Penile Mondor’s Syndrome after endovenous treatment of the great saphenous vein with 1470 nm diode laser

Introduction

Mondor's disease has been reported in women and men in different vessels. ¹ Penile Mondor's disease is also known as a superficial vein thrombosis (SVT) of the superficial dorsal penile vein. It has predominantly been observed in individuals with cancer and local infections or other diseases, which are associated with an increased thrombotic risk. Superficial vein thrombosis of the superficial dorsal penile vein after endovenous laser treatment has not been reported so far; nevertheless, this rare post-procedural complication should be noticed, as the rate of endovascular treatments of varicose veins is rising.

Case report

A 51-year-old male patient was attended to the vascular diagnostic unit of our hospital with symptoms of chronic venous insufficiency. Clinical examination and a duplex ultrasound of the deep and superficial veins of his lower extremities revealed an insufficiency of the great saphenous vein (GSV) of the left leg; significant reflux (>1 s) in the 13 mm wide GSV was measured with associated dependent moderate tributaries. Endovenous laser ablation (ELVA) of the GSV with additional foam sclerotherapy of distal tributaries was offered as a treatment option to this patient. After informed consent was given, the laser ablation was performed as described elsewere. ² A linear endovenous energy density (LEED) of 57 J/cm (2756 J on 48 cm length) was applied to the left GSV with a 1470 nm diode laser using a radial fiber (ELVeS-radial slim kit™, Biolitec Ag Jena, Germany). Distal lower leg tributaries were subsequently treated with foam sclerotherapy within the same session using overall 2 ml of 1% polidocanol. No foam was injected in the thigh area. The therapy could be finished without any complications. Immediately after the procedure, prophylaxis of venous thromboembolism was started with enoxaparin 40 mg s.c. and prescribed for the following five days. Compression therapy with a graduated class II stocking (30–40 mm Hg) was also initiated after the intervention for the following three weeks. A non-steroidal anti-inflammatory drug was prescribed for optional use. The patient was told to resume routine daily activities, but to avoid strenuous exercise for about one week.

Clinical and duplex ultrasound examinations were performed one week after the treatment and no abnormalities were observed. One week later, the patient complained about an indurated vein at the dorsal penis with prudent redness and slight pain in this area, which had started in the inguinal region. The duplex ultrasound imaging showed a thrombosed small side branch of the GSV, which communicated with the also occluded superficial dorsal penile vein, as shown in Figures 1 and 2. See also Videos 1 and 2. This small 3 mm wide side branch had not been noticed at the first duplexsonographic examination. No severe pain or sexual dysfunction in the past week was mentioned and no extraordinary manipulation on the penis was reported. OPEN IN VIEWER

OPEN IN VIEWER

Figure 2.

Sonographic view of the groin. SB: side branch; GSV: great saphenous vein; SFA: superficial femoral artery; PFA: profundal femoral artery; FV: femoral vein.

Therapy

We administered body-weight adjusted full dose of low-molecular weight heparin (enoxaparin) in a therapeutic dosage for 10 days. In addition, anti-inflammatory therapy with diclofenac-sodium 75 mg twice a day for the following five days was initiated. Three weeks later, the thrombus in the small GSV side branch had sonographically disappeared and only a short residual thrombus connected to the ablated GSV remained. Clinically, the patient described no further discomfort. At one month follow-up examination the patient reported no further discomfort or pain and the thrombophlebitis of the superficial dorsal penile vein had sonographically disappeared completely, whereas the connecting side branch to the ablated and completely closed GSV was still partly occluded.

Discussion

In patients with venous anatomic variations, EVLA and other endovascular therapy approaches can cause thrombosis of small side branches with unexpected side effects. There seems to be an interdisciplinary accordance to treat Mondor's disease with any kind of heparin and an anti-inflammatory drug. ³ A recent study of Decousus et al. ⁴ recommends fondaparinux 2.5 mg for 45 days in concordance with the CALISTO-trial ⁵ in cases of isolated SVT in the lower extremity. Furthermore, a non-steroidal anti-inflammatory drug in topic application has been recommended, which might reduce undesirable systemic or gastrointestinal side effects, whereas we administered the drug by oral use. In our case, we did not recommend to treat with antibiotics as occasionally mentioned in literature ¹ in infectious SVT of the penile vein, because the pathogenesis in our patient was most likely a sterile inflammatory reaction due to hemostasis in the vessel. Although thrombus progression into related vessels is often seen after the treatment and closure of the insufficient vein in short distances, we have no conclusive explanation for this special complication. Possibly, the compression stockings in this very slim patient were too tight favouring thrombus progression into more peripheral areas.