Nodular Induration Research Articles

How to Treat a Cyclist's Nodule?-Introduction of a Novel, ICG-Assisted Approach.

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. 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. 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. 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.

364 The Cycling Urologist: Effect on PSA, Haematuria, Pudendal Nerve Entrapment and Cyclists Nodules

Abstract Aim Cycle use has vastly increased over the last few years in the UK. The aim of this review was to evaluate the effect of cycling on the common conditions presenting to the urology clinic, in particular those of raised PSA, haematuria, soft tissue lesions (“cyclist nodules”) and pudendal nerve entrapment syndromes. Method A PUBMED search of the literature on cycling and genitourinary disorders was performed. The keywords included “Bicycling” AND “Prostate-specific antigen”, “Bicycling” AND “Haematuria”, “Bicycling” AND “Cyclist Nodules”, “Bicycling” AND “Pudendal Nerve Entrapment”. Results The literature suggests no significant change in total PSA levels after a bout of cycling, regardless of age. The type of cycling (mountain biking vs. road cycling) does not influence PSA levels. It is possible that the saddle used in cycling may displace the pressure across the perineal and gluteal region to effectively alleviate pressure on the prostate. Haematuria appears to be rare with cycling but has been described. Perineal nodular induration is a very rare - although possibly under diagnosed condition. It is thought to be caused by repetitive micro trauma from contact between the perineum and saddle. Pudendal nerve entrapment (PNE) represents the most common bicycling associated urogenital problem. Numbness in the perineum, penis, scrotum or the buttocks is the most common and most recognised symptom. Genital numbness may occur unrelated to erectile dysfunction (ED) although cycling related ED is invariably associated with genital numbness. Conclusions Urology Trainees and Consultants should be aware of how recreational and high-level cycling may result in presentation to the Urology clinic.

Urological issues in cyclists

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.

A tale of two sit-bones: The cyclist’s ischial hygroma (Perineal nodular induration)

The ischial hygroma or perineal nodular induration is a relatively rare and cycling specific injury that is often incorrectly diagnosed and managed. We highlight two cases with divergent managements to highlight the spectrum of treatment available to manage this rare condition. We describe the presentation, assessment and management of two cases of pernineal nodular induration.
 The management (surgical excision vs conservative management with saddle pressure mapping) highlight that there is no single optimal management and a multidisciplinary approach should be applied to treat these injuries successfully. Perineal nodular induration should be investigated appropriately to exclude less benign causes of perineal masses. Both conservative management and surgical excision can be successful. Clinicians should be familiar with assessment and management options for this relatively rare but debilitating condition in competitive cyclists.

US Assessment of Sports-related Hip Injuries.

Traumatic and overuse hip injuries occur frequently in amateur and professional athletes. After clinical assessment, imaging plays an important role in diagnosis and in defining care management of these injuries. Ultrasonography (US) is being increasingly used in assessment of hip injuries because of the wide availability of US machines, the lower cost, and the unique real-time imaging capability, which allows both static and dynamic evaluation as well as guidance of point-of-care interventions such as fluid aspiration and steroid injection. Accurate diagnosis of hip injuries is often challenging, given the complex soft-tissue anatomy of the hip and the wide spectrum of injuries that can occur. To conduct a skillful US evaluation of hip injuries, physicians must have pertinent knowledge of the normal anatomy and should make judicious use of surface anatomy landmarks while using a compartmentalized diagnostic approach. In this article, common sports-related injuries of the anterior, lateral, and posterior hip compartments are discussed. This review includes assessment of joint effusion, acetabular labral tear, acute and chronic tendon injuries including tendinopathy, partial and full-thickness tears, snapping hip syndromes, relevant US-guided procedures, and some other conditions such as Morel-Lavallée lesion and perineal nodular induration. Principles of care management and current knowledge on imaging findings that may affect return to activity are also presented. Using an oriented US examination technique and having knowledge of the normal hip anatomy will help physicians characterize US findings of common sports-related hip injuries and make accurate diagnoses. Online supplemental material is available for this article. ©RSNA, 2018.

A rare case of suspected perineal nodular induration

A rare case of suspected perineal nodular induration

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

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.

Perineal Nodular Induration (“Biker’s Nodule”)

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.

Biker’s Nodule: A Perineal Nodular Induration of the Cyclist

A case of “biker’s nodule” in an 80 year-old cyclist is reported. The “biker’s nodule” is caused by repeated microtrauma to the subcutaneous fatty tissue or collageneous tissue on the perineal region resulting in a perineal nodular induration.

Perineal Nodular Induration: A Trauma-induced Mass in a Female Equestrian

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.

Granulomatous gall bladder: A surgico-pathological challenge

Granulomatous gall bladder: A surgico-pathological challenge

Intralesional Interferon Alpha-2b Therapy for Adnexal Kaposi Sarcoma

To describe a case of adnexal Kaposi's sarcoma successfully treated with intralesional interferon alpha 2b injections. Case Report. A 31 year old black Haitian male presents with severe nodular induration and erythema of both eyelids with hemorrhagic infiltration of the bulbar and palpebral conjunctivae, advanced on the right. Clinical, histological, and immunohistochemical examination yielded the diagnosis of Kaposi's sarcoma. The patient was subsequently diagnosed with AIDS, started on highly active anti-retroviral therapy (HAART) and systemic doxorubicin, and initially received topical 3 million IU per mL of interferon alpha-2b eyedrops (Intron-A(R), Schering Corporation, Kenilworth, NJ) every 6 hours to the right eye for 9 weeks. This systemic therapy resulted in minimal clinical response with a CD4 count increase from 12 to 61 cells per microliter. Progressive entropion and corneal compromise on the right prompted a trial of intralesional injections of interferon alpha-2b. Over a 4 week period, 3 injections (3 million IU in 0.5mL, 1.5 million IU in 0.5mL, and 1.5 million IU in 0.5mL) were given. This resulted in a dramatic reduction in tumor burden and lid edema, an improvement in lid position, and corneal healing. Ocular adnexal and conjunctival Kaposi's sarcoma was successfully treated with 3 adjuvant intralesional interferon alpha-2b injections leading to a dramatic decrease in tumor mass.

Pathology of the rectal wall in solitary rectal ulcer syndrome and complete rectal prolapse.

The aetiology and pathology of rectal prolapse and solitary rectal ulcer are poorly understood. To examine the full thickness rectal wall in these two conditions. The pathological abnormalities in the surgically resected rectal wall were studied from nine patients with solitary rectal ulcer syndrome, 11 complete rectal prolapse, and nine cancer controls. Routine haematoxylin and eosin and Van Gieson staining for collagen were performed. The rectal wall from solitary rectal ulcer syndrome specimens was thickened compared with complete rectal prolapse and controls. The major difference was in the muscularis propria (2.2 v 1.1 v 1.2 mm, medians, p < 0.005) and particularly the inner circular muscular layer, and to a lesser extent the submucosal and outer longitudinal muscular layers. Some solitary rectal ulcer syndrome specimens showed unique features such as decussation of the two muscular layers (four of nine), nodular induration of inner circular layer (four of nine) and grouping of outer longitudinal layer into bundles (three of nine); these were not seen in complete rectal prolapse or control specimens. These features, which resemble the features of high pressure sphincter tissue, may be of aetiological importance, and suggest a different pathogenesis for these two disorders. Excess collagen was seen in both disorders, was more severe in solitary rectal ulcer syndrome specimens, and probably reflects a response to repeated trauma.

CHOLECYSTIC GRANULOMAS IN GALLSTONE DISEASE

This paper concerns with 17 cases of chronic cholecystitis with various granulomatous changes of the wall. All materials were obtained from patients who underwent cholecystectomy for various complications of gallstone disease. The only significant sign attributalbe to the granulomas was a palpable nodular induration in the wall at operation in several cases, and this led to a suspicion of neoplasm in one. Pathologically, these lesions were characterized principally by nodular proliferation (0.5–3.0 cm in size) of various forms of histiocytic cells, including lipid‐containing histiocytes (foam cells), PAS positive brown pigmented cells, and multinucleated giant cells. Deposition of bile pigment and/or cholesterin crystals were found deeply in the areas of granulomatous reaction in about two‐thirds of the cases. This finding supports a bile‐induced granulomatous process of these lesions. The granuloma in one of our series contained typical Michaelis‐Gutmann bodies seen in a case of malakoplakia. It is suggested that bile materials, which are capable of eliciting intense phagocytic reaction, may also act as an initiating factor in formation of malakoplakic lesions.

Ileocecal histoplasmosis.

Digestive tract histoplasmosis is rare, although the potential for gastrointestinal involvement has been recognized since the original description of disseminated histoplasmosis in 1906 (4). The spectrum of gastrointestinal lesions associated with histoplasmosis described in the literature is summarized in Table I. These abnormalities have been cited without radiologic documentation. Available case reports comprising roentgenographic studies published in the last decade are listed in Table II. The nine reports include seven cases of primary gastrointestinal histoplasmosis and four secondary cases of extrinsic esophageal involvement. This remarkably limited collection of roentgenologic studies is herein supplemented by descriptions of three patients with varied syndromes of ileocecal histoplasmosis. The first reported instance of the complication of small bowel obstruction is described in the third case. Case I: A 51-year-old fanner was hospitalized in July 1965 with the chief complaints of weight loss, dyspnea, and marked weakness of three months duration. Upon admission, the temperature was 99.4° F, pulse 84, respiration 20, and blood pressure 100∕60. Physical examination disclosed no abnormalities. Routine laboratory studies were essentially negative. A chest roentgenogram demonstrated an extensive right upper lobe infiltration of nonspecific type (Fig. 1). This noncavitary process was regarded as probable active tuberculosis. Sputum smears and cultures revealed no acid-fast bacilli, however. Tuberculin and histoplasmin skin tests were likewise negative. A survey barium enema study showed a constant subtraction type filling defect of the inner cecal wall (Fig. 2). An extrinsic compression deformity of an adjacent terminal ileal loop suggested extramural extension of a cecal neoplasm. The patient not only refused the recommended exploratory laparotomy, but he also insisted on dismissal from the hospital. Five days after discharge, the patient was readmitted from the Emergency Room with a blood pressure of 50∕0. Physical examination was nonrevealing aside from an extreme hypotensive state with profound asthenia. Despite obvious progressive deterioration of his general condition, the patient refused additional care and again signed out of the hospital against advice. He died two days after returning to his home. Postmortem examination revealed an unsuspected disseminated histoplasmosis. The right upper lobe of the lung was largely obliterated by nodular induration with caseation and necrosis. Both lungs were diffusely involved by miliary histoplasmosis. The adrenal glands had undergone such diffuse hyalinizing necrosis that only in rare instances could remnants of cortical cells be recognized. Adrenal gland destruction was deemed responsible for an Addison's syndrome with circulatory failure and death. Methenamine silver stains demonstrated Histoplasma capsulatum.

XCVII. ERYTHEMA ELEVATUM DIUTINUM

Bury 1 in 1889 described a small number of cases of a curious erythema of the hands in which there were nodular thickening and induration of the skin. This disease may have been the same condition described later by Crocker and Williams (1894) 2 and named by them erythema elevatum diutinum. In 1929 Weidman and Besancon, 3 in presenting 2 cases, made a comprehensive bacteriologic and histologic study of the condition. From a lesion in one of the cases they isolated Streptococcus ignavus, which they suggested may have been a possible etiologic agent. They stressed in particular the rheumatic background in the majority of cases reported. Coombs and Bluefarb 4 in 1940 reported a case which histologically and clinically was similar to those of Weidman and Besancon. No attempt was made to carry out cultural studies. We are reporting a case which histologically and clinically conforms to those described by