Mondor’s Disease Involving the Posterior Scrotal Vein: A Case Report

Abstract

Mondor’s disease (MD) is a rare, self-limiting thrombophlebitis, which typically affects the breast tissue and the chest wall. We report an exceptional case of a 33-year-old male who presented with a painless, mass-like suprascrotal lesion that mimicked a soft tissue tumor. Although multimodality imaging, such as ultrasonography and CT, of the mass strongly suggested MD, a diagnostic dilemma emerged because of the atypical presentation. Final diagnosis of MD of the posterior scrotal vein was confirmed by pathological examination following surgical excision. This case highlighted the importance of recognizing the characteristic imaging features of MD for accurate differential diagnosis, even in atypical presentations, to prevent potential misdiagnosis.

INTRODUCTION

Mondor’s disease (MD) is a benign, self-limiting thrombophlebitis of the superficial veins, and most commonly affects the chest wall or breast tissue (1). Genital involvement in males is rare and can typically manifest as penile MD (2,3,4). Involvement of the posterior scrotal vein is exceedingly rare, with only few cases reported till date (5,6,7).

This case report presents a rare case of posterior scrotal vein MD, highlights key radiologic findings, and discusses the differential diagnoses.

CASE REPORT

A 33-year-old male with no significant medical history presented with an incidentally discovered, painless, and non-tender mass in the left suprascrotal region. No systemic symptoms or signs of local infection were observed. He denied any pain or related symptoms and stated that he sought medical attention shortly after the mass was first noticed. The exact time of onset was uncertain.

Ultrasonography revealed a dilated, elongated tubular structure in the suprascrotal region, distal to the superficial inguinal ring. It presented with an ovoid, heterogeneously hyperechoic intraluminal lesion with partial anechoic areas, measuring approximately 4 cm in length, which raised suspicions of a partially thrombosed superficial vein. The lesion was non-compressible and showed no internal vascularity on color Doppler imaging. The lesion was located parallel to the spermatic cord but was clearly separated from the adjacent spermatic cord components (Fig. 1A, B).

Fig. 1. A 33-year-old man with Mondor’s disease involving the posterior scrotal vein.

A, B. Axial (A) and longitudinal (B) ultrasonography demonstrate a dilated tubular structure in the left suprascrotal area. It contains an intraluminal heterogeneous hyperechoic lesion (white arrowhead) and a partial anechoic portion (asterisk). It shows no internal vascularity on color Doppler imaging. It displaces the adjacent spermatic cord (yellow arrowhead), but is clearly separated from it.

C, D. Axial (C) and coronal (D) contrast-enhanced CT images reveal an elongated, non-enhancing tubular structure with a thin rim of peripheral wall enhancement in the left suprascrotal area (white arrowheads). The spermatic cord (yellow arrowheads) is seen again as a separate structure, displaced by but clearly distinct from the lesion.

E. Histologic specimen (hematoxylin and eosin stain, ×10) shows organizing thrombus (asterisks) in the dilated vein (arrowheads).

F. High-power view of the specimen (hematoxylin and eosin stain, ×200) shows infiltration of lymphocytes and hemosiderin-laden macrophages (asterisk) in the venous wall.

Subsequent contrast-enhanced CT demonstrated a non-enhanced tubular structure with thin peripheral wall enhancement which extended along the expected course of the posterior scrotal vein, and was suspected to be a thrombosed superficial vein (Fig. 1C, D). Based on these radiological findings, superficial thrombophlebitis was strongly suspected. However, the absence of pain and the lesion’s well-defined mass-like appearance necessitated the exclusion of other entities particularly, benign neoplastic conditions such as neurogenic tumors and non-neoplastic mimickers like epidermal inclusion cysts.

Given the atypical clinical presentation and diagnostic uncertainty, an excisional biopsy was performed after a thorough discussion with the patient to exclude these differential diagnoses. Histopathological analysis revealed an elongated and dilated vein containing an organizing thrombus, with chronic lymphocytic infiltration in the venous wall (Fig. 1E, F). These findings confirmed the diagnosis of MD involving the posterior scrotal vein.

The patient was discharged without postoperative complications, and no recurrence was observed during the 2-year follow-up period.

This case report was approved by the ethics committee, and the need for informed consent was waived by the Institutional Review Board of Inha University Hospital (IRB No. 2025-04-008-000).

DISCUSSION

MD is a rare, self-limiting superficial thrombophlebitis characterized by non-infectious inflammation and thrombosis of subcutaneous veins (1). Histopathologically, it is defined by the formation of a thrombus within a dilated vein, often accompanied by varying degrees of organizing hematoma and endothelial proliferation. Chronic cases might present with vessel wall fibrosis and inflammatory cell infiltration, predominantly lymphocytes and histiocytes, ultimately leading to partial or complete recanalization of the affected vein (8).

MD is typically diagnosed in the chest wall and breast regions but rare cases involving the genital region, particularly penile MD, have also been reported (2,3,4). Involvement of the posterior scrotal vein is extremely rare. Cases of MD involving the scrotal vein have been reported in association with thrombocythemia, hypercoagulable states, or following surgical procedures such as hernia repair or orchidopexy (5,6). Additionally, some cases occurred after sexual intercourse despite the absence of identifiable trauma (7). Our patient, however, presented with MD without any known predisposing factors.

In this case, ultrasonography revealed an elongated, non-compressible tubular structure with heterogeneous internal echogenicity in the suprascrotal region, displacing the spermatic cord without direct involvement—features suggestive of a superficial venous thrombosis. These findings closely resemble those described by Chin et al. (7), who reported thrombosed posterior scrotal veins as avascular intraluminal filling defects on ultrasonography.

However, the absence of pain in this case was atypical for superficial thrombophlebitis and initially posed a diagnostic challenge, prompting consideration of neoplastic conditions and non-neoplastic mimickers. An epidermal inclusion cyst was the first suspected differential diagnosis due to its superficial location and lack of enhancement. However, this lesion appeared as an elongated tubular structure along the anatomical course of the posterior scrotal vein, unlike the epidermal inclusion cyst which typically presents as a spherical or ovoid low-density cystic mass confined to the dermal or subcutaneous tissue and unrelated to vascular structures. Solid neoplasms such as neurogenic tumors were also considered, but the absence of internal flow on Doppler and lack of enhancement on CT (aside from a thin peripheral rim) were inconsistent with a solid tumor. These findings were most consistent with superficial venous thrombosis.

Histological examination revealed lymphocytic infiltration and hemosiderin-laden macrophages within the venous wall indicating an organizing thrombus with low-grade inflammation. This correlated well with the intraluminal heterogeneous echogenicity observed on ultrasonography, a feature commonly associated with subacute to chronic stage thrombus. Such echogenic changes have been attributed to progressive fibrin deposition, fibrosis, and cellular infiltration, distinguishing chronic thrombi from their typically hypoechoic acute thrombi (9).

The absence of pain, despite the lesion’s considerable size, can be explained by a combination of pathophysiologic and anatomic factors. First, the thrombus appeared to have developed insidiously, triggering only a low grade inflammatory response, and minimal stimulation of pain receptors. Second, the loose, highly compliant scrotal subcutaneous tissue likely accommodated progressive venous distension without generating appreciable mechanical tension on adjacent nerve endings in contrast to the denser connective tissues of the chest wall or breast, where MD is typically painful. Although no clinical studies have directly compared pain severity by anatomical site or correlated inflammation grade with symptom severity in superficial thrombophlebitis, this hypothesis could be a plausible explanation for this atypical presentation. Similar pain-free or minimally symptomatic presentations have been reported in breast MD, highlighting the variability of clinical manifestations depending on the stage of thrombus development (10).

This case has several clinical implications. To our knowledge, it represented the first detailed radiological description of MD affecting the posterior scrotal vein in Korea. Among the scarcely reported cases of genitourinary MD, none of the reports have documented a completely painless, mass-like presentation, underscoring the need to recognize this atypical presentation. Though our patient ultimately underwent excisional biopsy for pathologic confirmation, the characteristic findings on high-resolution ultrasonography and contrast-enhanced CT could ensure confident presumptive MD diagnosis, providing crucial radiological clues that allow for conservative management consideration in similar cases.