SCIENTIFIC
Penile Variant of Mondor ’ s Disease : A Challenging Diagnosis Requiring Primary Care and Urologic Collaboration
AUTHORS :
Benjamin J . Wendt , MD Emergency Department Attending Physician , Avita Health System Galion Hospital
Adam M . Franks , MD Professor , Department of Family & Community Health , Joan C . Edwards School of Medicine
Sara L . O . Dusing , MD Department of Family Medicine , UVA Primary Care Family Medicine
Kenton L . Hess , MD Department of Family Medicine , Washington Health System
Kathleen M . O ’ Hanlon , MD Professor , Department of Family & Community Health , Joan C . Edwards School of Medicine
Stephen M . Petrany , MD Professor and Chair , Department of Family & Community Health , Joan C . Edwards School of Medicine
CASE PRESENTATION
A 28-year-old man with a history of hypertension presented as an outpatient with a three-day history of pain at the base of his penis . Initially , he described the pain as a mild , intermittent ache that radiated to the bilateral inguinal regions . The pain was unrelated to movement but intensified over the next 24 hours , centering at the base of his penis with extension into the scrotum . Erection significantly exacerbated his discomfort , causing him to be unable to have intercourse with his wife . Additionally , the patient could palpate a small mass at the base of his penis that he associated with the pain . He denied dysuria , hesitancy , weak urinary stream , increased urinary frequency , hematuria or penile discharge . He also had no prior history of deep and superficial venous thrombosis . Furthermore , the patient denied previous penile trauma , whether accidental or from an intentional sexual act .
ABSTRACT
Thrombophlebitis of the superficial dorsal penile vein is an infrequently reported condition that presents with pain and induration at the base of the penis . Known clinically as the penile variant of Mondor ’ s disease ( PVMD ), this rare pathology can elicit fear and embarrassment in patients , making it difficult for them to seek medical care . PVMD is also frustrating
Physical examination revealed a well-nourished man with no abnormalities except in his genitalia . Examination of the penis was somewhat limited by the degree of penile pain with manipulation . No discoloration or edema was evident either at the base of the penis or distally . Palpation at the base of the penis revealed a 3.0 x 0.6-centimeter , tender , non-compressible mass extending distally midway between the right pubic tubercle and the pubic symphysis ( Figure 1 ). Ultrasound of the affected area demonstrated a thrombus in the superficial dorsal penile vein , with extension underneath the pubis ( Figure 2 ). Results of laboratory studies such as the serum complete blood count , antithrombin III , lupus anticoagulant , protein C , protein S , and factor V Leiden were all within normal limits , along with his international normalized ratio of 0.93 . Serum chemistry studies revealed a low calcium , albumin , and total protein levels .
The patient was admitted to the hospital for observation and urologic consultation . He was subsequently placed on low-molecularweight heparin ( LMWH ). The affected area was treated with warm compresses , and acetaminophen was administered for pain control . When no further clot progression was noted after 24 hours , the patient was discharged on treatment dose LMWH for two weeks , with a follow-up visit scheduled with his primary care physician and urologist . Evidence of thrombosis , with possible extension , was noted on the clinical examination several months after discharge . Prior to definitive treatment , five months to clinicians , as its etiology can be varied , typical laboratory abnormalities are often absent , its presentation can be imitated by other diagnoses , and a consensus on treatment has not yet been reached . As depicted in this case report , this challenging diagnosis requires the collaboration of primary care physicians and urologists to optimize patient care .
after his initial presentation , a follow-up ultrasound demonstrated resolution of the thrombus .
DISCUSSION
In 1939 , Henri Mondor first described superficial thrombophlebitis of the chest wall and breast . 1-6 Nearly 20 years later in 1958 , Braun-Falco noted that penile involvement was also possible . 2 , 4-8 Ultimately , it was Helm and Hodge who isolated superficial thrombophlebitis within the superficial dorsal penile vein . 2-6 , 9 Penile variant of Mondor ’ s disease ( PVMD ) is an underreported condition due to its embarrassing nature , frequent misdiagnosis , and spontaneous resolution . 2 Occurring in approximately 1.4 % of the male population , 2 , 10 PVMD is most common in sexually active young men between the ages of 20 and 40 years , but it has also been observed in patients as old as 71 years of age . 11
Understanding the presentation and management of PVMD is important to clinicians due to its sudden and disquieting presentation in the outpatient setting ( Table 1 ). Consequently , primary care physicians ’ familiarity with PVMD can provide reassurance to the distressed patient . Once medical care is ultimately sought , however , misdiagnosis remains a possibility if the primary care physician is unfamiliar with the disease . The disease most often presents suddenly as an erythematous , warm cord with induration located at the dorsum of the penis , near the sulcus coronaries . 9 The presence of pain varies from occurring
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