Scrotal Lymphoedema
Scrotal lymphoedema is persistent swelling caused by impaired lymphatic drainage within the scrotum. It can range from mild enlargement to substantial swelling that affects mobility, hygiene, urination, sexual function or everyday comfort.
Management depends on the cause, severity and tissues involved. Some men can be managed without surgery, while selected patients with advanced or persistent disease may benefit from reconstructive surgery after careful assessment.
Also called scrotal lymphedema, genital lymphoedema or, in severe cases, massive scrotal lymphoedema.
What is scrotal lymphoedema?
The lymphatic system normally helps return fluid from tissues to the circulation. When lymphatic drainage is impaired, protein-rich fluid can accumulate within the scrotal tissues.
With longstanding lymphoedema, the skin and underlying tissues may become progressively thickened and fibrotic. In more advanced cases the enlargement may obscure the penis or make walking, toileting, hygiene and clothing more difficult.
Scrotal lymphoedema may occur alone or as part of more extensive genital, groin or lower-limb lymphoedema.
Symptoms and problems it can cause
The effect of scrotal lymphoedema varies considerably between individuals. Assessment therefore focuses on both the physical findings and how the condition is affecting day-to-day function.
Scrotal enlargement
Persistent or progressive swelling, heaviness or enlargement of the scrotal tissues.
Skin changes
Longstanding lymphoedema may result in thickened, firm, irregular or chronically irritated skin.
Mobility
Significant enlargement can interfere with walking, exercise, sitting, clothing and normal daily activities.
Hygiene
Skin folds and persistent swelling can make washing, drying and general genital care more difficult.
Urination
Severe swelling can partly or completely conceal the penis, which may make directing the urinary stream difficult.
Sexual function
Genital enlargement or buried penile tissue can interfere with sexual activity for some men.
Why does scrotal lymphoedema occur?
Scrotal lymphoedema occurs when normal lymphatic drainage from the genital tissues is disrupted or overwhelmed. There is not always a single identifiable cause.
Understanding why the lymphoedema developed can influence investigation, treatment planning and the likelihood of ongoing swelling after treatment.
Potential contributing factors include:
- Previous pelvic, groin or genital surgery
- Previous treatment affecting pelvic or groin lymphatics
- Chronic inflammation or infection
- Obesity-associated massive localised lymphoedema
- Obstruction of lymphatic drainage
- Previous trauma
- Congenital or primary lymphatic disorders
- Less commonly, an underlying tumour or other pelvic disease
How scrotal lymphoedema is assessed
The first goal is to confirm that the swelling represents lymphoedema, determine its extent and look for an underlying or contributing condition.
History
When the swelling began, how it has changed, previous surgery or treatment, infections and its effect on daily activities.
Examination
Assessment of the scrotum, penis, testes, groins, skin and any associated lower-limb or abdominal swelling.
Investigation
Ultrasound or other imaging may be recommended when needed to assess the testes, soft tissues or a possible underlying cause.
Plan
Treatment is individualised according to the cause, severity, tissue quality, symptoms and overall health.
Sudden scrotal swelling needs a different approach
Sudden severe testicular or scrotal pain, rapidly developing swelling, fever, significant redness or acute illness should not be assumed to represent chronic lymphoedema. These symptoms may require urgent medical assessment.
Does scrotal lymphoedema always require surgery?
No. Treatment depends on the extent of disease and the problems it is causing.
Earlier or less severe lymphoedema may sometimes be managed with strategies aimed at controlling swelling, protecting the skin and addressing contributing factors.
Genital lymphoedema can be challenging to manage because conventional compression techniques used elsewhere on the body may not always be practical for the scrotum.
Non-surgical management may include
- Careful genital and skin care
- Treatment of active infection or inflammation when present
- Management of contributing medical conditions
- Weight management where clinically relevant
- Lymphoedema therapy in appropriate patients
- Monitoring when symptoms are limited and stable
The appropriate approach depends on the individual diagnosis.
When might scrotal lymphoedema surgery be considered?
Surgery may be discussed when lymphoedema has become substantial, persistent or fibrotic and is causing significant functional problems despite appropriate non-surgical management.
The aim is not simply to reduce the apparent size of the scrotum. Surgical planning considers urinary function, access to the penis, protection of the testes, mobility, hygiene and reconstruction of durable genital skin.
Remove diseased tissue
Severely thickened or fibrotic lymphoedematous skin and subcutaneous tissue may need to be excised.
Preserve normal structures
Surgery is planned around preservation of viable genital structures wherever clinically appropriate.
Reconstruct the scrotum
Remaining healthy tissue may be used to reconstruct the scrotum. More extensive disease can require a more complex reconstructive approach.
What if the penis is also buried?
Extensive genital lymphoedema can sometimes involve the surrounding tissues to the point that the penis becomes partially or completely concealed. In this situation, scrotal and penile reconstruction may need to be considered together.
Learn more about buried penis reconstruction →What are the limitations and risks of surgery?
Scrotal lymphoedema surgery can involve substantial soft-tissue reconstruction. The extent of surgery and its risks vary considerably according to the severity of disease and the patient's underlying health.
Importantly, surgery does not necessarily correct the underlying abnormality in lymphatic drainage. Persistent or recurrent lymphoedema can therefore occur.
Potential risks can include
- Bleeding or haematoma
- Wound-healing problems
- Infection
- Fluid collections
- Changes in sensation
- Scarring or contour irregularity
- Loss of reconstructed skin or tissue
- Persistent or recurrent swelling
- Need for further procedures
Recovery after scrotal lymphoedema surgery
Recovery varies substantially because the amount of tissue affected can range from relatively localised disease to extensive genital lymphoedema requiring major reconstruction.
Before surgery, the expected operation, wound care, activity restrictions and follow-up can be discussed according to the proposed reconstruction. More extensive procedures generally require a longer period of wound care and recovery.
Long-term management may also involve addressing factors that continue to impair lymphatic drainage.
A reconstructive urology assessment
Scrotal lymphoedema can involve the scrotum, penile skin, urinary function and surrounding genital tissues. Assessment therefore needs to consider more than the swelling alone.
Dr Jack Crozier is a Brisbane urologist with a clinical focus that includes male genital and urinary reconstruction. A consultation can help establish the diagnosis, assess the extent of disease and determine whether observation, non-surgical management or reconstructive surgery should be considered.
Explore related conditions and treatment
Penile, Genital & Urinary Reconstruction
Explore reconstructive conditions and treatment pathways involving the penis, scrotum and urinary tract.
Explore reconstruction →Buried Penis
Information about assessment and reconstructive options when the penis is partially or completely concealed by surrounding tissues.
Learn about buried penis →Scrotal lymphoedema FAQs
Is scrotal lymphoedema the same as a hydrocele?
No. A hydrocele usually involves fluid accumulating around a testicle, whereas lymphoedema involves swelling within the skin and soft tissues due to impaired lymphatic drainage. Examination and ultrasound can help distinguish different causes of scrotal swelling when necessary.
Can scrotal lymphoedema affect the penis?
Yes. More extensive genital lymphoedema can involve penile skin or surrounding tissues and may partially or completely conceal the penis. This can affect hygiene, urination and sexual function.
Can scrotal lymphoedema improve without surgery?
Some patients with less advanced disease can be managed without surgery. Once tissues have become substantially enlarged, thickened or fibrotic, conservative measures may have more limited ability to reverse the anatomical changes. Treatment needs to be individualised.
When is surgery considered?
Surgery may be considered when persistent lymphoedema causes significant problems with mobility, hygiene, urination, sexual function, clothing or recurrent skin problems, and when the expected benefits of reconstruction are considered reasonable in relation to its risks.
What does scrotal lymphoedema surgery involve?
The operation depends on the tissues involved. In advanced disease it may involve removal of severely affected skin and subcutaneous tissue followed by reconstruction of the scrotum using suitable healthy tissue. Penile reconstruction may also be required when surrounding tissues are involved.
Can lymphoedema return after surgery?
Yes. Surgery can remove abnormal tissue and reconstruct the genital area, but it may not eliminate the underlying problem affecting lymphatic drainage. Recurrence or persistent swelling is therefore possible.
Will I need scans before treatment?
Not every patient requires the same investigations. Ultrasound and, in selected circumstances, other imaging may be useful to assess the testes, deeper tissues or a possible underlying cause. Investigations are selected according to the clinical findings.
Does scrotal lymphoedema mean something is wrong with my testicles?
Not necessarily. Lymphoedema primarily affects the scrotal skin and surrounding soft tissues, although significant swelling can make examination of the testes more difficult. Any concerns regarding the testes can be assessed separately.
Concerned about persistent scrotal swelling?
A consultation can help determine the cause and extent of the swelling and whether non-surgical management or reconstructive treatment should be considered.