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Tromboflebite da Veia dorsal do pênis

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Postado em 10/07/2011 às 20:46:15 por Talles Leandro de Oliveira

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CASE REPORTS: Thrombophlebitis of the superficial dorsal vein of the penis

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This article presents a clinical case about the condition and describes the symptomatology, diagnosis, and treatment of superficial thrombophlebitis of the dorsal vein of the penis. 

Keywords: Mondor’s disease, superficial thrombophlebitis
Corresponding Author: Leandro de Oliveira, Talles (Oliveira TL)  e-mail: Physician Assistant Urology, University Hospital Alcides Carneiro, Federal University of Campina Grande, PB

Penile Mondor’s disease (superficial thrombophlebitis of the dorsal vein of the penis) is an important clinical diagnosis and with auto-limitited benign course. Although penile Mondor’s disease is rare, proper diagnosis and consequent reassurance can help to dissipate the anxiety typically experienced by patients with the disease. This article presents a clinical case about the condition and describes the symptomatology, diagnosis, and treatment of superficial thrombophlebitis of the dorsal vein of the penis. 
Objective: To present a clinical case of thrombophlebitis of the superficial dorsal vein of the penis and show a literature review of diagnosis and treatment.
Although first described in 1869 by Flagge, thrombophlebitis superficial vessels thoracoepigastric only merited the attention of physicians in 1939 when Henri Mondor edited their review article entitled "Tronculite cutanée subaiguë sous la paro thoracique anterolateral"1 . Later Braun-Falco (1955) describes a case of thrombophlebitis of the superficial dorsal vein of the penis (TVDSP)2 in 1958 and Helm and Hodge and Harrow and Sloan in 1963  warn that this entity is more frequent than it was pensava3.
This is a situation of benign clinical diagnosis which is easily accomplished at the bedside but which must be substantiated by penile Doppler ultrasound study, which usually evidence of vessel thrombosis.
Although Mondor's disease (thrombophlebitis of the superficial dorsal vein of the penis) is rare, proper diagnosis can help to dispel the anxiety typically experienced by patients with the disease. This article describes the symptoms, diagnosis and treatment of superficial thrombophlebitis of the penis dorsal vein.
Case Report
Male patient, 47 years complaining of pain penile erection associated with the presence of induration on the dorsal penis, evolving for 1 week. Also refers erection curved upward. Deny urinary symptoms or recent history of trauma or vigorous sexual activity. There is no reporting of medication use. Deny hypertension or diabetes. Deny smoking and social uses of alcohol. At physical examination: presence of superficial induration on palpation (type thin cord Induration) in the dorsal region of the penis. It was made possible diagnosis of superficial thrombophlebitis of the dorsal vein of the penis. Prompted U.S. Doppler and started NSAIDs for 7 days and 400mg vitamin E daily, and instructed to avoid sexual activity during treatment. Twenty days later the patient returns and refers no pain anymore but still complaining about superficial induration on the penis. The Doppler ultrasound revealed no flow in the superficial dorsal penile vein and thrombus (fig 1 e 2). Oriented continuation of vitamin E for over a month. There was complete resolution of induration after this period.
Figure 1: thickning of the venous wall.The lúmen being     
Figure 2: Abcence of blood flow in the dorsal vein of the penis
  occupied by echogenical material corresponding to thrombus.
Thrombosis of the dorsal vein of the penis is a rare disorder that tends to affects males in the 21-70 years age range1,4. The reported causal factors comprise traumatisms, excessive sexual activity, prolonged sexual abstinence, local or distant infectious processes, venous obstruction secondary to bladder distension, pelvic tumors or constrictive elements used in certain sexual practices, and the abuse of certain intravenous drugs. There have been reports of associations with certain tumors (of the bladder and prostate gland), and the condition has also been described as an unusual initial manifestation of disseminated pancreatic adenocarcinoma4. Up until 1996, a total of 42 cases of this disorder have been reported in the literature – the most extensive series corresponding to that of Findlay and Whiting5.
The histopathological study reveals thinning of the vascular wall, with the loss of differentiation between the intimal layer (which appears thinned, with thickened endothelial cells) and the connective tissue (reduced elastic tissue). The venous lumen moreover appears occupied by conventional thrombotic material (red cells, fibrin, platelets) associated to a local inflammatory reaction6.
Penile Mondor’s disease can be diagnosed from the information obtained during the history and physical examination. Patients consistently present with a ropelike cord on the dorsum of the penis. The cord is the thrombosed dorsal vein, which has become thickened and adherent to the overlying skin. Often, the lesion will extend superiorly into the suprapubic area. The vein may appear to be swollen and erythematous. The patient will report having a significant amount of pain, which can be either episodic or constant. Symptoms typically last from 6 to 8 weeks and resolve completely. There is no evidence of any long-term sequelae from this disease7.
The diagnosis must be supported with an ultrasound study of the penis with Doppler especially in cases where the diagnosis is not very evident. Ultrasound findings are more relevant to non-compressibility or absence of flow within the superficial dorsal vein of the penis; Sometimes the ultrasound observe the presence of a clot intravascular8.
Thrombophlebitis of the superficial dorsal vein can be divided into three clinical stages: Acute, subacute and re-permeabilized. The acute stage tends to manifest in males in the 20-40 years interval, and typically manifests in the 24 hours following prolonged sexual activity, possibly secondary to vascular endothelial trauma. Finally, repermeation of the vein is observed, with elimination of the thrombus and resolution of the clinical picture within 6-8 week9. Sclerosing lymphangitis and Peyronie’s disease both need to considered in the differential diagnosis of a painful, fibrotic lesion of the penis, however.
Several methods of treating penile Mondor’s disease have been proposed, none of which has been shown to significantly decrease disease duration10. Treatment is conservative, with rest, nonsteroidal antiinflammatory medication, and occasionally topical heparinizing agents to reduce the pain and local inflammation. The use of antibiotics is particularly indicated in patients with evidence of cellulites at physical examination11.
The use of anticoagulants is subject to controversy. In general terms, the literature does not recommend their use in patients diagnosed with Mondor’s syndrome. However, Sasso and colleagues recommend anticoagulation in the acute phase (24-48 hours) in order to avoid possible additional thrombotic events. They are also indicated in patients with a history of thrombotic disease or coagulation disorders6. Ramirez and colleagues recommend the use of vitamin E as additional treatment for their anti-oxidants  actions8.
In those cases where the symptoms persist after 8 weeks, surgery can be considered – the most common technique being thrombectomy, and in some cases excision of the superficial dorsal vein of the penis. In some cases the preputial edema and surrounding inflammation caused by the vascular damage may give rise to phimosis, which is amenable to treatment in the form of circumcision12.
Patients also should avoid sexual devices or practices that are capable of causing venous stasis and injury to the penis. 
Mondor’s syndrome is an infrequent and generally self-limiting condition caused by vigorous sexual activity, coagulation problems, infections and neoplastic processes. When the condition is clinically suspected, doppler ultrasound is indicated, revealing thrombosis of the superficial dorsal vein of the penis. Treatment is based on nonsteroidal antiinflammatory medication, antibiotherapy in selected cases, and sexual abstinence.&o6319;
1.Mondor H. - Tronculite sous-cutanée subaiguë de la paroi thoracique antéro-laterále. Mém Acad Chir 1939; 65: 1271-8 
2.Braun-Falco O; Zur KlinikHistologie und Pathogenese der strangförmigen oberflächlichen Phlebitiden. Derm Wschr, 1955; 132: 705-15 
3. Helm JD Jr; Hodge IG – Thrombophlebitis of a dorsal vein of the penis: report a case treated by phenylbutazone (Butazolidin). J Urol, 1958; 79: 306-7 penis presenting to na STD clinic. Genitourin Med, 1994 Dec; 70 (6): 406-9 
4. Swierzewski SJ 3rd, Denil J, Ohl DA. The management of penile Mondor´s phlebitis: superficial dorsal penile vein thrombosis. J Urol 1993 Jul;150(1):77-78.
5. Sasso F, Gulino G, Basar M, Carbone A, Torricelli P, Alcini E. Penile Mondor`s disease: an underestimated pathology. Br J Urol 1996 May;77(5):729-732
6. Escudero RM, Benavente RC, Gardiner JIM, Diez IL, Jimenez JT, Fagundo EP and Fernandez CH. MONDOR’S SÍNDROME. CASE REVIEW AND BIBLIOGRAPHIC REVIEW. Arch. Esp. Urol. 2009; 62 (4): 316-319
7. Rodriguez FO, Parra ML, Gomez CSC,  Martin BJL, Escaf BS. Thrombosis of the dorsal vein of the penis (Mondor’s phlebitis). A case report. Actas Urol Esp 2006; 30 (1): 80-82
8. Ramires R, Lima E, Versos R, Sousa P, Soares J, Carvalho LF, Queiroz J, Soares P Ribeiro M e Pimenta A. Tromboflebite da veia dorsal superficial do pénis: a propósito de um caso. Acta Urológica Portuguesa 2001, 18; 1: 61-65
9. Arango O, Peyri E, Alvarez-Vijande R. Lesiones vasculares cutáneas de los genitales masculinos. Jarpyo Ed. Madrid 1998;55
10. Griger DT, Angelo TE and Grisier DB. Penile Mondor’s disease in a 22-year-old man. JAOAVol 101 • No 4 • April 2001 • 235 
11. Al-Mwalad, Loertzer H, Wicht A., et al. Subcutaneous penile vein thrombosis: Pathogenesis, diagnosis and therapy. Urology 2006; 67: 586–588.
12. Lilias LA, Mumtaz FH, Madders DJ. Phimosis after penile Mondor´s phlebitis. BJU Int 1999; 83: 520- 521.

Date added to 01/06/2010 (publication information)
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Million thanks to Oliveira TL for a reported case of penile thrombophlebitis. I ,myself preferred to find any other skin lesions as Janeway & Osler's spots wherelse could appear on thoroughly physical examination and this will be the best for clinical picture, perhaps.


Warawit Chaianant MD.

 7/6/2010; 13.09pm.

Submitted by: warawit chaianant
Date Submitted: 08/06/2010

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