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Case Report
Superficial Dorsal Penile Vein
Thrombosis (Mondor Disease of
the Penis) Involving the Superficial
External Pudendal Vein
Color Doppler Sonographic Findings
Is¸ik Conkbayır, MD, Bahar Yanik, MD, Bahri Keyik, MD,
Baki Hekimog˘lu, MD
M
ondor disease of the penis is an uncommon condition characterized by
thrombosis in the superficial dorsal penile vein (SDPV). Sonographic findings of SDPV thrombosis have been well documented in the literature.
However, to our knowledge, the color Doppler sonographic findings of
SDPV thrombosis involving the superficial external pudendal vein (SEPV) have not
been reported before. We report the color Doppler sonographic findings of a case with
SDPV thrombosis extending into the SEPV to its confluence with the long saphenous
vein and discuss the importance of interruption in this venous drainage route as an etiologic factor of the disease.
Case Report
Abbreviations
SDPV, superficial dorsal penile vein; SEPV, superficial
external pudendal vein
Received March 4, 2010, from the Department of
Radiology, Ministry of Health, Yildirim Beyazit
Dis¸kapi Educational and Research Hospital, Dis¸kapi,
Ankara, Turkey. Revision requested March 8, 2010.
Revised manuscript accepted for publication March
17, 2010.
Address correspondence to Is¸ik Conkbayır, MD,
EMA Asmabahçe Konutlari, E/10 Çayyolu, Yenimahalle,
TR-06440 Ankara, Turkey.
E-mail: [email protected]
A 49-year-old male bus driver presented with a mild
painful thickening on the dorsal aspect of his penis
extending from the corona of the glans to the base. This
cordlike thickening had appeared 1 week previously and
was more painful during erections. There was no history
of erectile dysfunction, recent extensive sexual activity,
trauma, recent surgery, or sexually transmitted or urinary
infectious disease. Physical examination revealed no
other abnormality, and urinalysis and coagulation test
results were normal.
Sonography revealed a dilated, noncompressible SDPV
with an internal hypoechoic thrombus (Figure 1). At the
base of the penis, the thrombus extending to the right
SEPV in its entire course through the confluence with the
right long saphenous vein was shown in the right
inguinal region in the oblique plane. There was no communication between the SDPV and left SEPV. Color
© 2010 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2010; 29:1243–1245 • 0278-4297/10/$3.50
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Superficial Dorsal Penile Vein Thrombosis
Doppler sonography showed no blood flow signal
in the SDPV or right SEPV, confirming the diagnosis of superficial thrombophlebitis: so-called
Mondor disease of the penis (Figures 2 and 3).
The patient was treated with nonsteroidal antiinflammatory drugs for 6 weeks, and he was
advised to abstain from sexual activity until the
symptoms resolved. The cordlike thickening
disappeared after 6 weeks of treatment, and a
flow signal was established in the SDPV and right
SEPV on color Doppler sonography after the
sixth week.
Figure 1. Montage of 2 contiguous gray scale sonograms of the
penile shaft in the longitudinal plane showing a hypoechoic,
thrombus-filled SDPV (arrows).
Discussion
Figure 2. Color Doppler sonogram of the penile shaft in the
transverse plane showing the absence of a flow signal in the
SDPV (arrow) and a flow signal in both of the dorsal penile arteries (arrowheads).
Figure 3. Montage of 2 contiguous color Doppler sonograms in
the oblique plane showing the absence of a flow signal in the
thrombosed SEPV (arrows). A flow signal is shown in the long
saphenous vein (curved arrow).
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Thrombosis of the SDPV was originally described
as a variant of Mondor disease, which is superficial venous thrombosis of the anterolateral thoracoabdominal wall.1,2 Mondor disease of the
penis is a rare entity, with reported incidence of
1.39%.3 It has been considered an underestimated condition because it is a self-limiting process,
and most patients do not consult a physician
because of fear and embarrassment, and many
cases have not been diagnosed correctly.2–5
Mondor disease of the penis presents with a
cordlike induration, which is often painful in the
dorsal aspect of the penis. Although it is a selflimiting process, various treatment modalities
such as antibiotics, anticoagulant drugs, antiinflammatory agents, and local heparin creams
have been proposed in the literature. For most
patients, recanalization of the vein usually occurs
after 6 to 8 weeks of conservative treatment. In
rare persistent cases, surgical treatments such as
thrombectomy and SPDV resection have been
recommended.5,6
The etiopathogenesis of penile Mondor disease
is still controversial. Events that precipitate this
disorder include excessive sexual activity, prolonged sexual abstinence, infection, venous
compression due to a tumor or distended bladder, injection of illegal drugs into the penile
dorsal vein, deep venous thrombosis of the leg,
migratory phlebitis associated with cancer, and
surgical repair of an inguinal hernia.5,7 For idiopathic penile venous thrombosis, deficiencies of
antithrombin III, protein C, and protein S can be
considered risk factors.8 Our case did not have
any abnormal laboratory findings or precipitating factor except his job, which required him to
sit in a driving position for a long time. In the literature, a similar case that occurred after a longhaul flight was also reported.9
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Conkbayır et al
In most cases, the diagnosis is based on clinical
findings. Color Doppler sonography is useful in
both the diagnosis and follow-up of these
patients to visualize resolution of the thrombosis
and appearance of normal blood flow during and
after treatment.5,6 Magnetic resonance angiographic findings were also found to be valuable
for the depiction of a thrombosed SDPV.10 The
color Doppler sonographic findings of thrombosis without a blood flow signal in the SDPV and
the low, highly resistant flow in the cavernosal
artery have been reported as suggestive findings
for Mondor disease of the penis.1 However, in a
recently published report, a case with the
presence of a high-resistance pattern with low
systolic peaks in the cavernosal arteries before
injection of a vasoactive agent and normal
spectral Doppler findings after the injection
was reported.11 The normal Doppler waveforms
of the cavernosal arteries in the flaccid state
before vasoactive agent injection showed a highresistance pattern with low systolic peaks and
absent or reverses diastolic flow.12 In our case,
we also observed this normal waveform pattern
in the cavernosal arteries and did not perform an
examination with injection of a vasoactive agent
because erectile dysfunction was not indicated
in the patient’s medical history.
The venous outflow of the skin and subcutaneous
tissue superficial to the Buck fascia of the penis is
through the SDPV into the right or left SEPV, or
both, and then into the long saphenous vein at the
groin.2 An anomalous course of an SEPV, passing
through the inguinal canal, was also reported in the
literature.13 Therefore, it is possible that bilateral
ligation surgery of the tributaries of the saphenofemoral junction for lower limb varices, surgical
procedures in the inguinal region such as inguinal
hernia repair, and thrombosis at the saphenofemoral junction affecting the confluence of
the SEPV may interrupt the superficial venous
drainage of the penis, with consequent venous stasis and thrombophlebitis. In 20% of cases, the
SPDV drainage is unilateral, and this variation presumably increases the risk of venous occlusion.2,5,7
In our case, only the right SEPV drained the SDPV,
and the extension of the thrombus from the
SDPV into the SEPV over its entire course to the confluence with the right long sapheneous vein was
shown on color Doppler sonography.
J Ultrasound Med 2010; 29:1243–1245
In conclusion, after long saphenous vein and
inguinal region surgery or in the case of thrombosis at the saphenofemoral junction that
affects the confluence of the SEPV, Mondor disease of the penis may occur. These patients can
be followed with clinical examinations and color
Doppler sonography, which easily shows the
thrombus in the SDPV and its extension into the
SEPV.
References
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