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The Surgical Management of Scrotal and Penile Lymphedema
Vol. 113, February
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
THE SURGICAL MANAGEMENT OF SCROTAL AND PENILE LYMPHEDEMA STEPHEN K. VAUGHT, AUSTINS. LITVAK
AND
J. WILLIAM MCROBERTS
From the Division of Urology, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
Lymphedema describes an abnormal condition in which there is retention of lymphatic fluid within the loose subcutaneous tissues. This condition may occur in any location throughout the body as the fluid accumulates owing to inadequate drainage through lymphatic channels. Lymphedema of the penis and scrotum is quite common in the tropics secondary to filarial infestations but is not common in this country. Patients with this abnormality may have genital swelling and secondary symptoms of dysuria, local inflammation, and sexual dysfunction. We present 3 patients with genital lyniphedema that required surgical correction and discuss the techniques and results of operative therapy. CASE REPORTS
Case 1. W. D., 23-47-60-7, a 20-year-old white man, had complaints of penile, scrotal and bilateral lower extremity swelling. The lower extremity involvement had been present for an undetermined period but at least since the patient was 7 years old. The scrotal and penile swelling had been present for approximately a year. Complaints of painful erections and inability to have intercourse were also expressed. There was no history of an hereditary or infectious etiology. Physical examination was remarkable only in noting 4 plus brawny edema of the penis, scrotum and both lower extremities up to the inguinal ligaments. Lymphangiograms revealed filling of the superficial and deep lymphatics with the appearance of ectatic lymphatic channels in both superficial inguinal areas. No filling was noted above the inguinal ligaments bilaterally. Surgical treatment consisted of complete excision of the penile skin with a split-thickness skin graft from the thigh for coverage. A pear-shaped segment of scrotal skin was then excised, leaving a small amount of posterior scrotal skin with only small lateral scrotal flaps. The remaining scrotal skin was then undermined, removing as much subcutaneous tissue as possible. The testes were completely isolated and cleared of edematous tissue. Bilateral orchiopexy was then done and the scrotal skin was closed in a Y fashion. A strip of x-ray film was rolled into a tube and fitted to make a splint to immobilize the penis and skin graft (fig. 1). The sutures for the distal graft-penile skin anastomosis were also brought through the splint. Pathological examination reAccepted for publication July 12, 1974.
vealed chronic infection and prominent lymphatics consistent with lymphedema. Six months postoperatively the patient has had no recurrent scrotal or penile edema and has completely satisfactory sexual function. Case 2. H. P., 06-72-87-3, a 57-year-old white man, noted intermittent swelling of the scrotum and penis for 2 to 3 years prior to hospitalization. The onset of the edema coincided with being kicked in the groin by a horse. Complaints of intermittent dysuria associated with irritation of the foreskin were also voiced. There was no history suggestive of an infectious or hereditary etiology of the genital lymphedema. Physical examination was unremarkable except for the moderate penile and scrotal edema. There was no involvement of the lower extremities. Lymphangiograms were not done. All routine laboratory values were normal. Surgical treatment consisted of excision of the penile skin and replacement with a split-thickness skin graft from the thigh. The edematous scrotal skin was also excised, leaving a posterior full thickness skin flap which was brought anteriorly to cover the testes after the latter were fixed to prevent torsion. Pathological examination revealed chronic dermatitis with local lymphangiectasis and prominent lymphatic vessels consistent with lymphedema. This patient has been followed for more than 2 years and there has been no recurrence of the edema (fig. 2). He also claims completely normal sexual function. Case 3. R. P., X60279, a 21-year-old white man, presented with a history of persistent scrotal and penile swelling 14 months in duration. About 8 months after the patient was stationed in the coastal area of South Vietnam intermittent episodes developed of fever, headaches, and bilateral inguinal lymphadenopathy associated with mildto-moderate scrotal and right lower extremity edema. Despite the absence of microfilaria on multiple night blood smears, the diagnosis was Bancroft's filariasis and the patient was treated with diethylcarbamazine (hetrazan) for 2 weeks. During this interval systemic symptoms disappeared with resolution of the right leg edema but with no noticeable improvement in the scrotal swelling. About 4 and 6 months later the patient had 2 separate episodes of streptococcal lymphangitis involving the scrotum, penis and inguinal areas bilaterally which responded to penicillin therapy. However, the scrotal swelling persisted 204
SURGICAL MANAGEMENT OF SCROTAL AND PENILE LYMPHEDEMA
205
FIG. 1. Surgical technique shows use of x-ray film for splint and penile skin graft with scrotal excision
FIG. 2. Preoperative and postoperative views
and was accompanied by a milky-white scrotal discharge. At this point the scrotal and penile lesions precluded satisfactory coitus. Physical examination revealed the scrotum to be 3 times normal size with thick, coarse, edematous scrotal skin leaking milky-white fluid on compression. The penis was only moderately edematous without any cutaneous discharge. The lower inguinal areas exhibited mildly tender, shoddy lymphadenopathy. The lower extremiti~s were normal. Scrotal lymphangiograms revealed lymphangiectasia of the superficial inguinal lymphatics bilaterally with stasis of contrast material in these
lymphatics on the 24-hour examination. The paraaortic lymphatics and nodes were morphologically normal. Excretory urography and cystoscopy were normal and the filarial complementation-fixation test was negative. Complete blood count was normal without eosinophilia. Surgical treatment of the scrotum consisted of a midline scrotal skin incision, removal of all subcutaneous edematous tissue and fat, trimming of the redundant scrotal skin but leaving a full-thickness posterior scrotal skin flap, fixation of the testicles and reapproximation of the medial margins of the scrotal skin flap. By means of the circumferential
206
VAUGHT, LITVAK AND MCROBERTS
coronal skin incision and a 4 cm. dorsal slit, the penile skin was retracted to the penoscrotal angle, the subcutaneous tissue of the penis was removed by sharp dissection and the skin was replaced. The pathology report of the scrotal subcutaneous tissue revealed chronic inflammation and fibrosis. Four months postoperatively the patient is free of all penile edema and essentially all of the scrotal edema with a good cosmetic appearance. In addition, the patient is now able to have satisfactory sexual relations.
DISCUSSION
Scrotal and penile lymphedema may have several etiologies. Bulkley presented a classification of lymphedema which provides a helpful approach in the evaluation of genital lymphedema. Primary: 1) congenital (Milroy's disease) and 2) lymphedema praecox (developing at puberty). Secondary or obstructive: 1) inflammatory (filarial and lymphogranuloma, chancroid, tuberculosis, syphilis, erysipelas and leprosy), 2) surgical (lymph node dissection of inguinal region and scars in groin), 3) carcinoma with blockage of the lymphatics, 4) post-irradiation destruction of lymphatics and 5) medical (cardiac or renal failure, venous thrombosis and hypoproteinemia). 1 Although the incidence of lymphedema of the penis and scrotum is not high, it represents a tremendous burden to those so afflicted. Attempts must be made in each case to determine the exact etiology since most patients will respond to nonsurgical therapy. The goals of treatment are to relieve discomfort, allow return of sexual function, preserve testicular function and prevent recurrence. Numerous modes of surgical therapy have been proposed. In 1820 Delpech used thigh and abdomi1 Bulkley, G. J.: Scrotal and penile lymphedema. J. Urol., 87: 422, 1962.
nal flaps to cover the denuded penis and testes. 2 Muller and Jordan denuded the penis and used split-thickness skin grafts for coverage and also excised the involved scrotal skin using the non-involved posterior skin flaps for scrotal reconstruction. 3 In the treatment of scrotal lymphedema it has been noted that the posterior and the posterolateral aspects of the scrotum are little affected and therefore, these areas may be used for scrotal reconstruction.• The reason for sparing of this posterior area is unclear but may be owing to collateral flow through perirectal lymphatics. Accordingly, large portions of the affected scrotal skin can be excised, the testes and cord can be completely skeletonized, and the remaining scrotal skin can be undermined, thus removing edematous tissue. This procedure leaves thin scrotal flaps to be closed anteriorly after fixing both testes to prevent torsion. Complete removal of the penile skin with split-thickness skin grafting is now an accepted method of treating penile lymphedema. Catheter drainage and antibiotics are used postoperatively. Drains are also used routinely and left in place 3 to 4 days postoperatively. The x-ray film used as a splint in case 1 was effective in providing a protective dressing and a splint to the penile skin graft. SUMMARY
Presented here are 3 cases of penile and scrotal lymphedema of different etiologies and the results of surgical treatment. Also presented is a brief discussion of the etiology, pathophysiology and surgical techniques useful in treating scrotal and penile lymphedema. 2 Delpech, J. M.: Chirurgie Clinique de Montpelier. Paris and Montpelier, vol. 2, 1828. 'Muller, G. P. and Jordan, C. G.: Elephantiasis nostra. Ann. Surg., 97: 226, 1933. •Jones, H. W. and Kahn, R. A.: Surgical treatment of elephantiasis of the male genitalia. Plast. Reconstr. Surg., 46: 8, 1970.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
THE SURGICAL MANAGEMENT OF SCROTAL AND PENILE LYMPHEDEMA STEPHEN K. VAUGHT, AUSTINS. LITVAK
AND
J. WILLIAM MCROBERTS
From the Division of Urology, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
Lymphedema describes an abnormal condition in which there is retention of lymphatic fluid within the loose subcutaneous tissues. This condition may occur in any location throughout the body as the fluid accumulates owing to inadequate drainage through lymphatic channels. Lymphedema of the penis and scrotum is quite common in the tropics secondary to filarial infestations but is not common in this country. Patients with this abnormality may have genital swelling and secondary symptoms of dysuria, local inflammation, and sexual dysfunction. We present 3 patients with genital lyniphedema that required surgical correction and discuss the techniques and results of operative therapy. CASE REPORTS
Case 1. W. D., 23-47-60-7, a 20-year-old white man, had complaints of penile, scrotal and bilateral lower extremity swelling. The lower extremity involvement had been present for an undetermined period but at least since the patient was 7 years old. The scrotal and penile swelling had been present for approximately a year. Complaints of painful erections and inability to have intercourse were also expressed. There was no history of an hereditary or infectious etiology. Physical examination was remarkable only in noting 4 plus brawny edema of the penis, scrotum and both lower extremities up to the inguinal ligaments. Lymphangiograms revealed filling of the superficial and deep lymphatics with the appearance of ectatic lymphatic channels in both superficial inguinal areas. No filling was noted above the inguinal ligaments bilaterally. Surgical treatment consisted of complete excision of the penile skin with a split-thickness skin graft from the thigh for coverage. A pear-shaped segment of scrotal skin was then excised, leaving a small amount of posterior scrotal skin with only small lateral scrotal flaps. The remaining scrotal skin was then undermined, removing as much subcutaneous tissue as possible. The testes were completely isolated and cleared of edematous tissue. Bilateral orchiopexy was then done and the scrotal skin was closed in a Y fashion. A strip of x-ray film was rolled into a tube and fitted to make a splint to immobilize the penis and skin graft (fig. 1). The sutures for the distal graft-penile skin anastomosis were also brought through the splint. Pathological examination reAccepted for publication July 12, 1974.
vealed chronic infection and prominent lymphatics consistent with lymphedema. Six months postoperatively the patient has had no recurrent scrotal or penile edema and has completely satisfactory sexual function. Case 2. H. P., 06-72-87-3, a 57-year-old white man, noted intermittent swelling of the scrotum and penis for 2 to 3 years prior to hospitalization. The onset of the edema coincided with being kicked in the groin by a horse. Complaints of intermittent dysuria associated with irritation of the foreskin were also voiced. There was no history suggestive of an infectious or hereditary etiology of the genital lymphedema. Physical examination was unremarkable except for the moderate penile and scrotal edema. There was no involvement of the lower extremities. Lymphangiograms were not done. All routine laboratory values were normal. Surgical treatment consisted of excision of the penile skin and replacement with a split-thickness skin graft from the thigh. The edematous scrotal skin was also excised, leaving a posterior full thickness skin flap which was brought anteriorly to cover the testes after the latter were fixed to prevent torsion. Pathological examination revealed chronic dermatitis with local lymphangiectasis and prominent lymphatic vessels consistent with lymphedema. This patient has been followed for more than 2 years and there has been no recurrence of the edema (fig. 2). He also claims completely normal sexual function. Case 3. R. P., X60279, a 21-year-old white man, presented with a history of persistent scrotal and penile swelling 14 months in duration. About 8 months after the patient was stationed in the coastal area of South Vietnam intermittent episodes developed of fever, headaches, and bilateral inguinal lymphadenopathy associated with mildto-moderate scrotal and right lower extremity edema. Despite the absence of microfilaria on multiple night blood smears, the diagnosis was Bancroft's filariasis and the patient was treated with diethylcarbamazine (hetrazan) for 2 weeks. During this interval systemic symptoms disappeared with resolution of the right leg edema but with no noticeable improvement in the scrotal swelling. About 4 and 6 months later the patient had 2 separate episodes of streptococcal lymphangitis involving the scrotum, penis and inguinal areas bilaterally which responded to penicillin therapy. However, the scrotal swelling persisted 204
SURGICAL MANAGEMENT OF SCROTAL AND PENILE LYMPHEDEMA
205
FIG. 1. Surgical technique shows use of x-ray film for splint and penile skin graft with scrotal excision
FIG. 2. Preoperative and postoperative views
and was accompanied by a milky-white scrotal discharge. At this point the scrotal and penile lesions precluded satisfactory coitus. Physical examination revealed the scrotum to be 3 times normal size with thick, coarse, edematous scrotal skin leaking milky-white fluid on compression. The penis was only moderately edematous without any cutaneous discharge. The lower inguinal areas exhibited mildly tender, shoddy lymphadenopathy. The lower extremiti~s were normal. Scrotal lymphangiograms revealed lymphangiectasia of the superficial inguinal lymphatics bilaterally with stasis of contrast material in these
lymphatics on the 24-hour examination. The paraaortic lymphatics and nodes were morphologically normal. Excretory urography and cystoscopy were normal and the filarial complementation-fixation test was negative. Complete blood count was normal without eosinophilia. Surgical treatment of the scrotum consisted of a midline scrotal skin incision, removal of all subcutaneous edematous tissue and fat, trimming of the redundant scrotal skin but leaving a full-thickness posterior scrotal skin flap, fixation of the testicles and reapproximation of the medial margins of the scrotal skin flap. By means of the circumferential
206
VAUGHT, LITVAK AND MCROBERTS
coronal skin incision and a 4 cm. dorsal slit, the penile skin was retracted to the penoscrotal angle, the subcutaneous tissue of the penis was removed by sharp dissection and the skin was replaced. The pathology report of the scrotal subcutaneous tissue revealed chronic inflammation and fibrosis. Four months postoperatively the patient is free of all penile edema and essentially all of the scrotal edema with a good cosmetic appearance. In addition, the patient is now able to have satisfactory sexual relations.
DISCUSSION
Scrotal and penile lymphedema may have several etiologies. Bulkley presented a classification of lymphedema which provides a helpful approach in the evaluation of genital lymphedema. Primary: 1) congenital (Milroy's disease) and 2) lymphedema praecox (developing at puberty). Secondary or obstructive: 1) inflammatory (filarial and lymphogranuloma, chancroid, tuberculosis, syphilis, erysipelas and leprosy), 2) surgical (lymph node dissection of inguinal region and scars in groin), 3) carcinoma with blockage of the lymphatics, 4) post-irradiation destruction of lymphatics and 5) medical (cardiac or renal failure, venous thrombosis and hypoproteinemia). 1 Although the incidence of lymphedema of the penis and scrotum is not high, it represents a tremendous burden to those so afflicted. Attempts must be made in each case to determine the exact etiology since most patients will respond to nonsurgical therapy. The goals of treatment are to relieve discomfort, allow return of sexual function, preserve testicular function and prevent recurrence. Numerous modes of surgical therapy have been proposed. In 1820 Delpech used thigh and abdomi1 Bulkley, G. J.: Scrotal and penile lymphedema. J. Urol., 87: 422, 1962.
nal flaps to cover the denuded penis and testes. 2 Muller and Jordan denuded the penis and used split-thickness skin grafts for coverage and also excised the involved scrotal skin using the non-involved posterior skin flaps for scrotal reconstruction. 3 In the treatment of scrotal lymphedema it has been noted that the posterior and the posterolateral aspects of the scrotum are little affected and therefore, these areas may be used for scrotal reconstruction.• The reason for sparing of this posterior area is unclear but may be owing to collateral flow through perirectal lymphatics. Accordingly, large portions of the affected scrotal skin can be excised, the testes and cord can be completely skeletonized, and the remaining scrotal skin can be undermined, thus removing edematous tissue. This procedure leaves thin scrotal flaps to be closed anteriorly after fixing both testes to prevent torsion. Complete removal of the penile skin with split-thickness skin grafting is now an accepted method of treating penile lymphedema. Catheter drainage and antibiotics are used postoperatively. Drains are also used routinely and left in place 3 to 4 days postoperatively. The x-ray film used as a splint in case 1 was effective in providing a protective dressing and a splint to the penile skin graft. SUMMARY
Presented here are 3 cases of penile and scrotal lymphedema of different etiologies and the results of surgical treatment. Also presented is a brief discussion of the etiology, pathophysiology and surgical techniques useful in treating scrotal and penile lymphedema. 2 Delpech, J. M.: Chirurgie Clinique de Montpelier. Paris and Montpelier, vol. 2, 1828. 'Muller, G. P. and Jordan, C. G.: Elephantiasis nostra. Ann. Surg., 97: 226, 1933. •Jones, H. W. and Kahn, R. A.: Surgical treatment of elephantiasis of the male genitalia. Plast. Reconstr. Surg., 46: 8, 1970.