Scrotal Lymphedema

Related Terms

Male Genital Lymphedema, lymphedema of the scrotum, lymphedema of the penis, genital elephantiasis

Because of the prevalence of scrotal lymphedema, I decided a separate page, apart from our Male Genital Lymphedema would be in order. While scrotal lymphedema may be common, lymphedema of the penis is less so, and the proposed surgery for this is brutal and the patient should seriously think about having it done.

The usual treatment for scrotal lymphedema is surgery, although it can also be treated through Manual Lymphatic Drainage, MLD, also referred to as Comprehensive Decongestive Therapy, CDT, or Complete Decongestive Therapy. For information on this see: The Treatment of Genital Lymphedema

Pat

Dec. 24, 2011

Buck's Fascia Surgery

For scrotal lymphedema, the safest and most effective surgery is called Buck's Fascia. In this surgery, the subcutaneous tissues (layer of swelling/fluid collection) of the scrotum is removed, the skin is then resected with the excess being removed.

You may find additional information under our section on genital lymphedema. The two surgical procedures described here are the safest and most effective techniques used. However, both also may require skin grafts.

For his leg lymphedema, he should be referred to a certified therapist to have decongestive therapy. Once the leg edema is brought under control, there are wraps and garments available that will hold that swelling in check.

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Abstracts and Studies

The treatment of scrotal lymphedema.

Worldwide, most cases of scrotal lymphedema result from inflammation as a sequela of filarial infection, usually in tropical regions where the filariasis is endemic. In the U.S., the cause is usually surgery, irradiation, and/or cancer. The mainstay of therapy is surgical with medical therapy such as diuretics and scrotal elevation of little value except for very mild cases. Any underlying medical or infectious cause for the lymphedema, however, should be treated prior to attempting surgical therapy.

Surgical therapy can be categorized as either bypassing (lymphangioplasty) or excisional (lymphangiectomy). While numerous lymphangioplasty procedures have been conceived using autogenous material (skin bridges, omental transposition), prosthetic conduits (nonabsorbable suture threads), and microsurgical techniques (lymphaticovenous shunts), none have found to be consistently satisfactory in long-term results. It is generally agreed that excisional therapy, which was first described by Delpech in 1820, still provides the most expeditious and reproducible results.

Numerous variations of lymphangiectomy exist but they all have in common the excision of superficial lymphatics, subcutaneous tissue, and skin at the level of Buck’s fascia on the penis with dissection of the spermatic cord and testicles from the edematous scrotal mass. Scrotal reconstruction and coverage varies. If there is not enough scrotal skin left then split-thickness skin grafts and/or fasciocutaneous thigh flaps may be necessary. Yale School of Medicine

Yale Surgery - link no longer available

Scrotal Lymphedema

2011

Craig Pastor, MD and Mark S. Granick, MD Division of Plastic Surgery, University of Medicine and Dentistry of New Jersey, Newark, NJ Correspondence: Email: pastorcr@umdnj.edu

Description

A 39-year-old man presents with a several-year history of an enlarged scrotum that developed after a bout of epididymitis.

Discussion

Scrotal elephantiasis, or massive scrotal lymphedema, is a disease that is caused by obstruction, aplasia, or hypoplasia of the lymphatic vessels draining the scrotum. The scrotal skin is thickened and may exhibit ulcerations in severe cases. It can be either congenital or acquired in nature, with the most common acquired etiology being infection. The most common infections leading to scrotal elephantiasis are lymphogranuloma venereum or filarial infestation with Wuchereria bancrofti. The rare occurrence of these infections in Western nations makes scrotal elephantiasis an uncommon disease outside of Africa and Asia. Other causes of this disease include chronic inflammation, neoplasm, irradiation, and lymph node dissection.

Treatment of this condition is guided by the etiology. Response often depends on whether the lymphatic derangement can be reversed. In cases where the lymphedema is caused by fluid overload or congestive heart failure, diuretics can be of benefit. Mild and acute cases due to sarcoidosis may benefit from steroids. Antibiotics may be all that is necessary in cases of acute infection. When the lymphedema is chronic, with resultant skin and subcutaneous fibrosis, more aggressive therapy is warranted. There are several surgical options. In most cases requiring surgery, the skin is involved and needs to be removed. The testicular subcutaneous tissue is indurated and full of lymphatic fluid and similarly needs to be removed. The testicles and spermatic cord are generally preserved and unaffected by the lymphedema. However, in some cases, the penile skin can be chronically avulsed off the penile shaft by the weight of the affected scrotum, as in our case. The penile shaft should be split-thickness skin grafted when it has been denuded in this fashion. The testicles can be implanted in the thighs or lower abdomen unless there is sufficient residual tissue to reconstruct a scrotal sac. If the testicles are replaced into a neo-sac, then they must be pexed to prevent torsion.

Our patient is a 39-year-old man who presented to the plastic surgery office with a several-year history of an enlarged scrotum that extended to his knees. The patient's penis was completely obscured by the scrotal tissue and his urinary stream emerged from a tunnel of avulsed penile shaft skin embedded in his scrotum. The patient denied travel to areas endemic with Chlamydia trachomatis or Wuchereria bancrofti but reported that following a case of epididymitis, his scrotum began to enlarge progressively. Because of the chronic nature of the patient's disease and the irreversible changes to his skin and subcutaneous tissue, he would not have benefited from conservative management. The patient underwent excision of scrotal skin and subcutaneous tissue, orchiopexy, skin graft to his penis shaft, and reconstruction of his scrotum with perineal skin that had been spared from the disease process.

References

1. McDougal SW. Lymphedema of external genitalia. J Urol. 2003;170:711–6. [PubMed] 2. Hornberger BJ, Elmore JM, Roehrborn CG. Idiopathic scrotal elephantiasis. Urology. 2005;65(2):389. [PubMed] 3. Denzinger S, Watzlawek E, Burger M, Wieland WF, Otto W. Giant scrotal elephantiasis of inflammatory etiology: a case report. J Med Case Reports. 2007;1(1):23. [PMC free article] [PubMed] 4. Zacharakis E, Dudderidge T, Zacharakis E, Ioannidis E. Surgical repair of idiopathic scrotal elephantiasis. South Med J. 2008;101(2):208–10. [PubMed]

NIH

Surgical management of scrotal lymphedema using local flaps.

Jul 2007

Ann Plast Surg. 2007 Jul; Halperin TJ, Slavin SA, Olumi AF, Borud LJ. Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA. thalperin@partners.org

Lymphedema affects all parts of the body, including the scrotum and penis. Genital lymphedema can be a functionally and emotionally incapacitating problem for patients. Patients suffer pain, chronic irritation, repeated infections, drainage, and sexual dysfunction. No ideal surgical or medical therapy exists for the treatment of male genital lymphedema. Fasciocutaneous thigh flaps have been used for coverage of the testes after scrotal lymphedema resection, but these flaps alter testicular thermoregulation and may cause infertility. Skin grafts have also been used for coverage. Use of posteriorly based perineal flaps may preserve perirectal lymphatics that provide collateral lymphatic drainage. We present 2 cases of severe scrotal lymphedema treated by lymphangiectomy and reconstruction with local flaps. Both patients were satisfied with their results and had improved quality of life. We present our miniseries of scrotal lymphedema treated by excision and anterior and posterior flap reconstruction as a successful treatment of this difficult problem.

Annals of Plastic Surgery