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Surgical excision of perineal nodular induration: A cyclist’s third testicle

  • May 2017
  • Canadian Urological Association journal = Journal de l'Association des urologues du Canada 11(5):244
DOI:10.5489/cuaj.4169
Authors:
Mohannad Awad at University of Texas Southwestern Medical Center
Mohannad Awad
Gregory P. Murphy at UCSF University of California, San Francisco
Gregory P. Murphy
Thomas W Gaither at University of California, Los Angeles
Thomas W Gaither
E. Charles Osterberg
E. Charles Osterberg
E. Charles Osterberg
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Abstract and Figures

Perineal nodular induration (PNI), or biker’s nodule, is a rare, bothersome, pseudotumour. Herein, we describe the surgical technique used to treat a healthy cyclist who developed an enlarging PNI for five years that grew into a perineal mass. The mass prevented him from cycling due to worsening discomfort and heaviness. The PNI-associated mass was successfully removed by wide surgical excision and a local advancement flap. Subsequently, the patient resumed cycling. Histopathology report demonstrated a benign lesion with abundant ropy collagen with native smooth muscle, vessels, and rare fibroblast-like spindle cells. With the increasing popularity of cycling, PNI may become more common, and health providers should be aware of this rare entity and how it can be safely removed.
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TECHNIQUES IN UROLOGY
Cite as: Can Urol Assoc J 2017;11(5):E244-7. http://dx.doi.org/10.5489/cuaj.4169
Published online May 9, 2017
Abstract
Perineal nodular induration (PNI), or biker’s nodule, is a rare, both-
ersome, pseudotumour. Herein, we describe the surgical technique
used to treat a healthy cyclist who developed an enlarging PNI
for five years that grew into a perineal mass. The mass prevented
him from cycling due to worsening discomfort and heaviness. The
PNI-associated mass was successfully removed by wide surgical
excision and a local advancement flap. Subsequently, the patient
resumed cycling. Histopathology report demonstrated a benign
lesion with abundant ropy collagen with native smooth muscle,
vessels, and rare fibroblast-like spindle cells. With the increasing
popularity of cycling, PNI may become more common, and health
providers should be aware of this rare entity and how it can be
safely removed.
Introduction
Bicycle riding is one of the most popular methods for trans-
portation, exercise, and leisure. According to U.S. Bicycling
Participation Benchmarking 2015 report, 34% or 103.7
million Americans (ages three and older) rode a bicycle at
least once in the past year, with 14% of this population
reporting frequent riding more than 104 times/year.1 The
health benefits of bicycling as an aerobic exercise are well-
known.2-4 Endurance cycling may cause injuries affecting the
genitourinary system.5 Perineal nodular induration (PNI) also
known as biker’s nodule, cyclist’s nodule, ischiatic hygroma,
third testicle, or an accessory testicle is a benign pseudo-
tumour that presents most commonly in avid male cyclists
with repetitive perineal microtrauma.6 It usually develops
posterior to the scrotum in the soft tissue of the perineum,
as two masses on both sides of the median raphe, or as a
single mass located midline, or lateralized over the ischial
tuberosity.6 Herein, we report our surgical technique for PNI
treatment and the histopathological characteristics of PNI.
History
A 48-year-old healthy male who is an avid cyclist presented
with a progressive inferior perineal and scrotal swelling for
five years. He had been actively cycling for 20 years, riding an
average of 100 miles/week. When he presented to our clinic,
he complained of redundant scrotal and perineal skin. He
reported a history of saddle sores that resolved in the past. On
physical examination, there was a large, mobile, non-tender,
and soft mound of perineal tissue that was posterior to the
scrotum with redundant tissue, covered by normal skin (Fig.
1). Ultrasound of the scrotum demonstrated redundant soft tis-
sue in the perineum inferior to the raphe. The bulge restricted
the patient’s daily activity and he opted for surgical excision.
Surgical technique
The patient was placed in a lithotomy position. An elliptical
incision was made from the apex, near the scrotum, down
to 2 cm above the anus. The dissection was superior to
the bulbospongiosus muscle. After complete mobilization,
the mass was transected and sent to pathology. It measured
approximately 14 x 5 cm (Fig. 2). In order to close the inci-
sion in a tension-free manner, lateral flaps were raised that
were approximately 15 x 3 cm. The subcutaneous layers
were closed using interrupted 2-0 vicryl for the deep and
superificial layers. In total, there were four layers of closure.
The patient tolerated the procedure well and was discharged
in the same day in a good condition.
Pathology
Grossly, the specimen consisted of a 14 x 5.5 cm x 2 cm
thick fragment of hair-bearing skin and subcutaneous tissue
Mohannad A. Awad, MD1,2; Gregory P. Murphy, MD1; Thomas W. Gaither, MD1; E. Charles Osterberg, MD3;
Thomas A. Sanford, MD1; Andrew E. Horvai, MD4; Benjamin N. Breyer1,5
1Department of Urology, University of California–San Francisco, San Francisco, CA, United States; 2Department of Surgery, King Abdulaziz University, Rabigh, Saudi Arabia; 3Department of Surgery, University
of Texas, Dell Medical School, Austin, TX, United States; 4Department of Pathology, University of California–San Francisco, San Francisco, CA, United States; 5Department of Biostatistics and Epidemiology,
University of California–San Francisco, San Francisco, CA, United States
Surgical excision of perineal nodular induration:
A cyclist’s third testicle
CUAJ • May 2017 • Volume 11, Issue 5
© 2017 Canadian Urological Association
E244
CUAJ • May 2017 • Volume 11, Issue 5 E245
with a homogeneous, fibrotic cut surface. The epidermis and
dermis were unremarkable microscopically (not shown). The
deeper soft tissues showed abundant ropy collagen bundles
mixed with native smooth muscle, vessels, and rare fibro-
blast-like spindle cells. There was no atypia, necrosis, or
mitotic activity (Fig. 3).
Followup
The patient began cycling roughly two months after the
operation with mild discomfort that improved over time.
He denied any sexual or urinary side effects. Fig. 4 shows
the patient’s perineum and scrotum in followup, with no
signs of residual mass at two months’ followup.
Discussion
Although the pathogenesis of PNI is unknown, it may be
related to the repetitive compression and friction of the
perineal fascia between the bike’s saddle and ischial tuber-
osities.7 Beyond cyclists, this complication has been docu-
mented in a patient who was an equestrian and another who
tested lawn mowers.8,9 It is more commonly seen in males,
but recently, five female cases have been reported.9,10 Its
latency period varies from a few weeks to one year. Although
the nodule in our case was mobile, most reports state that it
is fixed to the soft tissue or ischial tuberosity, has a fibrous
to elastic consistency, and is covered by normal skin.6,7,11
Perineal nodular induration
Fig. 1. Large, perineal fat posterior to the scrotum with redundant tissue
resembling an accessory testicle (arrow).
Fig. 2. Excised mass measuring approximately 14 x 5 cm.
Fig. 3. (A) Microscopically, the excision specimen demonstrated abundant ropy collagen with rare, bland fibroblast-like spindle cells mixed with native smooth
muscle and small vessels; (B) at higher magnification, some of the collagen bundles showed a hyaline, keloidal quality.
The histopathological appearance of PNI varies. It is often
characterized by a central pseudocystic space surrounded by
fibrous tissue containing fibroblast spindle cells and clusters
of small-sized vessels.7,11,12 The central pseudocystic space
somewhat resembles that seen in ischemic fasciitis, which
occur in elderly patients over the bony prominences who are
often, though not always, immobilized.13-15 Other possible
differential diagnoses are listed in Table 1.
In most cases, history and physical examination can
diagnose PNI. Imaging modalities, such as ultrasound and
magnetic resonance imaging, may be needed in some cases.
Final diagnosis is made by histopathological examination.
Primary treatment options include adjustment of cyclist
position to change the distribution of weight on the saddle,
as well as limiting the source of friction, which includes
using adequate saddle/perineal lubricant and proper fitting
cycling clothing. Patients can be counselled that there are no
reports of spontaneous regression, but it is possible to limit
progression and discomfort. Second, some authors reported
that intralesional corticosteroids or hyalurodinase injection
may offer some relief. These injections are only preferable
for small nodules and may cause subcutaneous atrophy.22,23
Both of the previous treatment options were not suitable for
our patient, as the mass was quite large and bothersome.
Finally, surgical excision of the mass is the most often used
treatment with superior results.6 The technique to remove this
mass could vary depending on the exact size and location.
With smaller masses, the need to raise local skin flaps as in
our case, may not be necessary. For larger masses, if skin
flaps cannot be mobilized well enough, a split-thickness
skin graft could also be applied to any areas not able to be
closed in a tension-free manner.
Conclusion
PNI is a poorly recognized, rare, bothersome benign pseu-
dotumour that mostly appears in professional and avid
cyclists. Diagnosis is made by clinical history and exami-
nation. Surgical excision is the treatment of choice. With
the increasing popularity of cycling, PNI may become more
common, and healthcare providers should be aware of this
entity and how it can be safely removed.
Competing interests: This research was funded by the Bicycle React Grant. The authors report no
competing personal or financial interests.
This paper has been peer-reviewed.
References
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CUAJ • May 2017 • Volume 11, Issue 5
E246
Awad et al.
Fig. 4. Patient perineum and scrotum at two months’ followup showing no signs
of residual mass.
Table 1. Differential diagnoses for perineal nodular induration
Differential diagnosis Histolopathological features
Ischemic fasciitis13-15 Outer fringe of mitotically active fibroblasts and occasional ganglion-like cells and small vessels
surrounding a central zone of necrobiosis
Cellular angofibrom*16 Uniformly moderately cellular with plump, bland spindle cells, hyalinized round, thick and walled
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Angiomyofibroblastoma-like tumour
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Mammary type fibroblastoma*18 Well-circumscribed, more cellular, and lacks a central zone pattern. Bundles of thick, ropy collagen
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Massive localized lymphedema19 Edematous stroma, dilated vascular channels, and mature adipose tissue separated by fibrous
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Prepuberal vulvar formation20 Poorly marginated, hypocellular tumours, formed by bland of spindle-shaped cells in a
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Rare to moderate cellular interconnected fibrous bands, encircled lobules of fat, vessels, and
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Correspondence: Dr. Mohannad A. Awad, Department of Urology, University of California–San
Francisco, San Francisco, CA, United States; mohannad.awad@ucsf.edu
Perineal nodular induration
... Perineal nodular induration (PNI), more commonly known as "third testicle" or "cyclist's nodule" [1], is a rare and benign (myo)fibroblastic pseudotumor associated with saddle sports, such as cycling or horseback-riding [2][3][4][5][6]. The clinical appearance of PNI is characterized by unspecific swelling of the soft tissue posterior at the perineum or over the ischial tuberosity [7]. ...
... The PNI manifests as two nodules, with one on each side of the perineal raphe; in other cases, it presents as a single nodule [1]. This localization of the swelling led to reports in journals on various medical disciplines, such as urology [2,8], gynecology [9,10], dermatology [1,3], orthopedic surgery [11] and plastic surgery, as well as histopathology [4,12] and radiology [13][14][15]. Overall, PNI is a rare disease and the knowledge about its treatment is limited. ...
... Only two of these articles gave further insight into detailed surgical techniques. In one article, a spindle-shaped mass excision and wound closure by bilateral advancement flaps was mentioned [2]. Respectively, an incision at the lateral side of the perineum and a resection of the mass and simple wound closure was described in the other [16]. ...
How to Treat a Cyclist’s Nodule?—Introduction of a Novel, ICG-Assisted Approach
Article
Full-text available
  • Feb 2024
Background: Perineal nodular induration (PNI) is a benign proliferation of the soft tissue in the perineal region that is associated with saddle sports, especially road cycling. The etiology has not been conclusively clarified; however, repeated microtrauma to the collagen and subcutaneous fat tissue by pressure, vibration and shear forces is considered a mechanical pathomechanism. In this context, chronic lymphedema resulting in the development of fibrous tissue has been suggested as an etiological pathway of PNI. The primary aim of this study was to introduce and elucidate a novel operative technique regarding PNI that is assisted by indocyanine green (ICG). In order to provide some context for this approach, we conducted a comprehensive review of the existing literature. This dual objective aimed to contribute to the existing body of knowledge while introducing an innovative surgical approach for managing PNI. Methods: We reviewed publications relating to PNI published between 1990 and 2023. In addition to the thorough review of the literature, we presented our novel surgical approach. We described how this elaborate approach for extensive cases of PNI involves surgical excision combined with tissue doubling and intraoperative ICG visualization for exact lymphatic vessel obliteration to minimize the risk of recurrence based on the presumed context of lymphatic congestion. Results: The literature research yielded 16 PubMed articles encompassing 23 cases of perineal nodular induration (PNI) or cyclist’s nodule. Of these, 9 cases involved females, and 14 involved males. Conservative treatment was documented in 7 cases (30%), while surgical approaches were reported in 16 cases (70%). Notably, a limited number of articles focused on histopathological or radiological characteristics, with a shortage of structured reviews on surgical treatment options. Only two articles provided detailed insights into surgical techniques. Similarly to the two cases of surgical intervention identified in the literature research, the post-operative recovery in our ICG assisted surgical approach was prompt, meaning a return to cycling was possible six weeks after surgery. At the end of the observation period (twelve months after surgery), regular scar formation and no signs of recurrence were seen. Conclusion: We hope that this article draws attention to the condition of PNI in times of increasing popularity of cycling as a sport. We aimed to contribute to the existing body of knowledge through our thorough review of the existing literature while introducing an innovative surgical approach for managing PNI. Due to the successful outcome, the combination of tissue doubling, intraoperative ICG visualization and postoperative negative wound therapy should be considered as a therapeutic strategy in cases of large PNI.
View
... Saddle sores are referred to as lesions affecting the skin in the saddle area, which can be acute or chronic [1,[3][4][5]9,10,[13][14][15][16][17][18][19][20][21][22]. Acute phase saddle sores present with chafing of the skin and erythema and are associated with infections such as folliculitis and furunculitis [1,9,13]. ...
... This chronic stage is most commonly referred to as PNI. The variety of names used interchangeably with PNI in the literature reflect how nodules can form in different regions within the saddle area and include ischial hygroma [18], coccygeal nodule [3], cyclist's nodule [19], accessory testicle [20], third testicle [13] and biker's nodule [17]. PNIs have been observed to be preceded by saddle sores and increase in size over time in case studies [5,17]. ...
... The variety of names used interchangeably with PNI in the literature reflect how nodules can form in different regions within the saddle area and include ischial hygroma [18], coccygeal nodule [3], cyclist's nodule [19], accessory testicle [20], third testicle [13] and biker's nodule [17]. PNIs have been observed to be preceded by saddle sores and increase in size over time in case studies [5,17]. ...
Getting to the Bottom of Saddle Sores: A Scoping Review of the Definition, Prevalence, Management and Prevention of Saddle Sores in Cycling
Article
Full-text available
Abstract: Objectives To summarise and map the existing evidence relating to the definition, preva- 1 lence, prevention and management of saddle sores within the literature and highlight research gaps. 2 Design Scoping Review. Data Sources 3 databases were searched using an appropriate search 3 strategy agreed on by the authors with the aid of an experienced medical librarian: MEDLINE, 4 EMBASE and Web of Science. Eligibility Criteria To be included in this review, studies must make 5 specific reference to dermatological conditions that affect the saddle area, specifically arising from 6 cycling, in either sex. Results 17 studies were selected for inclusion. Saddle sores in males were the 7 focus of 13 studies, with only 2 reporting in females. Saddle sores were defined as connective tissue 8 lesions affecting the skin in the saddle area which can be both acute and chronic. Commonly cited 9 preventions were chamois cream, high quality, well-fitting cycling equipment and good personal 10 hygiene. Management in the early stages usually involves rest. Topical and intralesional steroids 11 and lubricating creams are recommended treatments for small saddle sores, with surgical excision 12 an option for larger, persistent saddle sores. However, surgery and steroid use may increase risk of 13 recurrence. Conclusions Saddle sores are an underrepresented, male dominated issue within the 14 literature, with limited evidence, particularly around treatment options, including topical steroids 15 and surgical removal. Further well-designed observational studies and/or randomised controlled 16 trials will help provide further evidence on prevalence, prevention and treatment available in the 17 future.
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... Perineal nodular induration (PNI), also known as cyclist ś nodule, ischial hygroma, third testicle or accessory testicle, is an uncommon entity caused by repetitive trauma associated with "saddle sports" [1] , that almost exclusively affects male patients who are either professional or very active amateur cyclists [ 2 ,3 ]. On histological evaluation, PNI shows a predominant fibrous component [4][5][6][7] . On physical examination this condition has a characteristic appearance, which typically consists of solitary or bilateral nodular lesions in the perineum or groin, that may allow the diagnosis in the appropriate clinical setting [7] , which highlights the importance of a specific questioning about patient ś habits when this particular condition is suspected. ...
... On histological evaluation, PNI shows a predominant fibrous component [4][5][6][7] . On physical examination this condition has a characteristic appearance, which typically consists of solitary or bilateral nodular lesions in the perineum or groin, that may allow the diagnosis in the appropriate clinical setting [7] , which highlights the importance of a specific questioning about patient ś habits when this particular condition is suspected. However, although it is a rel-✩ Conflicts of interest: The authors report no conflict of interest. ...
... Histological features include pseudocyst formation surrounded by dense hyalinized fibrous tissue with adjacent areas of aseptic necrosis, edematous fibrous tissue containing fibroblast-like spindle cells, thick collagen bundles, degenerative elastic fibers, clusters of capillaries, and hemorrhagic foci [5][6][7] . ...
MR imaging findings in perineal nodular induration (“cyclist´s nodule”): A case report
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Full-text available
  • Jul 2020
Perineal nodular induration (PNI) is a rare condition related to sports linked to the use of a saddle, mostly cycling, thought to be caused by the compression of the soft tissue between the saddle and the ischial tuberosity. We report a case of a 59-year-old amateur cyclist male who presented with 2 bilateral nodular perineal lesions that were evaluated with ultrasound and magnetic resonance imaging (MRI). MRI findings, along with the history of a strong cycling habit, led to the diagnosis of PNI, and a conservative management was adopted. MRI features of PNI are characteristic, and may provide the diagnosis in the proper clinical setting.
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Pressure and Skin: A Review of Disease Entities Driven or Influenced by Mechanical Pressure
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  • Dec 2023
Skin perceives and reacts to external mechanical forces to create resistance against the external environment. Excessive or inappropriate stimuli of pressure may lead to cellular alterations of the skin and the development of both benign and malignant skin disorders. We conducted a comprehensive literature review to delve into the pressure-induced and aggravated skin disorders and their underlying pressure-related mechanisms. Dysregulated mechanical responses of the skin give rise to local inflammation, ischemia, necrosis, proliferation, hyperkeratosis, impaired regeneration, atrophy, or other injurious reactions, resulting in various disease entities. The use of personal devices, activities, occupations, weight bearing, and even unintentional object contact and postures are potential scenarios that account for the development of pressure-related skin disorders. The spectrum of these skin disorders may involve the epidermis (keratinocytes and melanocytes), hair follicles, eccrine glands, nail apparatuses, dermis (fibroblasts, mast cells, and vasculature), subcutis, and fascia. Clarifying the clinical context of each patient and recognizing how pressure at the cellular and tissue levels leads to skin lesions can enhance our comprehension of pressure-related skin disorders to attain better management.
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Urological issues in cyclists
Article
  • Nov 2020
Cycle use has grown rapidly over the last few years in the UK. British Cycling membership has increased threefold since the 2012 Olympic and Paralympic Games, and this is likely to rise in the wake of the Coronavirus pandemic. As urologists, day-to-day encounters with cyclists are commonplace, who may present with acute traumatic injuries or chronic overuse injuries. The aim of this literature review was to evaluate the effect of cycling on conditions presenting to the urology clinic, in particular those of raised prostate-specific antigen (PSA), haematuria and soft-tissue lesions (‘cyclist nodules’). Furthermore, the review aimed to summarize the relationship between cycling and pudendal nerve entrapment (PNE) syndromes. A PubMed search of the literature on cycling and genitourinary disorders was performed. The literature suggests no significant change in PSA levels after a bout of cycling. Age appears to have no effect on the change in PSA experienced following a bout of cycling, in particular when comparing those <50 years of age to those >50 years of age. Haematuria appears to be rare with cycling but has been described, even with stationary bike riding. It is imperative to exclude coexisting urinary-tract pathological conditions, and cycling-induced haematuria should always be considered a diagnosis of exclusion. Perineal nodular induration (‘cyclist nodules’) is a rare condition, related to pressure and repetitive micro-trauma between the perineum and saddle. Pudendal Nerve Entrapment (PNE) represents the most common bicycling-associated urogenital complaint. Numbness in the perineum, penis, scrotum or buttocks—‘genital numbness’—is the most common and most recognized symptom of pudendal compression. Despite several studies demonstrating a link between elite cyclists and erectile dysfunction, for the average cyclist riding may actually have a protective effect on sexual function.
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“Bumpy” Ride for the Female Cyclist: A Rare Case of Perineal Nodular Induration, the Ischial Hygroma
Article
Full-text available
  • Jul 2020
Introduction Cycling is known to cause groin pain, typically adductor/hamstring strains and “saddle sores” (skin abrasion, ulceration and/or folliculitis). Rarely does it result in pathological mesenchymal lesions. Presentation of case We report a case of a 52-year-old female avid cyclist with chronic groin pain. Activity alteration, bike fit, and saddle modification did not ameliorate her symptoms. MRI revealed no hamstring or bony abnormality but demonstrated low T1/high T2 signal in the right perineum inferior to the ischial tuberosity. Discussion Perineal nodular induration, or “cyclist’s nodule,” is a reactive fibroblastic and myofibroblastic pseudotumor almost exclusively reported in male cyclists. PNI can become so nodular that it has even been referred to as an accessory testicle or “the cyclist’s third testicle.” Conclusion We report an unusual case of PNI in a female cyclist and review the differential diagnosis of non-infectious soft tissue perineal pain in cyclists. Clinicians should be aware of this rare condition to avoid confusion with other mesenchymal lesions.
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Massive localized lymphedema: A clinicopathologic study of 46 patients with an enrichment for multiplicity
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  • Nov 2015
  • Mod Pathol
Massive localized lymphedema is a monstrous tumefactive pseudosarcoma seen in middle-aged morbidly obese adults. Since its initial description in 1998, the etiology remains unknown, although associations with trauma, surgeries, and hypothyroidism have been reported. Herein, we report the largest study of massive localized lymphedema and expand upon its clinicopathologic features. Fifty-four cases from 46 patients were retrospectively identified from the institutional archives of The Ohio State University Wexner Medical Center between 2002 and 2015. Forty-six patients (21 males and 25 females, mean age 50 years) presented with large masses developing over a 5-60-month period. The majority of patients were Caucasian (n=39). All patients were obese with a mean weight of 384.7 lb and a mean body mass index of 59.6 kg/m(2). Thirty-six patients had a history of atherosclerotic cardiovascular disease and diabetes mellitus type 2 was present in 22 patients. Eight patients had multifocal massive localized lymphedema. The sites included thigh (n=33), abdomen (n=17), suprapubic region (n=1), mons pubis (n=6), scrotum (n=2), perianal region (n=1), and right flank (n=1). Mostly, the clinical impression was benign processes, including pannus or lymphedema pseudotumor. Grossly, the mean weight was 8237 g and the mean size was 53.2 cm. Histologically, eight cases showed a unique pattern of dystrophic calcifications mimicking hyperchromatic, atypical nuclei that might lead to misdiagnosis of liposarcoma, four cases showed focal metaplastic ossification, and three cases showed multinucleated cells in addition to prototypic features of massive localized lymphedema. We report that this is the largest series of massive localized lymphedema. This is a lesion mostly seen in morbidly obese patients and the thigh is the most common site of involvement. We note a marked racial predilection for Caucasians and a tendency towards multiplicity. We suggest that obesity itself and the related metabolic syndrome have an important role in its pathogenesis.Modern Pathology advance online publication, 20 November 2015; doi:10.1038/modpathol.2015.135.
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Perineal Nodular Induration ("Biker's Nodule"): Report of Two Cases With Fine- Needle Aspiration Cytology and Immunohistochemical Study
Article
  • Nov 2012
  • INT J SURG PATHOL
Perineal nodular induration (PNI) is a fibroblastic pseudotumor that presents almost exclusively in male cyclists. It develops in the soft tissues of the perineum immediately posterior to the scrotum, as a bilateral or single, central or lateralized mass. Although well known to sport medicine specialists, it is a scarcely documented entity in the pathology literature. We present 2 cases of PNI with fine-needle aspiration cytology and immunohistochemistry. They consisted of a paucicellular fibroblastic proliferation containing CD34-reactive spindle and epithelioid cells, small foci of fibrinoid degeneration, numerous blood vessels, and entrapped groups of mature fat cells. Our cases show that the histopathological features of PNI are more varied than those previously described and its immunohistochemical profile is wider. A central cystic focus and a zonal pattern are not consistent features of this entity. The lesional cells can express CD34, a hitherto unreported immunohistochemical finding.
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“Biker's nodule”– die perineale knotige Induration des Radsportlers
Article
  • Oct 2000
Beim “biker's nodule” handelt es sich um eine selten auftretende perineale knotige Induration des Radsportlers. Wiederholte Mikrotraumen des Kollagen- und Unterhautfettgewebes durch Druck oder Vibrationen, die vom Fahrradsattel auf den Dammbereich ausgeübt werden, führen zum Entstehen von Kollagendegenerationen mit myxoiden Veränderungen und Pseudozysten. Die subkutan entstehenden schmerzhaften Knoten zwingen den Patienten zur Reduzierung oder Aufgabe des Trainings. Die Therapie des “biker's nodule” besteht in der Vermeidung der auslösenden Ursache, also aus vorübergehender Trainingskarenz sowie Druckentlastung der Perinealregion. Ebenso kann ein Therapieversuch durch intraläsionale Injektion von Hyaluronidase oder Kortikosteroiden unternommen werden. The “biker's nodule” is a rarely appearing perineal nodular induration of the cyclist. Repeated microtrauma to the subcutaneous fatty tissue or collageneous tissue, caused by pressure or vibration which the bicycle's saddle exerts on the perineal region, leads to collagenous degeneration, myxoid alteration and pseudocyst formation. Because of the painful subcutaneous nodules the patient is often forced to reduce or even give up his training. Therapy of the “biker's nodule” consists in avoiding the pathogenetic factors, i.e. giving up training for a temporary period of time and reducing pressure on the perineal region. Intralesional injection of either hyaluronidase or corticosteroids may also be helpful.
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Reactive Fibroblastic and Myofibroblastic Proliferation of the Vulva (Cyclist's Nodule): A Hitherto Poorly Described Vulval Lesion Occurring in Cyclists
Article
  • Jan 2011
Perineal nodules occurring in male cyclists are reported in the literature, although the histologic features are not extensively documented. There has been little description of similar lesions in the female population. We describe 4 cases in which a vulval nodule or swelling developed in competitive female cyclists aged 15 to 45 years. The lesions were unilateral and occurred on the right or left labium majus (2 cases each). The histologic features were similar in all cases and consisted of a haphazard admixture of adipose tissue, variably cellular hyalinized tissue containing bland spindle-shaped fibroblasts, blood vessels, and nerve fibers. In some areas, thick cords of fibrous tissue imparted a keloid-like appearance. Other histologic features included plump mesenchymal cells with round or ovoid nuclei and abundant eosinophilic cytoplasm resulting in an epithelioid, plasmacytoid, or ganglion-like appearance (2 cases), a lymphocytic infiltrate around blood vessels (3 cases), foci of fat necrosis (1 case), and collections of elastic fibers (2 cases). One case recurred, the histologic features of the recurrent lesion being identical to the original. The overall morphologic appearances, especially in the cases with plump mesenchymal cells, bore some resemblance to proliferative fasciitis. Immunohistochemically, the cells were estrogen receptor positive and the plump mesenchymal cells were smooth muscle actin positive, in keeping with myofibroblasts. Desmin, S100, CD34, and HMGA2 were negative. Pathologists should be aware of this pseudoneoplastic lesion occurring on the vulva, which arises in a specific clinical setting and has the potential to be misdiagnosed as a variety of other mesenchymal lesions. We term this lesion as reactive fibroblastic and myofibroblastic proliferation of the vulva or "cyclist's nodule."
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Perineal Nodular Induration: A Trauma-induced Mass in a Female Equestrian
Article
  • Jul 2010
A 55-year-old female equestrian presented with a 3.5 cm painful left perineal mass. Histologic examination of the excised mass showed a poorly circumscribed mesenchymal proliferation involving fibroadipose and fibrous tissue. The lesion consisted of a bland spindle cell proliferation with areas of fat necrosis, hemosiderin-laden macrophages, multinucleated histiocytes, and extracellular hyalinization with degenerative features. Immunohistochemical studies showed vimentin positivity and no staining for actin, desmin, and CD34. On the basis of clinical, morphologic, and immunostaining findings, the lesion was consistent with a diagnosis of perineal nodular induration. This lesion has been described almost exclusively in avid male cyclists with repetitive perineal trauma. A similar etiology of longstanding and repetitive perineal trauma from horseback riding is postulated for this case. Perineal nodular induration should be considered in the differential diagnosis of perineal masses in women with persistent perineal trauma, such as equestrianism, as well as other similar sport activities.
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Reduction in Incident Stroke Risk With Vigorous Physical Activity Evidence From 7.7-Year Follow-Up of the National Runners' Health Study
Article
  • Mar 2009
  • STROKE
The purpose of this study was to assess the dose-response relationship between vigorous physical activity (running distance, km/d) and the participant-reported physician-diagnosed stroke. Age-adjusted survival analysis of 29 279 men and 12 123 women followed prospectively for 7.7 years. One hundred men and 19 women reported incident strokes. Per km/d run, the age- and smoking-adjusted risk for stroke decreased 12% in men (P=0.0007), and 11% in men and women combined (P=0.001), which remained significant when further adjusted for baseline diabetes, hypercholesterolemia, hypertension, and BMI (8% and 7% reduction per km/d run, respectively, P=0.03). Men and women who ran >or=2 km/d (ie, exceeded the recommended AHA/CDC and NIH guideline activity level) had significantly lower risk than those who ran less (P=0.05), and those who ran >or=4 km/d had significantly lower risk than those who ran 2 to 3.9 km/d (P=0.02). Men and women who ran >or=8 km/d were at 60% lower risk than those who ran <2 km/d (P=0.00). The risk for incident stroke is substantially reduced in those who exceed the guideline physical activity level, which cannot be attributed to less hypertension, diabetes, hypercholesterolemia, or body weight.
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Ischemic Fasciitis: Analysis of 44 Cases Indicating an Inconsistent Association With Immobility or Debilitation
Article
  • Sep 2008
Ischemic fasciitis is a rare pseudosarcomatous proliferation of atypical fibroblasts described to be located over bony protuberances and said to develop most often in immobile elderly or debilitated patients. We report the clinicopathologic features of 44 cases of this pseudosarcomatous reactive fibroblastic/myofibroblastic proliferation. There were 15 female and 29 male patients between 23 and 96 years of age (median: 74 y). Tumor size, known in 34 cases, ranged from 1.3 to 10 cm (median: 4.7 cm). The lesions developed mostly in the deep subcutis (27 cases) and infiltration of deep dermis, muscle, and tendinous tissue was sometimes observed. In 3 cases, the lesion developed within skeletal muscle. In 33 cases (76.7%), the tumor was located around the limb girdles and sacral region; 5 tumors each (23.3%) occurred on the chest wall and the back. A history of physical debilitation could be confirmed in only 7 patients. Nine patients had a history of chronic or malignant diseases and 4 patients had a history of local trauma. The histologic hallmark of this reactive proliferation is a zonal appearance with central fibrinoid degeneration/necrosis and cystic changes surrounded by a granulation tissuelike vascular component, mixed with plump amphophilic reactive fibroblasts and myofibroblasts morphologically similar to proliferative fasciitis. Immunohistochemistry was performed in 18 cases, showing focal positivity for smooth muscle actin (37.5%), desmin (40%), or both (14.3%), underlining the fibroblastic/myofibroblastic nature of these lesions, whereas S-100 and Pan-keratin were consistently negative. Follow-up data were available in 13 cases and ranged between 6 and 72 months (median: 31.3 mo); local recurrence was observed in 1 case in which the patient was physically debilitated. Recognition of this distinct entity as a reactive process, by no means always associated with debilitation, is essential to avoid confusion with soft tissue sarcomas.
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Atypical Decubital Fibroplasia: A Distinctive Fibroblastic Pseudotumor Occurring in Debilitated Patients
Article
  • Aug 1992
  • AM J SURG PATHOL
We report 28 cases of atypical decubital fibroplasia, a distinctive pseudosarcomatous fibroblastic proliferation occurring primarily but not exclusively in physically debilitated or immobilized patients. The subjects included 16 women and 12 men ranging in age from 15 to 95 years. Peak incidence was in the 8th and 9th decades of life. Anatomic locations included the soft tissues overlying the shoulder (eight cases), posterior chest wall (five cases), sacrum (five cases), greater trochanter (four cases), buttock (two cases), thigh (two cases), and arm (two cases). Symptoms were due to a painless mass of 3 weeks' to 6 months' duration. Most lesions were ill-defined, focally myxoid masses that ranged from 1 to 8 cm. Histologically, they were situated in the deep subcutis and secondarily involved adjacent skeletal muscle (11 cases) and tendon (three cases). Extensive epidermal ulceration was typically absent. Microscopically, the lesions had a lobular configuration. They were characterized by zones of fibrinoid necrosis and a prominent myxoid stroma rimmed by ingrowing, ectatic, thin-walled vascular channels. All cases contained atypical, enlarged, degenerated fibroblasts with abundant basophilic cytoplasm, large hyperchromatic, smudged nuclei, and prominent nucleoli; these features resulted in a superficial resemblance to proliferative fasciitis. The enlarged, atypical fibroblasts stained diffusely and strongly for vimentin (15 of 15 cases) and focally for muscle-specific actin (10 of 15 cases), keratin (one of 15 cases), CD68 (10 of 15 cases), and CD34 (five of nine cases) antigens; none of the cases stained for desmin. A malignant diagnosis was considered in 43% of cases. Follow-up in 21 patients ranged from 2 to 78 months (median, 12 months). Two lesions recurred once, one recurred twice, and none metastasized; no deaths were attributable to the lesions. The clinical, histologic, and immunohistochemical features of atypical decubital fibroplasia indicate it is a unique type of pressure sore displaying degenerative and regenerative features distinct from decubitus ulcer. Its recognition by pathologists and clinicians in elderly and debilitated patients is important to avoid misdiagnosis as a sarcoma and to prevent or minimize the occurrence of decubital fibroplasia in progressively aging patient populations.
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Perineal nodular indurations ('accessory testicles') in cyclists. Fine needle aspiration cytologic and pathologic findings in two cases
Article
  • Jan 1988
The cytologic and histologic findings from two cases of perineal nodular indurations observed in two cyclists are reported. These lesions, also referred to as "accessory testicles" or "third testicle" or "ischial hygromas" of cyclists, consist of a localized aseptic area of necrosis with pseudocyst formation involving connective tissue in the superficial fascia of the perineum. These histologic findings, which were seen in the subsequent surgical specimens in these two cases, were reflected in the fine needle aspiration findings. The aspirates contained few cellular elements, mainly a few vacuolated histiocytes, against a background of fibrinous material. These indurations, which develop as a result of repeated, chronic microtrauma to the perineum impressed by the vibration of the saddle of the bicycle, constitute an authentic handicap for the professional cyclist and are a contraindication to cycling for amateur cyclists.
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