Understanding surgery, scrotal reconstruction and recovery for men with severe hidradenitis suppurativa
Dr Jack Crozier | Urologist & Andrologist | Brisbane, Australia
Hidradenitis suppurativa (HS) is a long-term inflammatory skin condition that can cause painful lumps, recurrent abscesses, draining wounds and scarring. Although HS commonly affects the armpits and groin, it can also involve the scrotum, perineum (the area between the scrotum and anus) and surrounding genital skin.
For some men, scrotal hidradenitis suppurativa becomes a persistent problem despite antibiotics, specialist skin treatments and other medical therapies.
As the disease progresses, repeated inflammation can lead to tunnels beneath the skin, thickened scar tissue and areas that continue to drain fluid. These changes may affect walking, sitting, hygiene, urination, sexual activity and everyday comfort.
When established tunnels and scarring do not respond adequately to medical treatment, surgery may be considered. The purpose of surgery is to remove permanently damaged tissue, reduce disease in the treated area and, where necessary, reconstruct the scrotum.
Current Australian and international guidelines support combining medical treatment with surgery in appropriately selected patients with advanced hidradenitis suppurativa. [1–3]
What is scrotal hidradenitis suppurativa?
Hidradenitis suppurativa is an inflammatory disease involving hair follicles and the surrounding skin.
It is not simply a skin infection, and it is not caused by poor personal hygiene. It is also not contagious.
The condition can cause repeated episodes of inflammation. Over time, the affected skin may develop:
Painful lumps or abscesses.
Wounds that discharge pus or blood.
Tunnels beneath the skin, called sinus tracts.
Thickened skin and extensive scarring.
Persistent swelling and discomfort.
An unpleasant smell associated with wound discharge.
In more severe cases, several affected areas become connected beneath the skin. The scrotum can become enlarged, scarred or difficult to clean.
Some men also develop genital swelling caused by impaired lymphatic drainage, known as scrotal lymphoedema.
In particularly advanced cases, swelling and scarring may involve the penile skin and contribute to a buried penis, where part of the penis becomes concealed by surrounding tissue.
Why can scrotal hidradenitis suppurativa become resistant to treatment?
Medical treatment plays an important role in controlling HS.
Depending on the severity of the disease, treatment may include antiseptic skin care, topical medication, oral antibiotics, anti-inflammatory treatment or specialist-prescribed biologic medicines.
These treatments aim to reduce inflammation, control symptoms and limit further disease activity.
However, once longstanding tunnels and dense scar tissue have developed, medication may not completely remove these structural changes.
This is an important distinction.
Medication can help control inflammation, but established tunnels and scarred tissue may require a surgical approach.
The Australasian and European HS guidelines recognise that patients with persistent tunnels or advanced disease may benefit from combined medical and surgical treatment rather than repeated courses of antibiotics alone. [1,2]
Surgery is not necessarily a replacement for medical treatment. Some patients continue to require dermatological care before and after their operation.
When should surgery be considered?
Not every man with scrotal hidradenitis suppurativa requires surgery.
For patients with limited or occasional inflammation, medical treatment may provide satisfactory disease control.
A surgical assessment may be appropriate when there are persistent areas of disease despite suitable medical management.
Examples include repeated abscesses affecting the same area, continuously draining wounds, extensive skin tunnels, thick scarring, repeated procedures that have not provided lasting relief, or difficulty with hygiene and normal daily activities.
Surgery may also be considered when disease causes significant distortion of the scrotum or surrounding genital skin.
The decision depends on the extent of disease, previous treatments, overall health and likely consequences of removing the affected tissue.
A specialist assessment should consider both the potential benefits and the risks of surgery.
What surgical treatments are available?
There is no single operation suitable for every patient with scrotal hidradenitis suppurativa.
The main options include deroofing of individual tunnels, removal of localised diseased skin, and wider excision of extensively affected tissue.
1. Deroofing of hidradenitis tunnels
Deroofing is a procedure used for selected localised areas of HS.
The surgeon opens the roof of an established tunnel beneath the skin, allowing the affected area to heal from the base.
This technique may preserve more surrounding healthy tissue than a larger excision.
It can be appropriate when disease is limited to one or a small number of tunnels.
However, deroofing may be unsuitable where extensive interconnected tunnels, heavy scarring or widespread scrotal skin involvement are present. [2–4]
2. Localised surgical excision
For a relatively small area of persistent disease, surgery may involve removing the affected skin and underlying scarred tissue.
Depending on the size and location of the wound, the skin may be closed directly or left to heal gradually.
The aim is to remove the local area of established disease while preserving healthy surrounding tissue.
This approach is considered when the disease is sufficiently localised and reconstruction can be achieved without excessive tension.
3. Wide excision of scrotal hidradenitis suppurativa
In severe or treatment-resistant cases, a more extensive operation may be necessary.
Wide excision involves removing the areas of skin and underlying tissue affected by persistent tunnels, inflammation and scarring.
This may include substantial portions of scrotal skin and, in selected cases, nearby penile, groin or perineal skin.
The amount of tissue removed depends on the distribution of disease.
A systematic review of HS surgery found that wider excision was associated with lower recurrence rates than limited local excision in the studies analysed. However, the available research is variable, and these findings cannot reliably predict an individual patient's outcome. [5]
The operation must balance adequate removal of diseased tissue against preservation of healthy structures and the potential need for reconstruction.
Will my testicles need to be removed?
This is an understandable concern for men considering surgery for severe scrotal hidradenitis suppurativa.
In most cases, surgery is directed at the diseased scrotal skin and surrounding soft tissue rather than the testicles themselves.
The testicles are anatomically separate from much of the affected skin and can usually be preserved.
Where extensive scrotal skin has been removed, the remaining tissues may need to be reconstructed to provide appropriate coverage and support.
The exact operation depends on the depth and extent of disease, previous surgery and the condition of the remaining tissues.
Patients should discuss any concerns about testicular health, fertility, sexual function and genital appearance before surgery.
How is the scrotum reconstructed after hidradenitis surgery?
Scrotal reconstruction is an important part of surgical planning when a large amount of diseased skin needs to be removed.
The aim is to obtain suitable tissue coverage while considering comfort, wound healing, hygiene and genital function.
Several approaches may be used.
Healing without immediate skin closure
Some wounds can be left open to heal gradually with regular dressings.
This is called secondary intention healing.
It avoids placing a skin graft or flap over the wound immediately but may require a prolonged period of wound care.
The wound slowly fills with healthy healing tissue and becomes covered by new skin.
This approach may be suitable in selected circumstances, although larger genital wounds can require substantial nursing support and follow-up.
Direct closure using remaining skin
When sufficient healthy and flexible scrotal skin remains, the wound may be closed using nearby tissue.
This is more likely to be possible following smaller excisions.
Skin graft reconstruction
If a large area of scrotal skin has been removed, a skin graft may be considered.
A thin layer of skin is usually taken from another part of the body, such as the thigh, and transferred to the surgical wound.
The graft must develop a blood supply from the underlying tissue to survive.
Skin grafting can provide coverage where there is insufficient remaining scrotal skin for direct closure.
Potential disadvantages include graft failure, contraction, altered sensation, differences in appearance and the need for additional wound care.
Reconstructive skin flaps
In some circumstances, healthy nearby skin and tissue can be moved into the affected area while maintaining its blood supply.
This is called flap reconstruction.
Flaps may be considered when the wound is complex or when particular structures require additional tissue coverage.
However, flap reconstruction can introduce additional surgical risks and may not be appropriate in the presence of widespread surrounding disease.
Published reports describe successful wound healing following staged excision and skin graft reconstruction in selected patients with severe anogenital HS. These reports are generally small studies, so they do not establish that one reconstructive technique is best for everyone. [7]
Patients with extensive genital involvement may benefit from an assessment within a reconstructive urology pathway, sometimes involving collaboration with dermatology, plastic surgery, wound-care or colorectal specialists.
What happens before surgery?
Assessment begins with confirming the diagnosis and understanding the distribution of disease.
Not every recurrent scrotal abscess or draining wound is caused by hidradenitis suppurativa. Other conditions, including infection, cysts and disease involving the anal region, may require different treatment.
Clinical assessment generally includes examination of the affected skin and review of previous treatment.
It is particularly important to establish whether disease extends into the perineum, around the anus or onto the penile skin.
Ultrasound or MRI may be useful in selected patients to assess deeper disease or map complex tunnels, particularly when the extent is difficult to determine from examination alone. [4]
Other aspects of preparation may include reviewing current medication, assessing diabetes or other medical conditions, considering smoking cessation, and arranging suitable postoperative wound care.
For patients with significant inflammation, coordination with a dermatologist may help determine whether additional medical treatment is appropriate before surgery.
Research has also examined the use of biologic treatment alongside surgery. The SHARPS randomised trial found that continuing a particular biologic treatment during the study's surgical pathway did not increase the observed rate of postoperative wound complications. This does not mean that all medicines should always be continued. Decisions must be individualised by the treating clinicians. [6]
What is recovery like after scrotal hidradenitis surgery?
Recovery depends on the extent of the operation and the method used to manage the wound.
Following a smaller excision, recovery may be relatively straightforward.
However, wide scrotal excision and reconstruction can involve a more substantial healing period.
Patients may require a hospital admission, postoperative dressings, wound reviews and a temporary reduction in activity.
Some patients require drains or a urinary catheter, depending on the procedure.
When skin grafts are used, movement may need to be restricted initially to protect the graft while it establishes a blood supply.
Wound healing can take several weeks or longer, particularly after large excisions or when wounds are left to heal gradually.
Patients should plan for the possibility of regular dressing changes, time away from physically demanding work, and delayed return to exercise or sexual activity.
The recovery plan should be discussed before surgery so that appropriate support is available at home.
What are the risks of surgery?
Surgery for severe scrotal hidradenitis suppurativa can be complex, particularly when substantial areas of tissue are affected.
Potential complications include bleeding, wound infection, delayed healing, wound separation, persistent discomfort, altered sensation, scarring and changes in genital appearance.
Skin grafting or flap reconstruction introduces additional risks, including partial or complete loss of the transferred tissue.
There may also be ongoing genital tightness or discomfort, and changes affecting urinary or sexual function. Damage to deeper structures is uncommon but is an important consideration in extensive surgery.
Further procedures may be necessary if healing is delayed, reconstruction is unsuccessful or disease recurs.
These risks need to be weighed against the impact of the existing condition and the potential benefits of treatment.
Can hidradenitis suppurativa return after surgery?
Yes. Hidradenitis suppurativa can recur after surgery.
Removing established tunnels and scarred tissue may provide lasting control within the treated area, but surgery does not remove the underlying tendency to develop HS.
New areas of inflammation can develop elsewhere, and disease may recur near or within previously treated regions.
Studies suggest that the extent of excision influences recurrence, but results vary considerably because the severity of disease, body site, surgical methods and follow-up periods differ between studies. [2,5]
It is therefore more accurate to regard surgery as a treatment for established local disease rather than a guaranteed cure for hidradenitis suppurativa.
Continued dermatological care may remain important.
When should I seek urgent medical attention?
Hidradenitis suppurativa usually develops over time, but a rapidly worsening genital infection requires urgent assessment.
Seek emergency medical care if scrotal or perineal pain and swelling worsen rapidly, especially with fever, significant illness, spreading redness, darkening skin or severe pain.
These symptoms can indicate a serious infection, including Fournier's gangrene, which is different from ordinary chronic HS and requires emergency treatment.
Do not wait for a routine specialist appointment if these symptoms develop.
Specialist assessment for complex scrotal hidradenitis suppurativa in Brisbane
Men with persistent scrotal hidradenitis suppurativa may benefit from assessment when medical treatment has not adequately controlled their symptoms or when scarring and recurrent wounds create reconstructive problems.
Dr Jack Crozier is a Brisbane-based urologist and andrologist with an interest in complex male genital and reconstructive urology.
A urological assessment focuses on the affected anatomy, previous treatment, urinary and genital function, and whether surgery may have an appropriate role.
In some cases, continued medical treatment or multidisciplinary review will be more suitable than an operation.
For patients whose previous procedures have not resolved the problem, further information is available through the complex and previous-treatment assessment pathway.
Patients from Brisbane, regional Queensland and interstate Australia
Patients from Brisbane, the Gold Coast, Sunshine Coast and other parts of Queensland can request a specialist consultation.
Interstate patients from New South Wales, Victoria, Western Australia and elsewhere in Australia may also enquire about assessment.
For patients travelling a substantial distance, relevant medical records, previous operation reports, clinical photographs where appropriate, and a summary of previous medication can help with preliminary planning.
Any decision about surgery requires suitable clinical assessment and consideration of postoperative follow-up arrangements.
International patients considering treatment in Brisbane
International patients with complex genital hidradenitis suppurativa may wish to obtain a specialist opinion regarding their condition and available surgical options.
Assessment and treatment planning may involve reviewing existing medical information before travel, where clinically appropriate.
Travel arrangements should take account of the potential need for hospital care, wound dressings, an extended recovery period and follow-up after returning home.
Further information is available on the international patients page.
Request an appointment
If you have persistent scrotal hidradenitis suppurativa, recurrent draining wounds or genital scarring despite treatment, a specialist assessment can help clarify the available options.
Request a consultation with Dr Jack Crozier
An appointment does not mean that surgery will necessarily be recommended. The purpose of assessment is to establish the diagnosis, review previous treatment and determine which management options are appropriate.
Frequently asked questions
Can severe scrotal hidradenitis suppurativa be treated without surgery?
Sometimes. Medical treatment can control inflammation and may reduce symptoms. However, longstanding tunnels and dense scar tissue may not resolve with medication alone. Surgery is one option when appropriate treatment has not provided satisfactory control.
Is scrotal hidradenitis surgery painful?
Some postoperative pain and discomfort are expected. The extent depends on the procedure performed. Anaesthesia and postoperative pain relief are planned according to the individual operation and medical circumstances.
Will surgery affect my fertility?
Surgery is usually directed at the scrotal skin rather than the testicles. However, extensive genital surgery can involve risks to surrounding structures. Patients who have concerns about fertility should discuss these before treatment.
Will the scrotum look normal afterwards?
The appearance of the scrotum may change following tissue removal or reconstruction. Scarring and differences in skin texture are possible. The outcome depends on how much tissue is affected and the reconstructive method used. A particular cosmetic result cannot be guaranteed.
How long will I need to stay in Brisbane after surgery?
This depends on the extent of surgery, healing progress and whether skin grafting or other reconstruction is required. Patients travelling from interstate or overseas should discuss expected follow-up requirements before finalising travel.
Can surgery help if antibiotics and biologic treatment have not worked?
Surgery may be considered when established tunnels, scar tissue and persistent draining wounds remain despite suitable medical treatment. This is particularly relevant where disease is affecting daily function. An examination is required to determine whether surgery is appropriate and what it would involve.
References
Frew J, Smith A, Fernandez Penas P, Ellis E, Foley P, Rubel D, et al. Australasian hidradenitis suppurativa management guidelines. Australas J Dermatol. 2025;66(2):75–89. doi:10.1111/ajd.14388.
Zouboulis CC, Bechara FG, Benhadou F, et al. European S2k guidelines for hidradenitis suppurativa/acne inversa part 2: Treatment. J Eur Acad Dermatol Venereol. 2025;39(5):899–941. doi:10.1111/jdv.20472.
Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76–90. doi:10.1016/j.jaad.2019.02.067.
Vilarrasa E, Guillem P, Horváth B, et al. Optimizing surgery in hidradenitis suppurativa. J Eur Acad Dermatol Venereol. Published online October 21, 2026. doi:10.1111/jdv.70768.
Riddle A, Westerkam L, Feltner C, Sayed C. Current surgical management of hidradenitis suppurativa: A systematic review and meta-analysis. Dermatol Surg. 2021;47(3):349–354. doi:10.1097/DSS.0000000000002892.
Bechara FG, Podda M, Prens EP, et al. Efficacy and safety of adalimumab in conjunction with surgery in moderate to severe hidradenitis suppurativa: The SHARPS randomized clinical trial. JAMA Surg. 2021;156(11):1001–1009. doi:10.1001/jamasurg.2021.3655.
Fuchs N, Pavljak L, Hauptman D, Mance M. Two-stage surgical management of anogenital hidradenitis suppurativa in patients on biologic therapy: A retrospective case series. Int Wound J. 2026;23(4). doi:10.1111/iwj.70874.
Medical disclaimer
This article provides general medical information for educational purposes only. It is not a substitute for individual medical advice, diagnosis or treatment by a qualified healthcare professional.
Hidradenitis suppurativa varies considerably between patients. The suitability of medical treatment, surgical excision or genital reconstruction depends on the extent of disease, medical history, previous treatment and findings during clinical assessment.
All surgical procedures carry risks, including complications, scarring, delayed healing and possible recurrence. Outcomes cannot be guaranteed.
Patients should consult an appropriately qualified medical practitioner before making decisions about treatment. Anyone experiencing rapidly worsening genital pain, swelling, fever or signs of serious infection should seek urgent medical assessment.
Information reflects the medical literature available at the time of preparation and may change as further evidence becomes available.
