Scrotal Lymphedema

High school reunions are scary. Especially the ten-year ones. On one hand, you want all those old classmates to see you as a completely different person – Professionally successful, much better looking, some version of happy. On the other hand, you just want to blend back in with the masses – Sneak in, talk to a few friends, get out while you still can before they notice that your hair has started to gray. 

Think about Bryan. Before getting surgery, his problem wasn't really conducive to sneaking in and out of places. He could hardly walk.

And as we get into the nitty gritty details of Bryan's condition, I just have some words for the men out there. Don't worry. It's RARE.

What the HECK is going on down there??

Well, a variety of disorders can enlarge… down there or… the scrotum. But, our patient Bryan suffers from a form of lymphedema, which is swelling caused by lymph (colorless fluid containing white blood cells) accumulating in the tissues in the affected areas. There are two types: Primary lymphedema and secondary lymphedema. Primary lymphedema remains a congenital inherited disorder, but secondary lymphedema, which Bryan has, can stem from an obstructive etiology due to one of the following:

• Previous surgery.
• Tumor.
• Mechanical trauma.
• Radiotherapy.
• Bacterial or fungal infection.

Also known as scrotal elephantiasis, it occurs more frequently in the tropics and sub-tropics from infection with sexually transmitted diseases or parasites.

But how does someone let it get so… Well, HUGE?!

Truthfully, it doesn't happen overnight. Many patients hesitate in seeking treatment because of the embarrassing location of the problem. The swelling starts off as small, painless, but it can gradually reach the point where the enlarged scrotum interferes with daily life. It can hinder one's ability to stand and walk as well as be emotionally distressing. The surrounding skin can become bumpy and irregular, burying the penis, and make a normal sex life almost impossible. The condition also greatly impairs the hygiene of the area, which can lead to even more health problems.

How does it go back to normal??

Treatment typically depends on the exact cause, but the patient will undergo an extensive work-up that may involve:

• Blood tests.
• Urinalysis.
• Ultrasounds.
• CT scans.
• Tissue cultures.

Not all lymphedema cases initially require surgery. For example, diuretics could be administered for patients who struggle with fluid overload; steroids could be given for circumstances associated with sarcoidosis; and acute infections can be treated with antibiotics. But when the lymphedema appears chronic with skin and tissue fibrosis, surgery remains the best option.

The primary goal of surgery is to excise all of the involved skin and subcutaneous tissue while preserving the penis, testicles, and spermatic cord. Often, such as Bryan's case, reconstruction of the genital area and skin grafts will be included with the debridement. Reports indicate that one of the major challenges to these surgeries is the reconstruction of the penile skin. Surgeons may use either local flaps or split thickness skin grafts to repair the area. Studies indicate that surgical management remains a viable option without local recurrence, restoring urinary and sexual function.

However, complications to surgical treatment may include:

• Hematoma.
• Hemorrhage.
• Urethral injury.
• Infection.
• Painful erection.
• Decrease of sensation.
• Scar in suture line.