Penile Mondor Disease

Penile Mondor disease is superficial thrombophlebitis of the dorsal vein of the penis. It is a rare, benign and self-limiting condition of young to middle aged men. It usually settles in 3 to 6 weeks without lasting harm.

Its importance is recognition: a tender cord on the dorsal shaft is easily mistaken for infection, Peyronie plaque or lymphatic disease.

Pathophysiology. Thrombosis of the superficial dorsal vein follows endothelial injury or stasis. Known precipitants:

• Prolonged or vigorous sexual activity, or long abstinence.
• Penile trauma, tight constricting devices and vacuum devices.
• Intracavernosal injection therapy and penile prosthesis surgery.
• Pelvic or inguinal surgery and vasectomy.
• Local infection (balanitis, urethritis, sexually transmitted infection).
• Thrombophilia (factor V Leiden, protein C or S deficiency, antiphospholipid syndrome).
• Rarely pelvic malignancy, and inflammatory disease.

No cause is found in many patients.

A painful, firm, cord like swelling along the dorsal shaft, often extending from the corona toward the pubis, with overlying erythema or oedema in some patients. Pain is worst on erection and palpation. No systemic illness. The urinary stream is normal.

Extension of thrombosis into the deep dorsal vein, fever with spreading erythema, or recurrent episodes needs investigation.

• Clinical diagnosis in most patients.
• Duplex ultrasound: a non-compressible dorsal vein with echogenic thrombus and absent or reduced flow. It also shows the extent and any deep vein involvement.
• Urinalysis and STI testing when urethritis or discharge is present.
• Thrombophilia screen (including antiphospholipid antibodies, protein C, protein S, antithrombin, factor V Leiden) for recurrent disease, spontaneous onset in a man with other thrombosis, or family history, with timing directed by haematology. Full blood count and coagulation screen.

Differential diagnosis.

• Non-venereal sclerosing lymphangitis
• Peyronie disease
• Cellulitis or lymphangitis
• Penile cancer
• Penile fracture or haematoma
• Urethral stricture with periurethral inflammation
• Superficial dorsal vein thrombosis with a deep vein thrombosis

• Conservative treatment for most: avoid sexual activity and erections for about 4 to 6 weeks, warm compresses, and scrotal support.
• Ibuprofen 400 mg orally every 8 hours with food for 1 to 2 weeks (maximum 2.4 g daily), or naproxen 500 mg orally twice daily. Avoid NSAIDs in eGFR under 30, peptic ulcer, and heart failure.
• Topical NSAID or heparinoid gel twice daily to the cord gives symptom relief.
• Infection: culture directed antibiotic.
• Anticoagulation is reserved for extension into the deep dorsal vein, thrombophilia, or persistent disease over 2 to 3 weeks, directed by haematology. An option is enoxaparin 1 mg/kg subcutaneously every 12 hours (halve the frequency when eGFR is under 30), followed by an oral anticoagulant, for about 4 to 12 weeks. Evidence is limited.
• Surgical thrombectomy or excision and ligation of the vein for persistent pain after 4 to 6 weeks, or a thrombus that fails to resolve.
• Stop suspected triggers (vacuum devices, constriction rings, injection therapy) until resolved.

Monitoring. Review at 2 weeks and 6 weeks. Repeat duplex ultrasound if the cord persists beyond 6 weeks, or recurs. Erectile function and curvature at the end of treatment.

Referral and escalation. Refer to urology for recurrence, atypical features or diagnostic doubt, and to haematology for thrombophilia or anticoagulation. Urgent referral for fever, spreading cellulitis or signs of deep vein thrombosis.