Unusual presentation of sclerosing lymphangitis of the penis with large ulcerations

Introduction

Sclerosing lymphangitis of the penis (SLP), also referred to as “Non-Venereal Plastic Lymphangitis of the Penis,” is a rare benign condition first described by Hoffman in 1923. ¹ This condition typically manifests as an asymptomatic, firm, cord-like swelling around the coronal sulcus of the penis. Here, we report an unusual presentation in a 75-year-old patient with penile swelling and multiple large and deep ulcerations.

Case report

A 75-year-old circumcised man, with no medical history, presented with penis swelling with discomfort during erections ongoing for 2 weeks. Examination showed marked penile edema (Figure 1(a) and 2(a)) with the presence of two deep ulcerations measuring 2 cm in diameter, with a fibrinous base, located on the ventral aspect of the penis near the balanopreputial sulcus (Figure 1(a)). Physical examination was otherwise unremarkable. Screening tests for sexually transmitted infections (STI), including syphilis, human immunodeficiency virus and hepatitis B and C viruses, were negative. Doppler ultrasound examination of the penis didn’t show superficial dorsal penile vein thrombosis. After 2 weeks of sexual abstinence alongside local care, complete healing of the ulcerations was observed (Figure 1(b)), with the presence of a skin-colored, firm, non-tender serpiginous cord-like lesion encircling the coronal sulcus of the penis (Figures 1(b), Figure 2(b)). Based on the unique clinical presentation, the diagnosis of SLP was established. Clinical follow-up after 2 months showed resolution of the penile swelling (Figures 1(c) and 2(c)).OPEN IN VIEWER

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Figure 2.

Dorsal aspect of the penis on presentation (a), after 2 weeks (b) and 2 months (c). Marked edema of the penis (a). A typical aspect of sclerosing lymphangitis of the penis was noted after 2 weeks (b).

Discussion

This case is remarkable as it represents the occurrence of SLP in an elderly patient, accompanied by marked penile edema and multiple overlying ulcerations, features that are rarely reported in the literature. ² Remarkably, the typical presentation of SLP was only apparent after healing of ulcerations suggesting that erosions and ulcerations are markers of severe SLP.

To date, the pathogenesis and etiology of sclerosing lymphangitis of the penis remain unclear. Although earlier cases suggested a potential association with venereal diseases, the most widely accepted hypothesis points to venous or lymphatic thrombosis. This thrombosis is thought to result from trauma caused by prolonged, frequent, or vigorous sexual activity, whether intercourse or masturbation. ² Sexually active men in their 30s and 40s are most frequently affected, though cases in men in their 60s have also been documented. The condition typically causes minimal discomfort and often resolves spontaneously and may therefore be underreported. While lesions are generally asymptomatic, some patients may experience pain or discomfort, especially during erections. Paraclinical investigations are not necessary for diagnosing SLP. However, screening for sexually transmitted infections is recommended, as these have been associated with the condition. The main differential diagnosis is penile Mondor’s Disease, a superficial thrombophlebitis of the dorsal vein. ³ Sclerosing lymphangitis of the penis is a self-limiting condition, with most lesions resolving spontaneously within days to weeks. Management typically includes reassurance and temporary sexual abstinence. ⁴ In some instances, non-steroidal anti-inflammatory drugs have been reported to yield favorable outcomes. ²

This observation represents a rare presentation of SLP in an elderly man, implying a high clinical suspicion of this entity even in unusual settings. The early presence of significant edema and ulcerations, followed by improvement of the typical appearance of a firm cord of the balano-preputial sulcus suggests that the initial aspect in our patient represents a severe clinical form of SLP never formally attached to SLP in literature.