis, otherwise known as superficial thrombophlebitis (STP) or thrombosis of the dorsal vein, is an under-reported benign condition, the aetiology of which is poorly understood. It is characterized by a sudden, indurated swelling of the vein, often occurring after vigorous sexual activity. We report a case of Mondor’s disease occurring 24 h following a 15-h flight. This gentleman also reported a history of STP of his left lower limb varicose veins following a similar- length flight three years previously. In the absence of any other clear predisposing factor, we propose long-haul flight as an important factor contributing to the development of dorsal vein thrombosis.
Keywords: Mondor’s disease, dorsal vein thrombosis, flight, thrombophlebitis
Case report
A 33-year-old British Caucasian heterosexual man presented to our genitourinary clinic concerned with a five-day history of prominent enlargement of the penile dorsal vein. It had enlarged, suddenly, 24 h following a 15-h flight home from a short business trip to the Philippines and was causing mild discomfort. He reported no meatal discharge, frequency or urethral dysuria.
The patient reported an isolated episode of unprotected fellatio with a Philippino (non-commercial sex worker) woman, nine days prior to presentation. He said that this activity had not been vigorous, traumatic or prolonged. At 14 days prior to presentation and before his trip to the Philippines, he reported unprotected vaginal intercourse with his British-born wife of five years. The patient had not used constriction rings, sex aids, or penile injections, excessively masturbated or otherwise suffered trauma to the genitals.
Previous medical history included mitral valve prolapse and lower limb greater saphenous vein varicosities. He reported a history of acute superficial thrombophlebitis (STP) of the left leg veins following a similar flight from the Philippines three years previously, but denied any family or personal history of deep venous thrombo-embolism, coagulation disorders, and periods of immobility or surgery. The patient was generally physically well, not overweight, and did not smoke.
On examination, the patient had a 2-cm long, indurated, cord- like lesion, palpable within the dorsal vein of the penis, extending to the base of the penile shaft (Figure 1). The vein was poorly compressible, minimally tender with no oedema or cellulitis evident. The presence of two long-standing epipidymal cysts was documented. Examination was otherwise unremarkable. He received a full genitourinary screen and was diagnosed with non-specific urethritis and treated with azithromycin. His genitourinary screen proved negative for Chlamydia trachomatis, Neisseria gonorrhoeae, and syphilis. We diagnosed Mondor’s disease clinically.
Discussion
Mondor’s disease, otherwise known as superficial dorsal penile vein thrombosis (DoVT) or thrombophlebitis, is an under-reported condition. It was first described as STP of the thoraco-epigastric veins and/or their confluent vessels in 1939, but the definition since 1958 includes the dorsal penile vein.1 It presents as a sudden, indurated cord-like swelling of the vein, measuring up to 5 cm in length.2 It may be associated with inflammation, pain, and fever.
Important differential diagnoses of penile swelling and deformity should include ruptured corpus cavernosum, Peyronie’s disease, and lymphoedema.
The exact aetiology of the thrombus remains unclear, but sexual activity, specifically of a traumatic, vigorous, prolonged or excessive nature, has been a consistent predisposing factor, usually reported to have occurred 24-48 h prior to its development.3-6 This activity may induce stretching or torsion of the vein, causing endothelial necrosis and subsequent thrombus formation.7 Other precipitants include trauma to the genitals such as penile strangulation or injection, presence of a pelvic tumour or distended bladder, sepsis, inguinal hernia repair, deep vein thrombosis, prolonged abstinence, and contact with menstrual blood, possibly acting as an irritant.3,4,8,9 The diagnosis is usually based on clinical findings, but Doppler ultrasound can be useful in cases of diagnostic uncertainty, where it may reveal a non-compressible distended vein.2 The patient need not require further investigation unless clinically indicated.2
Figure 1 Dorsal vein thrombosis of the penis
Spontaneous resolution following venous recanalization occurs within a mean of three weeks, but can take up to eight weeks.3 Non- steroidal anti-inflammatory agents may be used for symptomatic relief, although they do not affect the resolution rate.4 For refractory cases, venous resection can be effective in reducing pain, induration, and improving cosmesis.3,7 Anticoagulants are not necessary and may cause excess blood leakage if a ruptured corpus cavernosum is incorrectly diagnosed as DoVT.2
Mondor’s disease is generally a benign pathology with few complications. Phimosis has been reported rarely secondary to oedema.10 Erectile difficulties do not result although Mondor’s dis ease can mimic Peyronie’s disease.2 Recurrence can occur in relation to predisposing sexual activity.4 Above-knee STP of greater saphenous vein varieosities can be associated with deep vein thrombosis and, very rarely, pulmonary embolus. These conditions have fortunately not been reported with Mondor’s disease.
This is the first case of DoVT reported in relation to a recent long-haul flight. The aetiology of STP is associated with one or more components of the Virchow triad: intimai damage secondary to trauma, inflammation, and infection; venous stasis; change in blood constituents such as coagulation abnormalities. Evans et al. did not identify any coagulation abnormalities during the extensive work-up of their DoVT case series. In the absence of trauma, inflammation, and sepsis, or a clear predisposing factor for the development of Mondor’s disease and in view of the previous history of varicose vein STP, venous stasis due to prolonged immobility and dehydration as a result of longhaul travel may precipitate the development of Mondor’s disease.
Acknowledgements: We would like to acknowledge the staff in medical photography at St Thomas’ Hospital for their help in producing the photographic prints. We would like to thank the patient for allowing us to report this case and present his photographic imaging.
References
1 Katz R, Blachar A. Superficial dorsal penile vein thrombosis (Mondor’s disease). Harefuah 1997;132:544-5, 607
2 Evans DT, Ward OE. Dorsal vein thrombosis of the penis presenting to an STD clinic. Gcnitonrin Med 1994;70:406-9
3 Sasso F, Gulino G, Basar M, Carbone AD, Torricelli P, Alcini E. Penile Mondor’s disease: an underestimated pathology. Br J Ural 1996;77:729-32
4 Swierzewski III SJ, Denil J, OhI DA. The management of penile Mondor’s phlebitis: superficial dorsal penile vein thrombosis. J Urol 1993;150:77-8
5 Dicuio M, Pomara G, Cuttano MG, et ni. Penile Mondor’s disease after intensive masturbation in a 31- and a 33-yearold man. Thromb Haemost 2003;90:155-6
6 Ozkara H, Akkus E, Alici B, Akpinar H, Hattat H. Superficial dorsal penile vein thrombosis (penile Mondor’s disease). Int Urol Nephrol 1996;28:387-91
7 Kraus S, Ludecke G, Weidner W. Mondor’s disease of the penis. Urol Int 2000;64:99-100
8 Bird V, Krasnokutsky S, Zhou HS, Jarrahy R, Khan SA. Traumatic thrombophlebitis of the superficial dorsal vein of the penis: an occupational hazard. Am J Emerg Med 1997; 15:67-9
9 Nickel WR, Plumb RT. Nonvenereal sclerosing lymphangitis of the penis. Arch Derm 1962;86:761-3
10 Lilas LA, Mumtaz FH, Madders DJ, McNicholas TA. Phimosis after penile Mondor’s phlebitis. BJU Int 1999; 83:520
(Accepted 26 July 2004)
S Day MRCP and J S Bingham FRCP FRCOG
Lydia Department, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
Correspondence to: Dr S Day, 52 Hayes Grove, East Dulwich, London SE22 8DF, UK
Email: [email protected]
Copyright Royal Society of Medicine Press Ltd. Jul 2005
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