Mondor meets Trendelenburg: penile vein thrombosis after varicose vein surgery

Aetiological factors in superficial dorsal penile vein thrombosis include trauma, vigorous sexual activity, pelvic tumours and a distended bladder^1,2. Isolated penile vein phlebitis was originally described in 1958³ as a variant of Mondor's disease, which is a more generalized superficial venous thrombosis of the chest wall.

CASE HISTORIES

Three cases of superficial penile vein thrombosis were identified prospectively from a series of 231 men who underwent long saphenous vein surgery over a 4-year period. A total of 350 legs were operated on—241 legs for primary and 109 for recurrent varicose veins. A standard surgical procedure was used including flush ligation of the saphenofemoral junction with braided polyester and exposure of the femoral vein to identify all tributaries. The long saphenous vein was removed by inversion pin-stripping to the knee, with retrograde stripping for recurrences. The operations were performed by a single surgeon (AN) and all patients were seen for clinic review at 2 weeks.

Case 1

A man aged 39, previously fit and well, underwent bilateral long saphenous and left short saphenous surgery. At follow-up he was noted to have thrombophlebitis in one of the tributaries of the right long saphenous vein extending up onto the shaft of the penis. This settled without treatment.

Case 2

A man aged 44 underwent bilateral repeat long saphenous vein surgery, having been operated on 4 years previously. At follow-up he had an area of superficial thrombophlebitis down one of the left lateral dorsal veins of the penis. This was uncomfortable during sexual intercourse. He was seen again 4 months later when all had resolved.

Case 3

A man aged 61 had bilateral long saphenous vein surgery. Operation on the left side was complicated by the removal of a subcutaneous malignant melanoma from the skin over the knee. Postoperatively he developed thrombophlebitis on the right side of the penile root, extending onto the dorsum of the penis. This settled over 4-5 weeks.

COMMENT

We have been unable to find previous reports of thrombophlebitis of the superficial dorsal vein of the penis as a complication of long saphenous vein surgery. The incidence in this series, 3 per 231 patients, exceeds the 1% level of risk above which patients are usually warned as part of the consent process.

Anatomical studies of penile venous outflow have been performed by selective venography^4,5. The superficial dorsal vein drains the prepuce and skin of the penis into the right and left external pudendal veins and thence into the long saphenous vein at the groin. Superficial ventral veins also drain into the superficial dorsal vein. There is almost complete separation of the superficial and deep venous systems in the penis with the exception of occasional direct communications between the deep and superficial dorsal veins. It is therefore anatomically possible that a surgeon performing bilateral ligation of the tributaries of the saphenofemoral junction will interrupt the superficial venous drainage of the penis with consequent venous stasis and thrombophlebitis. In 20% of cases the superficial dorsal vein drainage is unilateral, presumably increasing the risk of venous occlusion after surgery.

Superficial thrombophlebitis of the penis presents with cord-like induration of the vein, associated with mild discomfort and inflammation. Most cases are reported to resolve completely, as did ours, with no permanent adverse effects on sexual function. Treatment with anti-inflammatory drugs is said to relieve symptoms but not to hasten resolution.

It is possible that this condition is underreported since it is self-limiting and most patients who undergo long saphenous surgery are not followed up.