We read with interest the recent paper by Awad et al in which a rare case of perineal nodular induration (PNI) is reported and the surgical technique employed to remove the benign pseudotumour is described.1
The authors allude to the multiple names for perineal nodular induration (PNI) or biker’s nodule and highlight cycling as the most frequent cause due to repetitive perineal microtrauma. The differential diagnoses for PNI are discussed in Table 1, with seven distinct histopathological entities mentioned.1
The authors proceed to discuss the management options, including saddle adjustment, intralesional steroids, and finally surgical excision. In male cyclists presenting with a presumed “third testicle” or perineal lump, conservative management has been described in the U.K. literature.2
It should also be acknowledged that in male cyclists presenting with suspected PNI, urethral pathologies should be considered in the differential diagnosis. Repeated perineal trauma from cycling causing urethral compression resulting in an obstructed syringocoele (obliterated Cowper’s Duct), but presenting as a perineal mass, has been described necessitating open urethral excision.3
The importance of an accurate history, including specific questioning regarding cycling and voiding dysfunction is relevant and may help to differentiate between a urethral cause and PNI, as urinary symptoms usually resolve following definitive treatment of the urethral problem.3,4 In addition to magnetic resonance imaging, urethrography should also be undertaken if a syringocele is suspected.3,5
Footnotes
Competing interests: The authors report no competing personal or financial interests.
References
- 1.Awad MA, Murphy GP, Gaither TW, et al. Surgical excision of perineal nodular induration: A cyclist’s third testicle. Can Urol Assoc J. 2017;11:E244–47. doi: 10.5489/cuaj.4169. https://doi.org/10.5489/cuaj.4169. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Amer T, Thayaparan A, Taslem A, et al. An avid cyclist presenting with a “third testicle”. J Clin Urol. 2014;8:429–31. https://doi.org/10.1177/2051415814529284. [Google Scholar]
- 3.Floyd MS, Jr, Hermans B, Waterschoot M, et al. An unusual perineal mass in a male cyclist. Int Urol Nephrol. 2016;48:371–2. doi: 10.1007/s11255-015-1198-3. https://doi.org/10.1007/s11255-015-1198-3. [DOI] [PubMed] [Google Scholar]
- 4.Shaw MB, Cole O, Terry TR. Cowper’s syringocele causing painful hematuria in an adult. Scientific World Journal. 2004;4(Suppl1):308–10. doi: 10.1100/tsw.2004.82. https://doi.org/10.1100/tsw.2004.82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Melquist J, Sharma V, Sciullo D, et al. Current diagnosis and management of syringocele: A review. Int Braz J Urol. 2010;36:3–9. doi: 10.1590/s1677-55382010000100002. https://doi.org/10.1590/S1677-55382010000100002. [DOI] [PubMed] [Google Scholar]