Reassuring patients with sclerosing lymphangitis of the penis that they will not get shafted

By Warren R. Heymann, MD, FAAD
July 17, 2024
Vol. 6, No. 29

Over the past decade of using our electronic medical record, I must have clicked on the word “reassurance” thousands of times for anxious patients with lesions of no biological concern. Today you will calm patients who are worried about seborrheic keratoses, epidermoid cysts, lipomas, sebaceous hyperplasia, etc., who have suffered through sleepless nights, convinced they had an aggressive malignancy. Men with new-onset genital lesions are often wracked with fear, guilt, and embarrassment as they anticipate learning they have a sexually transmitted disease or cancer. I have only diagnosed sclerosing lymphangitis of the penis (SLP) a few times — the term “reassurance” does not do justice to the palpable sense of relief men exhibit once they understand that this is a benign, self-limited disorder.

This commentary will focus on SLP.

A century has passed since Hoffman used the term “gonorrheal pseudo chancre” to describe a firm, worm-like subcutaneous lesion surrounding the penile shaft. Fifteen years later, he reported that there was no correlation of these lesions with venereal disease; he then called the disorder “nonvenereal plastic lymphangitis of the coronal sulcus of the penis with circumscribed edema.” (1)

Most cases of SLP occur in sexually active men in their 20s or 30s, although the reported age range is from 18 to 66 years. Most reports correlate the onset of SLP within a week of prolonged, frequent, and intense sexual activity or masturbation. (2,3) Clinically, SLP is characterized by the sudden appearance of an indurated cord around the coronal sulcus of the penis. (4) The disorder is usually asymptomatic, although it may be slightly tender during an erection. Atypical presentations include a serpiginous cord that involves the glans penis (5), erosions, and marked penile edema. (6) Lesions resolve spontaneously within 4-6 weeks without complications, following abstinence from sexual intercourse or masturbation. SLP may recur, perhaps in patients with an anatomical predisposition. (4)

The main differential diagnosis for SLP is penile Mondor disease (PMD). PMD is a rare illness that causes thrombophlebitis in the superficial veins of the penis manifesting as transient pain and swelling. PMD often is associated with penile trauma, prolonged or vigorous sexual intercourse, and has been linked to genetic disorders of hypercoagulability (such as Protein C or Protein S deficiency). An ultrasound helps differentiate PMD from SLP, in which the former demonstrates venous thrombosis and the latter thickened and expanded lymphatic vessels. Peyronie disease shows thickening of the tunica albuginea. Biopsies are not recommended unless lesions do not resolve within the expected time frame, and there is a high suspicion of malignancy or vasculitis. (7) The great mimicker secondary syphilis may present with lesions clinically indistinguishable from SLP. (8)

The pathogenesis of SLP is attributed to blockage of lymphatic vessels, although a venous origin may be considered because of reports of positive staining of Factor VIII-related antigens within vessels. For the rare occasions that lesions are indicated, hypertrophy, and sclerosis of lymphatic vessels would be observed. (3) Unsurprisingly, there are reports of associated sexually transmitted diseases (syphilis, gonorrhea, herpes, chlamydia, lymphogranuloma venereum, candida, and others) which may be observed in approximately 25% of SLP patients. (1,3)

Management of SLP is straightforward: 1) obtain an ultrasound if you are not confident of the diagnosis; 2) perform appropriate laboratory screening tests for other sexually transmitted diseases (assuming the patient is sexually active) — RPR, HIV, etc.; 3) abstain from sexual activity (or masturbation) until lesions resolve; 4) administer non-steroidal anti-inflammatory agents if symptomatic; 5) consider biopsy and/or surgical excision only if lesions persist. (1) Finally, reassure, reassure, reassure.

Point to Remember: Sclerosing lymphangitis of the penis may be anxiety-provoking but is a self-limited disorder that characteristically resolves within weeks without residual complications.

Our expert’s viewpoint

Jason B. Lee, MD, FAAD
Professor
Director, Dermatopathology Fellowship
Department of Dermatology & Cutaneous Pathology, Thomas Jefferson University

I wholeheartedly agree with Dr. Heymann that dermatologists reassure anxious and apprehensive patients on a daily basis, especially those concerned about skin cancers. To add to his list, dermatologists have the ability to instantly recognize and appropriately manage talon noir, hemorrhage of the nail plate, dermatofibromas, melanocytic nevi of various types, and, among the rashes and infections, venous stasis dermatitis, fixed-drug eruption, herpesvirus infection, dermatophytosis, and scabies. Additional investigations are sought when the clinician lacks the confidence, experience, or knowledge along with fear of missing a consequential diagnosis. The more diseases we can accurately and confidently diagnose, the more efficient and cost-effective our patient management becomes without unnecessary skin biopsies, blood tests, or repeat visits. Unfortunately, such efficient and cost-effective practice is not financially aligned as the business of health care is driven by volumes of care that incentivizes more procedures, tests, and visits.

Sclerosing lymphangitis is one condition that can be confidently diagnosed, and the patient can be reassured with no further work-up as long as no other risk factors for sexually transmitted diseases (STD) exist. Sclerosing lymphangitis is usually a condition of young men, but it can be encountered in older men now due to the availability of tadalafil and sildenafil. (9) Patients should not be reflexively worked up for STD as some of the previous reports suggest. Sclerosing lymphangitis is not a manifestation of STD, only that the person participated in vigorous sexual activity. Independent risk factors for STD should be assessed such as unprotected sex, multiple partners, history of STD, and other clinical findings such as lymphadenopathy and presence or history of recent ulcers prior to further work-up. The often-reported non-venereal sclerosing lymphangitis implies existence of venereal sclerosing lymphangitis. (3,5) In all cases reported in English, however, in which sclerosing lymphangitis was associated with STD, other independent risk factors or physical findings of STD were present such as presence or history of ulcers and lymphadenopathy. (8,10,11)

In sum, sclerosing lymphangitis is a manifestation of mechanical trauma and in the absence of independent risk factors for STDs, the patient should be reassured.

1. Rosen T, Hwong H. Sclerosing lymphangitis of the penis. J Am Acad Dermatol. 2003 Nov;49(5):916-8. doi: 10.1016/s0190-9622(03)00464-x. PMID: 14576679.

2. Alrubaiaan MT, Alotaibi M, Alekrish KA. Non-Venereal Sclerosing Lymphangitis of the Penis in a 35-Year-Old Saudi Male: A Case Report. Cureus. 2022 Nov 4;14(11):e31087. doi: 10.7759/cureus.31087. PMID: 36475165; PMCID: PMC9719693.

3. Bhanja DB, Chakraborty S, Sil A, Panigrahi A. Non-venereal sclerosing lymphangitis of the penis. Int J Dermatol. 2020 Nov;59(11):e395-e396. doi: 10.1111/ijd.15007. Epub 2020 Jun 9. PMID: 32516445.

4. Babu AK, Krishnan P, Andezuth DD. Sclerosing lymphangitis of penis - literature review and report of 2 cases. Dermatol Online J. 2014 Jul 15;20(7):13030/qt7gq9h1v9. PMID: 25046462.

5. Grimaux X. Nonvenereal sclerosing lymphangitis of the penis with involvement of the glans: first description. Int J Dermatol. 2023 Jul;62(7):e399-e400. doi: 10.1111/ijd.16704. Epub 2023 May 4. PMID: 37140124.

6. Karray M, Litaiem N, Jones M, Zeglaoui F. Sclerosing lymphangitis of the penis associated with marked penile oedema and skin erosions. BMJ Case Rep. 2017 Jul 27;2017:bcr2017221414. doi: 10.1136/bcr-2017-221414. PMID: 28754762; PMCID: PMC5624052.

7. Özkan B, Coşkuner ER. What We Know About Penile Mondor's Disease. Sex Med Rev. 2022 Jul;10(3):403-408. doi: 10.1016/j.sxmr.2021.12.006. Epub 2022 Mar 3. PMID: 35249861.

8. Sardinha JCG, Ramos MC, Schettini APM, Talhari S. Case for diagnosis. Atypical genital lesion. An Bras Dermatol. 2018 Jan-Feb;93(1):143-144. doi: 10.1590/abd1806-4841.20186969. PMID: 29641720; PMCID: PMC5871385.

9. Guarneri C, Guarneri F. Mondor's phlebitis after using tadalafil. Br J Dermatol. 2007;157(1):209-210. doi:10.1111/j.1365-2133.2007.07948.x.

10. Agrawal SK, Singal A, Pandhi D. Mondor's phlebitis of penis following recurrent candidal balanoposthitis. Int J Dermatol. 2005;44(1):83-84. doi:10.1111/j.1365-4632.2004.02061.x.

11. Goldstein AM, Fox JN. The hard penile circumferential fold as the presenting finding in primary syphilis: report of six cases. J Am Acad Dermatol. 1992;26(5 Pt 1):700-703. doi:10.1016/0190-9622(92)70095-w.

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