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Scrotal and Penile Lymphedema as a Complication of Testicular Prosthesis
Vol. 108, October
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
Printed in U.S.A.
SCROTAL AND PENILE LYMPHEDEMA AS A COMPLICATION OF TESTICULAR PROSTHESIS N ABIL I. ELSAHY
Chronic lymphedema is the swelling that occurs secondary to imperfect drainage of lymph from the tissues. Penile lymphedema is usually seen in conjunction with a similar process in the scrotum. Bulkley classified the etiology of scrotal and penile lymphedema into: 1) primary or idiopathic and 2) secondary or obstructive. 1 Herein is described a case in which testicular prosthesis is presented as a new factor that can lead to genital lymphedema of obstructive etiology.
On several occasions an inflammation appeared on the skin of the genitalia with pain accompanied by raised body temperature. Subsequent to recurrent local inflammation the penis and scrotum became thickened. Intromission was no longer possible. In September 1970 the patient· was admitted to St. Boniface Hospital. Under general anesthesia a transverse scrotal incision was made through which exploration was carried out. The prosthesis was found to be surrounded by gross evidence of chronic
Fm. 1. Patient's deformed penis. Nate normal glans CASlc REPORT
The patient was a 50-year-old, white, unmarried man. He was in good health until 1942, when he contracted mumps complicated by orchitis. In 1963 he had a left herniorrhaphy; at the same time a left orchiectomy was performed for unknown reasons. In 1965 a left testicular prosthesis was inserted. Since then he had noticed a gradual swelling of the penis and scrotum. Accepted for publication February 18, 1972. 1 Bulkley, G. J.: Scrotal and penile lymphedema. J. Urol., 87: 422, 1962.
inflammation and a large collection of purulent material was present. The prosthesis was removed, a Penrose drain was inserted and the scrotum was closed. The bacterial smears taken at that time were negative. In September 1971 the patient was admitted to the Grace General Hospital where a right herniorrhaphy was performed. Postoperatively the patient was referred to me. The penis was enlarged and deformed, measuring 12 cm. in length and 22 cm. in circumference (fig. 1). The thick prepuce was constricting the glans and
595
FIG. 2. A, dorsal incision. Note thickness of skin and subcutaneous tissue of penis. B, excision of skin and subcutaneous tissue of penis in continuity with partial excision of scrotum.
FIG. 3. A, hydrocele of right testicle. Note obliteration of scrotum by thickened fibrous tissue. B, denuded penis covered by split-thickness skin graft sutured in spiral fashion. C, immobilization of penis was obtained by surrounding it with sponge rubber held in place with adhesive tape. Note exposure of glans.
596
SCROTAL AND PENILE LYJVIPHEDEMA
597
FIG. 4. A, low power microscopic examination. Note normal appearance of the epidermis and thickened dermis which is full of dilated lymphatic vessels. B, high power microscopic examination. Note dilated lymphatic vessels and presence of multinucleated giant cells.
the skin was indurated and immobile. The glans was completely normal. The scrotum was the size of 2 male fists and the skin was thick and scarred. The night blood film was negative for microfilariae, and hematology was normal except for 9 per cent eosinophils and an erythrocyte sedimentation rate of 90. The Mantoux test was positive, the urinalysis was normal and the lymphangiogram revealed slightly enlarged inguinal lymph nodes. It was concluded that the cause of this genital elephantiasis was the recurrent infection around the testicular prosthesis, resulting in obstruction of the lymph flow from the penis and scrotum but not from the glans. OPERATION
Under general anesthesia, a Foley catheter was inserted through the urethra into the bladder. With a tourniquet at the root of the penis, the skin and subcutaneous tissue were excised from the root of the penis out to the prepuce and down to the fascia, leaving vessels and nerves on the dorsal aspect intact (fig. 2, A). Once the tourniquet was removed and complete hemostasis was obtained the denuded penis
was dressed with wet saline gauze. A V-shaped incision was then made in the scrotum and a mass of thick, fibrous tissue was removed in continuity with the excised mass from the penis (fig. 2, B). Careful dissection of the right spermatic cord was performed up to the level of the external inguinal ring. The right testicle was embedded in a mass of thick, edematous, fibrous tissue that filled the scrotum. The testicle was dissected free of its bed and found to be surrounded by a hydrocele (fig. 3, A). Aspiration and examination of its fluid failed to show tumor cells, acid-fast bacilli or any other organisms. The hydrocele was dealt with by everting the tunica vaginalis. After partial excision of the scrotum, 2 small stab wounds were made on either side of the scrotum through which a hemovac was inserted. The scrotum was easily closed. A medium-thickness split skin graft (0.020 inches) taken from the abdomen was draped around the penis and sutured in place in a spiral fashion so that any contracture that might occur would not be functionally troublesome (fig. 3, B). A dressing was applied and the penis was surrounded with sponge rubber, maintained in place
598
ELSAHY
with adhesive tape (fig. 3, C). The glans penis was left exposed to allow frequent observation for possible circulatory impairment. The initial dressing was changed and the Foley catheter was removed after 4 days. Histological examination of the excised tissue (fig. 4) revealed dense fibrohyaline connective tissue in the dermis and subcutaneous tissue, containing numerous distended vascular spaces, the appearance of which was consistent with that of lymphatic vessels. Separately, in relation to these channels there were several multinucleated giant cells. Fluid aspiration from the right hydrocele was negative for tumor cells, acidfast bacilli and any other organisms. Convalescence was uneventful, the graft healed completely and the patient was discharged from the hospital 2 weeks postoperatively. DISCUSSION
The surgical treatment just outlined is standard. In his excellent article Khanna summarized the
different operative procedures used in treating his series of 28 cases of elephantiasis of the scrotum and penis. 2 However, elephantiasis of the genitalia owing to testicular prosthesis has never been reported. SUMMARY
Testicular prosthesis may result in elephantiasis of the genitalia. A case of such a complication is reported herein. Drs. H.P. Krahn, R. Taylor and Banerjee assisted with this study. Percthouse 18, 233 Booth Drive, Winrcipeg, Manitoba, Canada R3J 3M4 2 Khanna, N. N.: Surgical treatment of elephantiasis of male genitalia. Plast. Reconstr. Surg., 46:
481, 1970.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
Printed in U.S.A.
SCROTAL AND PENILE LYMPHEDEMA AS A COMPLICATION OF TESTICULAR PROSTHESIS N ABIL I. ELSAHY
Chronic lymphedema is the swelling that occurs secondary to imperfect drainage of lymph from the tissues. Penile lymphedema is usually seen in conjunction with a similar process in the scrotum. Bulkley classified the etiology of scrotal and penile lymphedema into: 1) primary or idiopathic and 2) secondary or obstructive. 1 Herein is described a case in which testicular prosthesis is presented as a new factor that can lead to genital lymphedema of obstructive etiology.
On several occasions an inflammation appeared on the skin of the genitalia with pain accompanied by raised body temperature. Subsequent to recurrent local inflammation the penis and scrotum became thickened. Intromission was no longer possible. In September 1970 the patient· was admitted to St. Boniface Hospital. Under general anesthesia a transverse scrotal incision was made through which exploration was carried out. The prosthesis was found to be surrounded by gross evidence of chronic
Fm. 1. Patient's deformed penis. Nate normal glans CASlc REPORT
The patient was a 50-year-old, white, unmarried man. He was in good health until 1942, when he contracted mumps complicated by orchitis. In 1963 he had a left herniorrhaphy; at the same time a left orchiectomy was performed for unknown reasons. In 1965 a left testicular prosthesis was inserted. Since then he had noticed a gradual swelling of the penis and scrotum. Accepted for publication February 18, 1972. 1 Bulkley, G. J.: Scrotal and penile lymphedema. J. Urol., 87: 422, 1962.
inflammation and a large collection of purulent material was present. The prosthesis was removed, a Penrose drain was inserted and the scrotum was closed. The bacterial smears taken at that time were negative. In September 1971 the patient was admitted to the Grace General Hospital where a right herniorrhaphy was performed. Postoperatively the patient was referred to me. The penis was enlarged and deformed, measuring 12 cm. in length and 22 cm. in circumference (fig. 1). The thick prepuce was constricting the glans and
595
FIG. 2. A, dorsal incision. Note thickness of skin and subcutaneous tissue of penis. B, excision of skin and subcutaneous tissue of penis in continuity with partial excision of scrotum.
FIG. 3. A, hydrocele of right testicle. Note obliteration of scrotum by thickened fibrous tissue. B, denuded penis covered by split-thickness skin graft sutured in spiral fashion. C, immobilization of penis was obtained by surrounding it with sponge rubber held in place with adhesive tape. Note exposure of glans.
596
SCROTAL AND PENILE LYJVIPHEDEMA
597
FIG. 4. A, low power microscopic examination. Note normal appearance of the epidermis and thickened dermis which is full of dilated lymphatic vessels. B, high power microscopic examination. Note dilated lymphatic vessels and presence of multinucleated giant cells.
the skin was indurated and immobile. The glans was completely normal. The scrotum was the size of 2 male fists and the skin was thick and scarred. The night blood film was negative for microfilariae, and hematology was normal except for 9 per cent eosinophils and an erythrocyte sedimentation rate of 90. The Mantoux test was positive, the urinalysis was normal and the lymphangiogram revealed slightly enlarged inguinal lymph nodes. It was concluded that the cause of this genital elephantiasis was the recurrent infection around the testicular prosthesis, resulting in obstruction of the lymph flow from the penis and scrotum but not from the glans. OPERATION
Under general anesthesia, a Foley catheter was inserted through the urethra into the bladder. With a tourniquet at the root of the penis, the skin and subcutaneous tissue were excised from the root of the penis out to the prepuce and down to the fascia, leaving vessels and nerves on the dorsal aspect intact (fig. 2, A). Once the tourniquet was removed and complete hemostasis was obtained the denuded penis
was dressed with wet saline gauze. A V-shaped incision was then made in the scrotum and a mass of thick, fibrous tissue was removed in continuity with the excised mass from the penis (fig. 2, B). Careful dissection of the right spermatic cord was performed up to the level of the external inguinal ring. The right testicle was embedded in a mass of thick, edematous, fibrous tissue that filled the scrotum. The testicle was dissected free of its bed and found to be surrounded by a hydrocele (fig. 3, A). Aspiration and examination of its fluid failed to show tumor cells, acid-fast bacilli or any other organisms. The hydrocele was dealt with by everting the tunica vaginalis. After partial excision of the scrotum, 2 small stab wounds were made on either side of the scrotum through which a hemovac was inserted. The scrotum was easily closed. A medium-thickness split skin graft (0.020 inches) taken from the abdomen was draped around the penis and sutured in place in a spiral fashion so that any contracture that might occur would not be functionally troublesome (fig. 3, B). A dressing was applied and the penis was surrounded with sponge rubber, maintained in place
598
ELSAHY
with adhesive tape (fig. 3, C). The glans penis was left exposed to allow frequent observation for possible circulatory impairment. The initial dressing was changed and the Foley catheter was removed after 4 days. Histological examination of the excised tissue (fig. 4) revealed dense fibrohyaline connective tissue in the dermis and subcutaneous tissue, containing numerous distended vascular spaces, the appearance of which was consistent with that of lymphatic vessels. Separately, in relation to these channels there were several multinucleated giant cells. Fluid aspiration from the right hydrocele was negative for tumor cells, acidfast bacilli and any other organisms. Convalescence was uneventful, the graft healed completely and the patient was discharged from the hospital 2 weeks postoperatively. DISCUSSION
The surgical treatment just outlined is standard. In his excellent article Khanna summarized the
different operative procedures used in treating his series of 28 cases of elephantiasis of the scrotum and penis. 2 However, elephantiasis of the genitalia owing to testicular prosthesis has never been reported. SUMMARY
Testicular prosthesis may result in elephantiasis of the genitalia. A case of such a complication is reported herein. Drs. H.P. Krahn, R. Taylor and Banerjee assisted with this study. Percthouse 18, 233 Booth Drive, Winrcipeg, Manitoba, Canada R3J 3M4 2 Khanna, N. N.: Surgical treatment of elephantiasis of male genitalia. Plast. Reconstr. Surg., 46:
481, 1970.