Scrotal Lymphedema

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Scrotal Lymphedema

Postby patoco » Wed Jun 14, 2006 11:08 pm

Scrotal Lymphedema

Related Terms: lymphedema of the scrotum, genital lymphedema, lymphedema of the scrotum, lymphedema of the penis, scrotal edema, scrotal lymphedema, male genital lymphedema

Our Home page: Lymphedema

Peoplehttp://www.lymphedemapeople.com/

Genital lymphedema even in the year 2006 remains the last "hidden" domain of lymphedema. Patients suffer in silence with feelings of embarassment and hopelessness that there is any viable treatment available.

As far as I am aware, there are only two sites where this has been dicussed in an openand honest manner. The two places include this forum and our site Men with Lymphedema.

It is long past time for this subject to be rexamined, researched and for treatment modalities to be made available to patients.

If our discussion are an indication, scrotal lymphedema is far more wide spread then would be believed.

Also, with the advent of better cancer treatments and longer survivorship of cancer patients, the incident ratio is going to increase.

There is treatment, both surgically and through manual decongestive therapy. There is also a dire need to finding ways to successfully manage scrotal swelling, once the initial edema is removed.

Lymphedema experts are in disagreement over the use of compression garments on the scrotum. Many say there is no risk of complications involved, while others would indiate that compression of the scrotum will lead to tissue necrosis.

I must admit, from my own research, that I can find no clinical documentation whatsoever that a mild compression garment would present any danger.

In this page, we will explore the issue, present possible helps for treatment and will review the literature available.

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Treatment for Genital Lymphedema

[green]Our Deepest appreciation to Denise from

St. Ann's Hospice Lymphoedema Clinic

and to Silkie for obtaining this for us![/green]

Trunk massage and exercise routine (TMER) for patients with Genital Lymphoedema.

Choose a time each day to carry out this massage and exercise programme when you can lie on the bed and relax while you are doing it. You will also need to remove and or loosen any clothing which would get in the way of the massage.

Your skin should not look red or pink at the end of the massage- if it is you must be pressing too hard- go lighter.

1. Lie with your knees bent up, feet on the bed. Place both hands on your stomach just below your ribcage. Breathe in as deeply as you can through your nose so that the air pushes your stomach up under your hands. Then breathe out through your mouth, pulling your stomach muscles in at the same time to squeeze all the air out. Repeat 5 times

2. Place one arm above your head, place your other hand just below your arm pit and gently and slowly move the skin round in as big a circle as possible with your hand. After approximately one minute change and repeat the same routine under the other arm. For approx. 1 minute on each side.

3. Using both hands stroke gently and very slowly from your groins on both sides up towards your armpits. Then stroke from the centre- just above your genital area, up and out towards your arm pits You can do both sides at the same time, or just one side at a time which ever is easier. When massaging try to make sure that your hands are relaxed and the whole hand is in contact with the skin.

Try also to massage your back from the central crease between your buttocks up over your waist-line or ideally get somebody else to help you with this. Massage for at least 2-3 minutes on each side.

4. Place your hands in your groins and as you did in ‘2’, slowly move the skin round in as big a circle as you can. For approx. 1 minute

5. With your knees bent up, squeeze your buttocks together as firmly as possible hold this while you tighten the muscles of your pelvic floor between your legs and then pull in your stomach muscles as hard as you can- hold them tight all together- and then relax. Imagine you are trying to zip up a really tight pair of jeans and having to pull everything in to get the zip to close. As you tighten everything up, breathe out- as you relax, breathe in. Repeat 5 times.

6. Hip and knee exercise. Bend your knee up towards you. Clasp your hands round your thigh and gently pull your knee towards your chest hold it there for a count of 2 then release the pressure by straightening your elbows repeat this slowly a further 4 times. Change legs and go through the same routine on the other side.

7. Finish off with an ankle exercise. Pump each foot up and down at the ankle, slowly and deliberately, 20 times.

This combination of exercise and massage will generally improve the lymphatic drainage from your lower body. Movement and exercise always helps to stimulate lymph drainage. Try not to sit for long periods without movement, keep exercising the muscles of your pelvic floor it will help. You may need advice from a physiotherapist about this.

[orange]CARE OF THE SKIN[/orange] of your lower body and genital area is just as important as of the legs.

Moisturise with a very bland cream such as Aqueous Cream, gently massaging any very firm areas of swelling to soften them. This is best done after the massage and exercise routine above, so that you have cleared the way ahead for lymph to drain. .

Use Aqueous Cream to wash the genital area instead of soap, it is less drying and will reduce irritation.

Always dry very carefully in skin creases and folds and don’t let cream accumulate in them. Too much moisture in the creases encourages fungal infections. If the skin in the creases looks red and irritated, consult your doctor, you might need an anti-fungal cream.

Any infection can make the lymphoedema worse and needs prompt attention- particularly cellulitis.

SUPPORT for the genital area to reduce swelling can be helpful. Some of the hosiery companies do make garments rather like cycling shorts to provide compression in this area. But sometimes buying lycra firm support panties with legs in and placing a pad inside to put additional pressure on the genital area gives further support. Obviously it is important that they don’t constrict the lymph drainage from the legs.

Manual Lymphatic Drainage Massage (MLD) can be helpful with genital oedema. Find out if this is available from your nearest Lymphoedema Clinic. It is available privately in some areas- lists of practitioners are available from MLD UK

(c) Copyright 2005 by Pat O'Connor and Lymphedema People. Use of this information for educational purpose is encouraged and permitted. It must be available free and without charge and not used for financial renumeration or gain. Please include an acknowledgement to the author and a link to Lymphedema People. All links associated with this article must be listed as well.

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The most common surgical technique use is a modification of the very old Charles Procedure. This is a brutul surgery which involved extensive resections and skin grafts.

Brutal as well because afterwards, the patient is left with a loss of sexual function and the ability of procration.

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.

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From The Yale School of Medicine

The treatment of scrotal lymphedema.

Answer:
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.

http://yalesurgery.med.yale.edu/surgery/sections/plastics/Core%20Curriculum%20Pages/Lymphedema%20Page/LymphAns11.html

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A new surgical approach in genital lymphedema.

Yormuk E, Sevin K, Emiroglu M, Turker M.

Department of Plastic and Reconstructive Surgery, University of Ankara, Turkey.

A new surgical approach has been used in a case of genital lymphedema. After resection of the lymphedematous mass, U-shaped flaps were made from the suprapubic region anteriorly and the posterior scrotal skin posteriorly. The denuded penis was transposed to its original place by passing it through a buttonhole incision made on the anterior flap. The testicles were placed and fixed in pouches prepared between the anterior and posterior flaps. The patient had an acceptable postoperative outcome both in testicular function and habitual sexual activities.

PubMed

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2243862&itool=iconabstr

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Microlymphaticovenous anastomosis for treating scrotal elephantiasis.

Huang GK, Hu RQ, Liu ZZ, Pan GP.

Scrotal elephantiasis can be physically disabling and psychologically distressing to the victim. Ablative procedure has been used in its treatment and has achieved limited success. The authors developed a microlymphaticovenous procedure to treat elephantiasis of the scrotum and applied it clinically in three patients. The immediate and long-term (13-24 months) results have been very satisfactory. The scrotum size was dramatically reduced to a nearly normal level, and subjective symptoms and objective signs were improved. The operative techniques are described, the three case histories are illustrated, and the advantages of microlymphaticovenous anastomosis, the selection of patients, and the factors required for success of the surgery are discussed.

Publication Types:
Case Reports
PMID: 3990547 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/quer ... =iconabstr

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Scrotal reconstruction using thigh pedicle flaps: long-term follow-up of 12 cases.

Kochakarn W, Hotrapawanond P.

Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

INTRODUCTION: Genital skin loss in men may be caused by avulsion injuries of the penis and scrotum or by gangrene of the male genitalia. Reconstruction of the scrotum after complete loss of the overlying skin is a challenging problem. We report our experience on the management of this problem. MATERIAL AND METHOD: Medical records of all male patients with massive scrotal skin loss and exposed testes treated at Ramathibodi Hospital and Noparat Rajthanee Hospital from 1990 to 1999 were reviewed. The etiologies of scrotal skin loss, technique of treatment, post-operative consequence as well as complications were noted. RESULTS: Twelve patients were described in this study. Nine patients had avulsion injuries of the penile and scrotal skin secondary to agricultural machinery accidents. Three patients were after extensive debridement of Fournierris gangrene. The exposed testes had been placed in thigh pouches and scrotal reconstruction using thigh pedicle flaps was done 4-6 weeks later. No immediate and delayed complications were detected in all of the patients. They recovered without any sequelae and had a satisfactory cosmetic result. CONCLUSION: Extensive scrotal skin loss should be immediately treated surgically. Implantation of the exposed testes in the upper thigh pouch and delayed reconstruction of the scrotum using thigh pedicle flaps can provide excellent results

PMID: 11999821 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/quer ... =iconabstr

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Surgery of male genital lymphedema.

Das S, Tuerk D, Amar AD, Sommer J.

Incapacitating male genital lymphedema most commonly results from filariasis, which is endemic in the tropical and subtropical countries. However, with the advent of extensive ablative surgical and radiotherapeutic measures against abdominopelvic malignancies, more cases of iatrogenic lymphedema of the genitalia can be expected in other parts of the world as well. Surgical treatment of male genital lymphedema is essentially divided into 1) excision of subcutaneous lymphedematous tissues with genital reconstruction using the remaining skin and 2) complete excision of lymphedema followed by split thickness skin grafting of the denuded phallus. The rationale behind our preference for the latter procedure is discussed with illustrative case profiles and important salient surgical steps are outlined.

Publication Types:
Case Reports
PMID: 6343640 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/quer ... t=Abstract

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Lymphedema of male external genitalia: a retrospective study of 33 cases

[Article in French] 2005

Vignes S, Trevidic P.

Unite de Lymphologie, Hopital Cognacq-Jay, Site Broussais, Paris. stephane.vignes@hopital-cognacq-jay.fr

INTRODUCTION: The aim of this retrospective study was to describe the main characteristics and treatment of male external genitalia lymphedema. PATIENTS AND METHODS: From 1987 to 2003, all patients seen in a single hospital for lymphedema of male external genitalia were included. For each patient, the following characteristics were recorded: primary or secondary lymphedema, cause of secondary form, date of onset of lymphedema, associated lower limb lymphedema, clinical signs, and complications. In the primary forms, lower limb lymphoscintigraphy was performed. Specific surgery was proposed in all cases of symptomatic lymphedema (circumcision, scrotum and/or penile cutaneous excision). RESULTS: Thirty-three patients with lymphedema of external genitalia (17 primary, 16 secondary) were recruited. Two primary lymphedema were congenital, one isolated. Mean age +/- SD of the onset of the 15 other primary genital lymphedema was 23.4 +/- 17.5 years, always after the appearance of lower limb lymphedema. Sixteen men had secondary lymphedema (bladder, prostate, or rectum cancer, Hodgkin or non-Hodgkin lymphoma, aorto-bifemoral bypass grafting, biopsy or curretage of inguinal nodes). Secondary genitalia lymphedema was not associated with lower limb lymphedema in two cases and, in the others it occurred 66 +/- 122 months after (n=11), at the same time (n=2) or before lower limb lymphedema (n=1). Clinically, we noted genitalia heaviness (n=31), lower limb lymphedema (n=30), vaginal hydrocele (n=13), impaired miction due to prepucial swelling (n=10), leakage of lymphatic fluid (n=10). Lower limb lymphedema was complicated by at least one erysipelas (n=20), spreading to the external genitalia (n=4). In primary forms, lymphoscintigraphy showed ipsilateral hypoplasia of inguinal nodes in lower limb lymphedema (n=14) and/or external genitalia backflow (n=7). Surgical treatment was performed in 17 cases (11 primary, 6 secondary) with good results after 21 months' median follow up (1 month-10 years). Two patients died of cancer. One secondary lymphedema improved spontaneously and one disappeared after withdrawal of lower limb pneumatic compression. DISCUSSION: Lymphedema of external genitalia is responsible for discomfort and local complications. Surgical treatment is the main procedure of this disorder.

PMID: 15746602 [PubMed - indexed for MEDLINE]

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Skin graft reconstruction of chronic genital lymphedema.

Morey AF, Meng MV, McAninch JW.

Department of Urology, University of California, School of Medicine, San Francisco 94143-0738, USA.

OBJECTIVES: We present a simple, reliable method of scrotal and penile reconstruction yielding satisfactory cosmetic and functional results for patients with disabling chronic genital lymphedema. METHODS: Nine patients were treated with wide excision of the affected genital skin and subsequent coverage of exposed areas with split-thickness skin grafts in a single-stage procedure. RESULTS: All patients have had excellent cosmetic results without recurrence of genital lymphedema or compromise of sexual function postoperatively. CONCLUSIONS: Single-stage reconstruction for idiopathic genital lymphedema by radical skin excision and split-thickness skin grafting provides gratifying functional and cosmetic results.

PMID: 9301709 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/quer ... t=Abstract

[red]---------------------------------[/red]

[brown]The Risk of Genital Edema After External Pump Compression for Lower Limb Lymphedema [/brown]

http://www.lymphedema-therapy.com/98paper.html

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When Compression Is Not Appropriate

Scrotal Edema

Dr. Reid's Corner

I have seen several patients over the last months that highlight the risk of inappropriate use of compression. One patient had scrotal edema. He had non-Hodgkin's lymphoma and developed edema of the lower extremities and as this became worse, he developed edema of the scrotum. The edema was initially treated with diuretics, which temporarily resulted in decreased lower extremity edema but had very little effect on the edema of the scrotum. Unfortunately, the patient applied a compressive wrap. The scrotal skin is very thin and delicate and the edema further stretched the skin. The compressive garment did not help and caused area of skin breakdown leading to a severe infection. The proper treatment for this patient was to treat the cancer causing the problem, not applying compression of the swollen scrotum. The infection complicated the management of this patient since the infection had to be treated before the chemotherapy could be started. Fortunately, non-Hodgkin's lymphoma is a very treatable cancer and once the patient received the proper treatment with chemotherapy, the cancer decreased significantly in size and the scrotal edema resolved. For additional information on scrotal edema see Dr. Reid's Corner here

http://www.lymphedema.com/wcina.htm

Acknowledgment

Peninsula Medical, Dr. Reid's Corner

http://www.lymphedema.com/

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Scrotal Edema

Dr. Reid's Corner

I have received a number of questions about scrotal edema over the last few months. These questions have asked about using compression for treating edema of the scrotum. In short, I do not think this is a good general practice, let me explain why. Scrotal edema is generally divided into acute or chronic causes. Acute cases are generally a surgical issue and require evaluation by ultrasound. Torsion or twisting of the spermatic cord is the most common etiology of acute scrotum in children. Children with torsion usually present with acute scrotal pain, nausea and vomiting. Surgical treatment, within 6 hours of the onset of symptoms, may ensure the preservation of the testis. For that reason any acute scrotal pain with edema requires urgent and specialized evaluation.

Chronic edema of the scrotum can be caused by a number of conditions such as heart failure, liver failure, venous obstruction, lymphatic obstruction or prior surgery or trauma. For example, patients who have kidney failure and as a result have peritoneal dialysis catheters put in place can develop edema of the scrotum due to drainage from the peritoneal cavity through the inguinal canal and into the scrotum. The proper treatment in this case is surgical evaluation and treatment.

In the case of congestive heart failure or liver failure, the problem is that blood flow to the heart or through the liver is impaired. This results in back flow and accumulation of edema in the legs and often in the scrotum. The proper treatment in these cases is the management of the congestive heart failure or the liver failure. For example, in the case of congestive heart failure, scrotal edema will often improve when some of the stress on the heart is removed by medications. These medications reduce the work of the heart in pumping blood. Other medications cause excess fluid to be eliminated by urination. In liver failure, diuretics are used to remove excess fluid and help reduce the edema.

Edema of the scrotum can also occur due to compression of the veins in the pelvis or abdomen. For example, cancers such as prostate cancer or lymphoma can grow and put pressure on the veins or lymphatics and cause edema. In this case, the proper treatment is control of the cancer so that the pressure exerted on the veins and lymphatics is relieved. I have had many cases of severe edema of the scrotum that have resolved after effective treatment of the cancer that was putting pressure on the veins or lymphatics.

In some cases prostate cancer or non-cancerous enlargement of the prostate can make urination difficult, resulting in the retention of urine in the bladder. If the bladder gets large enough, it can cause compression of the pelvic veins resulting in bilateral lower extremity and scrotal edema. These patients improve dramatically when the excess urine in the bladder is removed and the enlarged prostate is treated by surgical reduction.

Since edema of the scrotum often occurs due to a blockage at the level of either the heart or the liver or the draining lymphatics or veins, application of compression of the scrotum will not fix the underlying problem and may result in worse edema. The scrotum has a limited blood supply and compression of the scrotum could further diminish that blood supply. This could potentially worsen the condition or even result in serious tissue breakdown. There are support devices to help support and cushion an enlarged scrotum. However, I do not know of any approved devices for compression of the scrotum to treat scrotal edema. I am including a figure of the anatomy of the blood flow to the testicles to make my point. The figure shows the arteries in red and the veins in blue. Please note the limited blood supply to the scrotum. Compression of an edematous scrotum may further diminish venous outflow potentially worsening the condition. In addition, the skin of the scrotum is very thin and compression could lead to skin breakdown. This could lead to further serious complications including infection and tissue necrosis.

Acknowledgment

Peninsula Medical, Dr. Reid's Corner

http://www.lymphedema.com/

http://www.lymphedema.com/scrotal.htm

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The Medical Alogorithms Project - Chapter 16

16.28 Male Genital Complications of Chronic Lymphatic Obstruction (Hydrocele Lymphedema Elephantiasis Lymph Scrotum)[/maroon][/b]

Overview:

Obstruction of lymphatic drainage from the male genitals can result in retention of interstitial fluid or chyle in the scrotum and/or penis. The duration and extent of the obstruction as well as development of complications determine the eventual outcome for the patient.

Causes of chronic lymphatic obstruction affecting the penis and/or scrotum:

(1) filariasis

(2) sexually transmitted infections

(3) leprosy tuberculosis or deep fungal infection

(4) malignancy

(5) idiopathic

(6) after surgery or lymph node dissection

(7) scarring and fibrosis from other causes

Manifestations:

(1) hydrocele – fluid accumulation in the scrotal sac without skin changes

(2) lymphedema - (elephantiasis when extreme) affects the scrotum and/or penis with changes in size and the skin quality

(3) lymph scrotum – vesicles filled with chylous fluid that easily break and leak

Distinction between hydrocele and lymphedema:

(1) A hydrocele may be unilateral while scrotal lymphedema is bilateral.

(2) A hydrocele does not affect the penis.

(3) In lymphedema the skin is abnormal while in hydrocele it is normal and soft.

(4) It may be hard to exclude hydrocele if lympedema is present.

Features of elephantiasis:

(1) marked deformity or enlargement of the external genitalia

(2) skin hard and thick

(3) presence of knobs or bumps

Complications:

(1) cellulitis

(2) recurrent trauma

(3) infertility

(4) psychological distress or embarassment

Preventive measures:

(1) drainage of hydrocele

(2) frequent cleansing with soap and water

(3) monitoring for breaks in the skin with prompt therapy of cellulitis

(4) proper wrapping to minimize trauma and to collect any exudate or lymph drainage

References:

Dreyer G Addiss D et al. Basic Lymphoedema Management. Treatment and Prevention of Problems Associated with Lymphatic Filariasis. Hollis Publishing Company. 2002. pages 53-62.

http://www.medal.org/xdocs/docs_ch16/do ... tml#A16.28
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