TRAUMATIC
COL. THOMAS MAJ. JAMES
LYMPHANGITIS
OF PENIS*
P. BALL JR., (MC) USAF
D. PICKETT,
(MC) USAF
From the Urology Service, Department Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas
of Surgery,
ABSTRACT - The appearance of a$rm, nodular, cord-like structure in the coronal sulcus of the penis has heretofore been considered and reported in the urologic literature as thrombophlebitis of the superficial veins. Further study and review of the literature reveal this condition to be a traumatic lymphangitis which is directly related to sexual trauma and runs a short, asymptomatic, self-limited course.
In 1958 Helm and Hodge’ reported a case of thrombophlebitis of the superficial veins of the penis which was successfully treated with phenylbutazone. No etiology for this condition was proposed, and the diagnosis was not confirmed pathologically. Five years later the second article on this subject was published by Harrow and Sloane.2 In their report 9 cases of “thrombophlebitis” of the penile veins were described, and correlation with sexual trauma was established as was the self-limiting course of this condition. Since 1963 there has been no further mention of this entity in the urologic literature, and urologists have continued to share their misconceptions regarding its nature with their colleagues in other specialities. While serving with the United States Air Force in Europe, we observed a series of cases in which findings were consistent with those described by Harrow and Sloane. Several of these patients were referred from great distances, having been treated with a variety of modalities including strict bedrest and anticoagulation. Referring diagnoses varied from Peyronie’s disease to carcinoma, but in most the diagnosis was thrombosis of the dorsal penile veins. Presented at the Kimbrough Urological Seminar, San Antonio, Texas, September 13, 1974. *The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force.
594
Case Abstracts Case 1 A twenty-two-year-old white male was transferred from the Azores Islands for evaluation of an episode described as thrombophlebitis of the dorsal vein of the penis. He had had a recent increase in the frequency of sexual intercourse and had noted some swelling and tenderness on the dorsum of the penis for which he was hospitalized and begun on anticoagulant therapy. All laboratory studies including urinalyses and a VDRL were negative. He had been started on warfarin (Coumadin) 7.5 mg. per day with gradual resolution of the swelling only to have it recur two times while in the hospital. On questioning it was revealed that the patient had been allowed out on pass and each of these times had again participated in vigorous sexual activity. The problem was explained to the patient, anticoagulants were discontinued, and after three weeks of abstinence the lesion was totally resolved. Case 2 A twenty-two-year-old white male was admitted with a dilated “vein” on the right side of the penis just behind the glans. The lesion was noted to become more prominent with erection and to become slightly tender after repeated intercourse. There was no evidence of inflammation, tenderness, or urethral symptoms, and no urethral discharge. With a decrease in frequency
UROLOGY
/ NOVEMBER
1975
/ VOLUME
VI, NUMBER
5
of intercourse, the lesion four weeks’ time.
resolved
completely
in
Case 3 A forty-nine-year-old civil servant was seen two days after the onset of a slightly tender, serpiginous swelling behind the corona of the glans penis which followed a “flurry” of sexual activity. There was no urethral discharge. Very slight edema was present, and the swelling was translucent and fluctuant proximally and dorsally but quite firm and freely mobile beneath the penile skin on the ventral surface. This lesion had the gross appearance of a lymph vessel and was believed to represent a true traumatic lymphangitis. Resolution was complete after three weeks. Case 4 A twenty-three-year-old white male Army lieutenant was evaluated for two firm masses on the left side of the penis which had appeared seven days previously. The patient had had vigorous sexual relations the night before the onset of the lesion. During the interim, the lesion had progressed somewhat in size but had no significant tenderness. Physical examination revealed a firm, serpiginous, freely movable lesion which extended almost completely around the penis behind the corona and distally on the inferior aspect of the glans. No treatment was provided, and the lesion regressed spontaneously. Case 5 A thirty-three-year-old white male was seen on January 7, 1970, with a four-day history of swelling on the left side of the penis which became worse with erection. He had had frequent intercourse during the holiday season. On examination a serpentine soft swelling of the left side of the penis behind the glans which extended around to the ventral surface was noted. The situation was explained to the patient, and spontaneous resolution was prompt.
Case 6 A twenty-seven-year-old Air Force civilian employee presented himself for evaluation one week prior to his marriage. He admitted to very frequent intercourse with his fiancee and had recently noted a hard, tender, nodular area just proximal to the glans penis. Physical examination revealed a circumferential thickening around the distal penile shaft which was most prominent on the right side (Fig. 1). This thickening was continuous up the dorsal aspect of the shaft along
UROLOGY
/ NOVEMBER1975
/ VOLUMEVI,
NUMBER5
FIGURES. Firm cartilaginous lymphatic vessel proximal to coronal sulcus of penis.
the line of the superficial dorsal vein of the penis. Six weeks later, in spite of his recent marriage, there was very little evidence of thickening remaining, and the patient was completely asymptomatic.
Case 7 A twenty-six-year-old white male noted a tender, soft, elongated mass on the ventral surface of the penis approximately two weeks prior to attending the clinic. The patient had had a recent increase in the frequency of sexual relations. The lesion was noted to increase slightly in size following intercourse. On physical examination a firm, slightly tortuous, cord-like structure was seen to arise in the region of the frenulum coursing around toward the dorsum of the penis. A small, nodular branch was noted in the coronal sulcus up the right side of the penis. The lesion was translucent giving the appearance of being filled with a clear fluid (Fig. 2). The patient was reassured, and the lesion subsequently cleared spontaneously.
595
FIGURE 2. Translucent nodular lymphatic in typical location behind and beneath glans.
Comment In each case the vascular nature of the lesion was apparent and each was managed conservatively with total resolution. While venous thrombosis was initially accepted as the cause, in several of our cases the serpiginous vessel was superficial enough for its clear fluid content to be apparent, and the possibility of this condition actually representing lymphagitis rather than thrombophlebitis was entertained. Since biopsies were not done, the true etiology was obscure until a review of the dermatologic literature produced four reports referring to the condition as nonvenereal sclerosing lymphangitis.3-6 In 1962 Nickle and Plumb3 described the entity and attributed its original recognition to Hoffman. 7 In the Nickle and Plumb case the cartilaginous-like structure was excised and proved to be a sclerosed lymphatic vessel. Dean and Dean’ recognized the presence of lymph varices and stated “these lesions are also unusual; they appear in the coronal sulcus and along the distribution of the dorsal lymph channels.”
596
No mention was made of etiology, duration, or treatment. Subsequent reports by Boyd,4 Greenberg and Perry,5 and Lassus et aL6 further described the condition and offered additional pathologic confirmation of a sclerosing lymphangitis. Because of its consistent relationship with sexual trauma, we have elected to refer to this condition simply as traumatic lymphangitis. While thrombosis and thrombophlebitis of the dorsal veins of the penis do occur, proved cases have usually been associated with thromboangiitis obliterans, idiopathic thrombophlebitis, and direct trauma. Grossman et aLg reported a case in which there was marked swelling and eventual sloughing of the distal penis in a patient with known recurrent thromboangiitis obliterans and thrombophlebitis of the right leg. In cases of true dorsal vein thrombophlebitis the physical signs are usually much more striking and are normally only part of a more extensive process. Another condition which must be differentiated from both thrombophlebitis and traumatic lymphangitis is the subacute angiitis which may present as a manifestation of polyarteritis or the usually drug-induced hypersensitivity angiitis. lo These lesions are multiple subcutaneous peasized nodules which are freely movable and may be found anywhere along the shaft of the penis. They do not have a vascular configuration and usually respond well to steroid therapy. l1 In each case of this type a careful evaluation must be made to determine the underlying cause prior to initiating therapy. Traumatic lymphangitis of the penis is a selflimited condition resulting almost invariably from prolonged or repeated intercourse or other vigorous sexual manipulation and is doubtless far more common than is realized. It presents as a translucent, firm, nodular, almost cartilaginous, cord-like or serpiginous structure which arises in the coronal sulcus and may involve only one side or virtually encircle the penis. It is usually nontender, freely mobile, and may extend proximally along the dorsum of the penis, hence the confusion with thrombophlebitis. This condition has not been described in association with urethritis, prolonged catheter drainage, or inflammatory lesions of the glans or urethral meatus unless the latter were acute and also associated with prolonged vigorous intercourse. This, plus the lack of involvement of the regional lymph nodes, further suggests that infection is not an etiologic factor. Figure 3 shows a comparison of the typical superficial venous
UROLOGY
/ NOVEMBER
1975 / VOLUME
VI, NUMBER
5
(A) Typical venous drainage from penis; and (B) lymphatic drainage FIGURE 3. of the penis. (From Gray, H., Anatomy of the Human Body, courtesy of Lea and Febiger, Philadelphia.)
drainage of the penis and the lymphatic pathways, the latter conforming completely with the pattern found in each of the cases described. Although often suspected, thrombophlebitis has not been biopsy-proved in any patient seen with this clinical syndrome. Several forms of therapy have been employed, but none have varied the natural course of the condition which is spontaneous regression in four to eight weeks unless reaggravated by repeated sexual trauma. It has been our recommendation that the patient defer sexual relations until the lesion is completely resolved, then resume in moderation. Wilford Hall USAF Medical Center Lackland Air Force Base, Texas 78236 (DR.
NOVEMBER 1975 /
5.
6. 7.
8.
9.
10.
1. HELM, J. D., JR., and HODGE, I. G.: Thrombophlebitis of a dorsal vein of the penis, J. Urol. 79: 306 (1958). 2. HARROW. B. R.. and SLOANE. 1. A.: Thrombonhle-
/
4.
BALL)
References
UROLOGY
3.
VOLUME VI, NUMBER 5
11.
bitis of superficial penile and scrotal veins, ibid. 89: 841 (1963). NICKLE, W. R., and PLUMB, R. T.: Nonvenereal sclerosing lymphangitis of penis, Arch. Dermatol. 86: 761 (1962). sclerosing lymphangitis of BOYD, A. S.: Non-venereal the penis, Br. J. Dermatol. 82: 632 (1970). GREENBERG, R. D., and PERRY,T. L. : Nonvenereal sclerosing lymphangitis of the penis, Arch. Dermatol. 105: 728 (1972). LASSUS, A., et al.: Sclerosing lymphangitis of the penis, Br. J. Vener. Dis. 48: 548 (1972). HOFFMAN, E. : Vortauschung primarer Syphilis durch Gonorrhersche Lymphangitis (gonorrheischer Pseudoprimaraflekt), Munchen Med. Wochenschr. 70: II67 (1923). DEAN, A. L., and DEAN, A. L., JR.: In Campbell, M. F., Ed.: Urology, 2nd ed., W.-B. SaundersCompany, Philadelphia, 1964, chap. 28, p. 1228. GROSSMAN, L. A., et al. : Thrombosis of the penis interesting facet ofthromboangiitis obliterans, J.A. M.A. 192: 129 (1965). ZEEK, P. M.: Periarteritis nodosa and other forms of necrotizing angiitis, New Engl. J. Med. 248: 764 (1953). RUBENSTEIN, M., and WOLFF, S. M.: Penile nodules as a major manifestation of subacute angiitis, Arch. Intern. Med. 114: 449 (1961).
597
COL. THOMAS MAJ. JAMES
LYMPHANGITIS
OF PENIS*
P. BALL JR., (MC) USAF
D. PICKETT,
(MC) USAF
From the Urology Service, Department Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas
of Surgery,
ABSTRACT - The appearance of a$rm, nodular, cord-like structure in the coronal sulcus of the penis has heretofore been considered and reported in the urologic literature as thrombophlebitis of the superficial veins. Further study and review of the literature reveal this condition to be a traumatic lymphangitis which is directly related to sexual trauma and runs a short, asymptomatic, self-limited course.
In 1958 Helm and Hodge’ reported a case of thrombophlebitis of the superficial veins of the penis which was successfully treated with phenylbutazone. No etiology for this condition was proposed, and the diagnosis was not confirmed pathologically. Five years later the second article on this subject was published by Harrow and Sloane.2 In their report 9 cases of “thrombophlebitis” of the penile veins were described, and correlation with sexual trauma was established as was the self-limiting course of this condition. Since 1963 there has been no further mention of this entity in the urologic literature, and urologists have continued to share their misconceptions regarding its nature with their colleagues in other specialities. While serving with the United States Air Force in Europe, we observed a series of cases in which findings were consistent with those described by Harrow and Sloane. Several of these patients were referred from great distances, having been treated with a variety of modalities including strict bedrest and anticoagulation. Referring diagnoses varied from Peyronie’s disease to carcinoma, but in most the diagnosis was thrombosis of the dorsal penile veins. Presented at the Kimbrough Urological Seminar, San Antonio, Texas, September 13, 1974. *The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force.
594
Case Abstracts Case 1 A twenty-two-year-old white male was transferred from the Azores Islands for evaluation of an episode described as thrombophlebitis of the dorsal vein of the penis. He had had a recent increase in the frequency of sexual intercourse and had noted some swelling and tenderness on the dorsum of the penis for which he was hospitalized and begun on anticoagulant therapy. All laboratory studies including urinalyses and a VDRL were negative. He had been started on warfarin (Coumadin) 7.5 mg. per day with gradual resolution of the swelling only to have it recur two times while in the hospital. On questioning it was revealed that the patient had been allowed out on pass and each of these times had again participated in vigorous sexual activity. The problem was explained to the patient, anticoagulants were discontinued, and after three weeks of abstinence the lesion was totally resolved. Case 2 A twenty-two-year-old white male was admitted with a dilated “vein” on the right side of the penis just behind the glans. The lesion was noted to become more prominent with erection and to become slightly tender after repeated intercourse. There was no evidence of inflammation, tenderness, or urethral symptoms, and no urethral discharge. With a decrease in frequency
UROLOGY
/ NOVEMBER
1975
/ VOLUME
VI, NUMBER
5
of intercourse, the lesion four weeks’ time.
resolved
completely
in
Case 3 A forty-nine-year-old civil servant was seen two days after the onset of a slightly tender, serpiginous swelling behind the corona of the glans penis which followed a “flurry” of sexual activity. There was no urethral discharge. Very slight edema was present, and the swelling was translucent and fluctuant proximally and dorsally but quite firm and freely mobile beneath the penile skin on the ventral surface. This lesion had the gross appearance of a lymph vessel and was believed to represent a true traumatic lymphangitis. Resolution was complete after three weeks. Case 4 A twenty-three-year-old white male Army lieutenant was evaluated for two firm masses on the left side of the penis which had appeared seven days previously. The patient had had vigorous sexual relations the night before the onset of the lesion. During the interim, the lesion had progressed somewhat in size but had no significant tenderness. Physical examination revealed a firm, serpiginous, freely movable lesion which extended almost completely around the penis behind the corona and distally on the inferior aspect of the glans. No treatment was provided, and the lesion regressed spontaneously. Case 5 A thirty-three-year-old white male was seen on January 7, 1970, with a four-day history of swelling on the left side of the penis which became worse with erection. He had had frequent intercourse during the holiday season. On examination a serpentine soft swelling of the left side of the penis behind the glans which extended around to the ventral surface was noted. The situation was explained to the patient, and spontaneous resolution was prompt.
Case 6 A twenty-seven-year-old Air Force civilian employee presented himself for evaluation one week prior to his marriage. He admitted to very frequent intercourse with his fiancee and had recently noted a hard, tender, nodular area just proximal to the glans penis. Physical examination revealed a circumferential thickening around the distal penile shaft which was most prominent on the right side (Fig. 1). This thickening was continuous up the dorsal aspect of the shaft along
UROLOGY
/ NOVEMBER1975
/ VOLUMEVI,
NUMBER5
FIGURES. Firm cartilaginous lymphatic vessel proximal to coronal sulcus of penis.
the line of the superficial dorsal vein of the penis. Six weeks later, in spite of his recent marriage, there was very little evidence of thickening remaining, and the patient was completely asymptomatic.
Case 7 A twenty-six-year-old white male noted a tender, soft, elongated mass on the ventral surface of the penis approximately two weeks prior to attending the clinic. The patient had had a recent increase in the frequency of sexual relations. The lesion was noted to increase slightly in size following intercourse. On physical examination a firm, slightly tortuous, cord-like structure was seen to arise in the region of the frenulum coursing around toward the dorsum of the penis. A small, nodular branch was noted in the coronal sulcus up the right side of the penis. The lesion was translucent giving the appearance of being filled with a clear fluid (Fig. 2). The patient was reassured, and the lesion subsequently cleared spontaneously.
595
FIGURE 2. Translucent nodular lymphatic in typical location behind and beneath glans.
Comment In each case the vascular nature of the lesion was apparent and each was managed conservatively with total resolution. While venous thrombosis was initially accepted as the cause, in several of our cases the serpiginous vessel was superficial enough for its clear fluid content to be apparent, and the possibility of this condition actually representing lymphagitis rather than thrombophlebitis was entertained. Since biopsies were not done, the true etiology was obscure until a review of the dermatologic literature produced four reports referring to the condition as nonvenereal sclerosing lymphangitis.3-6 In 1962 Nickle and Plumb3 described the entity and attributed its original recognition to Hoffman. 7 In the Nickle and Plumb case the cartilaginous-like structure was excised and proved to be a sclerosed lymphatic vessel. Dean and Dean’ recognized the presence of lymph varices and stated “these lesions are also unusual; they appear in the coronal sulcus and along the distribution of the dorsal lymph channels.”
596
No mention was made of etiology, duration, or treatment. Subsequent reports by Boyd,4 Greenberg and Perry,5 and Lassus et aL6 further described the condition and offered additional pathologic confirmation of a sclerosing lymphangitis. Because of its consistent relationship with sexual trauma, we have elected to refer to this condition simply as traumatic lymphangitis. While thrombosis and thrombophlebitis of the dorsal veins of the penis do occur, proved cases have usually been associated with thromboangiitis obliterans, idiopathic thrombophlebitis, and direct trauma. Grossman et aLg reported a case in which there was marked swelling and eventual sloughing of the distal penis in a patient with known recurrent thromboangiitis obliterans and thrombophlebitis of the right leg. In cases of true dorsal vein thrombophlebitis the physical signs are usually much more striking and are normally only part of a more extensive process. Another condition which must be differentiated from both thrombophlebitis and traumatic lymphangitis is the subacute angiitis which may present as a manifestation of polyarteritis or the usually drug-induced hypersensitivity angiitis. lo These lesions are multiple subcutaneous peasized nodules which are freely movable and may be found anywhere along the shaft of the penis. They do not have a vascular configuration and usually respond well to steroid therapy. l1 In each case of this type a careful evaluation must be made to determine the underlying cause prior to initiating therapy. Traumatic lymphangitis of the penis is a selflimited condition resulting almost invariably from prolonged or repeated intercourse or other vigorous sexual manipulation and is doubtless far more common than is realized. It presents as a translucent, firm, nodular, almost cartilaginous, cord-like or serpiginous structure which arises in the coronal sulcus and may involve only one side or virtually encircle the penis. It is usually nontender, freely mobile, and may extend proximally along the dorsum of the penis, hence the confusion with thrombophlebitis. This condition has not been described in association with urethritis, prolonged catheter drainage, or inflammatory lesions of the glans or urethral meatus unless the latter were acute and also associated with prolonged vigorous intercourse. This, plus the lack of involvement of the regional lymph nodes, further suggests that infection is not an etiologic factor. Figure 3 shows a comparison of the typical superficial venous
UROLOGY
/ NOVEMBER
1975 / VOLUME
VI, NUMBER
5
(A) Typical venous drainage from penis; and (B) lymphatic drainage FIGURE 3. of the penis. (From Gray, H., Anatomy of the Human Body, courtesy of Lea and Febiger, Philadelphia.)
drainage of the penis and the lymphatic pathways, the latter conforming completely with the pattern found in each of the cases described. Although often suspected, thrombophlebitis has not been biopsy-proved in any patient seen with this clinical syndrome. Several forms of therapy have been employed, but none have varied the natural course of the condition which is spontaneous regression in four to eight weeks unless reaggravated by repeated sexual trauma. It has been our recommendation that the patient defer sexual relations until the lesion is completely resolved, then resume in moderation. Wilford Hall USAF Medical Center Lackland Air Force Base, Texas 78236 (DR.
NOVEMBER 1975 /
5.
6. 7.
8.
9.
10.
1. HELM, J. D., JR., and HODGE, I. G.: Thrombophlebitis of a dorsal vein of the penis, J. Urol. 79: 306 (1958). 2. HARROW. B. R.. and SLOANE. 1. A.: Thrombonhle-
/
4.
BALL)
References
UROLOGY
3.
VOLUME VI, NUMBER 5
11.
bitis of superficial penile and scrotal veins, ibid. 89: 841 (1963). NICKLE, W. R., and PLUMB, R. T.: Nonvenereal sclerosing lymphangitis of penis, Arch. Dermatol. 86: 761 (1962). sclerosing lymphangitis of BOYD, A. S.: Non-venereal the penis, Br. J. Dermatol. 82: 632 (1970). GREENBERG, R. D., and PERRY,T. L. : Nonvenereal sclerosing lymphangitis of the penis, Arch. Dermatol. 105: 728 (1972). LASSUS, A., et al.: Sclerosing lymphangitis of the penis, Br. J. Vener. Dis. 48: 548 (1972). HOFFMAN, E. : Vortauschung primarer Syphilis durch Gonorrhersche Lymphangitis (gonorrheischer Pseudoprimaraflekt), Munchen Med. Wochenschr. 70: II67 (1923). DEAN, A. L., and DEAN, A. L., JR.: In Campbell, M. F., Ed.: Urology, 2nd ed., W.-B. SaundersCompany, Philadelphia, 1964, chap. 28, p. 1228. GROSSMAN, L. A., et al. : Thrombosis of the penis interesting facet ofthromboangiitis obliterans, J.A. M.A. 192: 129 (1965). ZEEK, P. M.: Periarteritis nodosa and other forms of necrotizing angiitis, New Engl. J. Med. 248: 764 (1953). RUBENSTEIN, M., and WOLFF, S. M.: Penile nodules as a major manifestation of subacute angiitis, Arch. Intern. Med. 114: 449 (1961).
597
