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Scrotal Lymphedema

Scrotal lymphedema is a chronic condition characterized by impaired lymphatic drainage of the scrotum, leading to progressive swelling, fibrosis, and significant functional and psychosocial morbidity.[1] Combined penoscrotal involvement occurs in 72–80% of cases, and end-stage disease produces massive scrotal enlargement — termed scrotal elephantiasis — with specimens up to 55 cm reported.[5][14] Management spans conservative decongestive therapy to total excision with lymphatic reconstruction, framed by disease stage and etiology.

For the inflammatory dermatologic condition that may co-exist or contribute, see Hidradenitis Suppurativa (Genitourinary). For surgical reconstruction technique, see Scrotal Reconstruction.

Etiology and Classification​

Scrotal lymphedema is classified as primary or secondary:

Primary (congenital/idiopathic): Caused by developmental lymphatic vascular anomalies. In pediatric series, 92% of male genital lymphedema cases were primary, with 60.9% presenting in infancy and 26.1% in adolescence; 24% are familial or syndromic.[1]

Secondary (acquired): Results from disruption of lymphatic drainage by one of the following:

CauseNotes
Lymphatic filariasisMost common cause globally — Wuchereria bancrofti accounts for 90% of an estimated 120 million cases; adult worms lodge in scrotal and extremity lymphatics, causing lymphangiectasia, hydrocele, and elephantiasis[2]
Cancer treatmentRadical prostatectomy, pelvic lymphadenectomy, and pelvic radiation are important causes in developed countries[3][4]
ObesityMassive localized lymphedema (MLL) — a reactive pseudotumor strongly associated with obesity; most cases involve diffuse scrotal edema[5]
Ano-genital granulomatosis / Crohn's disease40% of ano-genital granulomatosis cases are associated with Crohn's; intralymphatic granulomatous inflammation obstructs drainage[6]
Hidradenitis suppurativaLongstanding HS (Hurley stage III) destroys superficial lymphatics[7]
Infection, trauma, radiationIncluding recurrent cellulitis / erysipelas, which both result from and worsen lymphedema[8][9]

Pathophysiology​

Lymphatic stasis results from an imbalance between lymph production and transport capacity.[10] Sustained fluid accumulation drives a self-amplifying cascade:

  • Inflammation — upregulation of pro-inflammatory cytokines and immune cell infiltration
  • Fibrosis — progressive stromal fibrosis and adipose tissue expansion
  • Immunosuppression — impaired local immune trafficking predisposes to recurrent infections[11]
  • Lymphangiectasia — dilation of lymphatic vessels with dermal backflow[12]

In filariasis, death of adult worms triggers lymphangitis and granulomatous encapsulation with progressive lymphatic vessel dysfunction leading to hydrocele and lymphedema.[2] Recurrent episodes of acute dermatolymphangioadenitis further damage lymphatics, creating a vicious cycle of worsening edema.[2][13]

Clinical Presentation​

  • Swelling — progressive, non-pitting scrotal enlargement; concurrent lower extremity lymphedema is present in 76% of pediatric patients[1][6]
  • Skin changes — papillomatosis, verrucous (warty) growths, lymph vesicles with lymphorrhea (lymph oozing), and peau d'orange appearance[4][11]
  • Functional impairment — difficulty with ambulation, urination (buried penis effect), and sexual intercourse[7]
  • Giant/end-stage disease — massive scrotal enlargement with specimens up to 55 cm reported (scrotal elephantiasis)[5][14]

Complications​

  • Cellulitis — most common complication, occurring in 24% of pediatric patients; lymphedema is the strongest risk factor (OR 6.8), as lymphatic fluid impairs local immune clearance; stage III lymphedema carries roughly twice the cellulitis rate of stage II (61.7% vs. 31.8%)[1][13][15]
  • Recurrent infections — create a vicious cycle, further damaging lymphatics and worsening edema[13]
  • Psychosocial impact — profound effects on body image, sexual function, and quality of life; patients may be unable to work, marry, or have children[4][16]
  • Malignancy — chronic lymphedema predisposes to angiosarcoma (Stewart–Treves syndrome) and non-melanoma skin cancer, though this is rare in the scrotal location[11]

Diagnosis​

Diagnosis is primarily clinical, based on history and physical examination. Imaging modalities include:

ModalityRole
Lymphoscintigraphy (⁹⁹ᵐTc-sulfur colloid)Demonstrates dermal backflow into superficial scrotum and thighs, confirming impaired lymphatic drainage[12]
MR lymphangiographyComplementary anatomic detail; correlates with lymphoscintigraphy findings[12]
ICG lymphographyReal-time visualization of lymphatic function and staging[8][17]
UltrasoundExcludes other causes of scrotal swelling (hydrocele, hernia, tumor)
BiopsyIndicated when MLL is suspected; histology shows stromal fibrosis, edema, multinucleated stromal cells, perivascular inflammation, and lymphangiectasia; in ano-genital granulomatosis, non-caseating granulomas found in 50% and intralymphatic granulomas in 14%[5][6]
Filarial antigen testingCirculating filarial antigen or microfilariae detection in endemic areas[18]

Management​

Conservative Therapy​

Conservative therapy is first-line, though more challenging in the genital region than in extremities.[4]

Complex decongestive therapy (CDT) — the gold standard for non-surgical lymphedema management, consisting of manual lymphatic drainage (MLD), compression therapy, exercise, and skin care. In scrotal lymphedema, CDT requires creative adaptation of compression bandages and support garments; even 6 sessions over 14 days demonstrate significant scrotal volume reduction.[10][19][20][7]

Treatment of underlying cause:

  • Filariasis — anti-filarial therapy (diethylcarbamazine, ivermectin, albendazole) reduces microfilarial burden and limits lymphatic progression[18][21]
  • Ano-genital granulomatosis / Crohn's-related — immunosuppression (corticosteroids, azathioprine, anti-TNF agents)[6]

Surgical Therapy​

Surgical intervention is indicated for advanced or refractory disease. Approaches by strategy:

ApproachProceduresKey Data
Excisional (Charles' procedure)Total excision of lymphedematous skin and subcutis with STSG coverageEffective for advanced disease; high complication rates (54.2% in SR[23]); includes testicular burial, STSG, and scrotal reconstruction
Microsurgical lymphatic reconstructionLVA (lymphaticovenous anastomosis), VLNT (vascularized lymph node transfer), SCIP-LYSTLowest complication rate (9% in SR[23]); SCIP-based LYST provides functioning lymph nodes with well-vascularized tissue coverage[17]
Combined (CHASCIP)Charles' procedure + SCIP lymphatic flap transferCiudad 2025: integrates excision with lymphatic reconstruction in a single stage; sustained improvement at median 34–49 months[17]
Pedicled lymph node transferCombined pedicled LNT + LVAAbdelfattah 2023: median GBI score +41; no recurrence at median 34-month follow-up[24]

An integrated approach combining perioperative CDT with surgical reduction yields the most consistent results — conservative therapy facilitates surgery by reducing volume preoperatively, while surgery stabilizes the gains of conservative treatment.[22]

Microsurgical vs. Excisional: SR Summary

A systematic review found that microsurgical LVA procedures had the lowest complication rate (9%) compared with excision and flap reconstruction (54.2%), though patients undergoing excisional procedures tended to have more advanced disease. Excisional procedures are not inferior — they address larger-volume disease that microsurgical approaches alone cannot correct. The decision is stage-driven.[23]

Prognosis​

Scrotal lymphedema is a chronic, progressive condition with no definitive cure.[9] With appropriate management, progression and complications can be limited. Surgical intervention for advanced disease achieves sustained improvement — pediatric patients maintained improvement at a median of 4.2 years post-surgery, and adult series report no recurrence at median follow-ups of 34–49 months with combined excisional and lymphatic reconstructive approaches.[1][14][17] Quality of life consistently improves after surgical intervention, with median Glasgow Benefit Inventory scores of +41.[24]

References​

1. Schook CC, Kulungowski AM, Greene AK, Fishman SJ. "Male Genital Lymphedema: Clinical Features and Management in 25 Pediatric Patients." J Pediatr Surg. 2014;49(11):1647–51. doi:10.1016/j.jpedsurg.2014.05.031

2. Taylor MJ, Hoerauf A, Bockarie M. "Lymphatic Filariasis and Onchocerciasis." Lancet. 2010;376(9747):1175–85. doi:10.1016/S0140-6736(10)60586-7

3. Abdelfattah U, Elbanoby T, Ayad W, Elshamy M, Allam E. "Treatment of Secondary Scrotal and Lower Extremity Lymphedema Using Combined Pedicled Lymph Node Transfer and Lymphaticovenous Anastomosis: A Case Report." Microsurgery. 2020;40(8):901–905. doi:10.1002/micr.30656

4. Vignes S. "Genital Lymphedema After Cancer Treatment: A Narrative Review." Cancers. 2022;14(23):5809. doi:10.3390/cancers14235809

5. Lee S, Han JS, Ross HM, Epstein JI. "Massive Localized Lymphedema of the Male External Genitalia: A Clinicopathologic Study of 6 Cases." Hum Pathol. 2013;44(2):277–81. doi:10.1016/j.humpath.2012.05.023

6. Alexakis C, Gordon K, Mellor R, et al. "Ano-Genital Granulomatosis and Crohn's Disease: A Case Series of Males Presenting With Genital Lymphoedema." J Crohns Colitis. 2017;11(4):454–459. doi:10.1093/ecco-jcc/jjw173

7. Yaman A, Borman P, Eşme P, Çalışkan E. "Complex Decongestive Therapy in Hidradenitis Suppurativa-Related Genital Lymphoedema: A Case Report." J Wound Care. 2024;33(Sup2a):xxviii–xxxi. doi:10.12968/jowc.2024.33.Sup2a.xxviii

8. Wu T, Pu J, Yao Q, et al. "Advances in Etiology, Pathophysiology, Diagnosis, and Management of Lymphedema: A Comprehensive Review." Front Med. 2025;12:1666522. doi:10.3389/fmed.2025.1666522

9. Grada AA, Phillips TJ. "Lymphedema: Pathophysiology and Clinical Manifestations." J Am Acad Dermatol. 2017;77(6):1009–1020. doi:10.1016/j.jaad.2017.03.022

10. Rockson SG. "Diagnosis and Management of Lymphatic Vascular Disease." J Am Coll Cardiol. 2008;52(10):799–806. doi:10.1016/j.jacc.2008.06.005

11. Carlson JA. "Lymphedema and Subclinical Lymphostasis (Microlymphedema) Facilitate Cutaneous Infection, Inflammatory Dermatoses, and Neoplasia: A Locus Minoris Resistentiae." Clin Dermatol. 2014;32(5):599–615. doi:10.1016/j.clindermatol.2014.04.007

12. Rhee A, Flug JA, Casey WJ, et al. "Diagnosis of Primary Scrotal Lymphedema Using 99mTc-Sulfur Colloid Lymphoscintigram: Correlation With MR Lymphangiogram." Clin Nucl Med. 2022;47(5):e417–e418. doi:10.1097/RLU.0000000000004132

13. Lurie F, Malgor RD, Carman T, et al. "The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine Expert Opinion Consensus on Lymphedema Diagnosis and Treatment." Phlebology. 2022;37(4):252–266. doi:10.1177/02683555211053532

14. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. "Giant Penoscrotal Lymphedema — What to Do? Presentation of a Curative Treatment Algorithm." J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586

15. Raff AB, Kroshinsky D. "Cellulitis: A Review." JAMA. 2016;316(3):325–37. doi:10.1001/jama.2016.8825

16. Chakraborty S, Gurusamy M, Zawieja DC, Muthuchamy M. "Lymphatic Filariasis: Perspectives on Lymphatic Remodeling and Contractile Dysfunction in Filarial Disease Pathogenesis." Microcirculation. 2013;20(5):349–64. doi:10.1111/micc.12031

17. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. "Surgical Management of Genital Lymphedema Using the Combined Charles' Procedure and Lymphatic Superficial Circumflex Iliac Artery Perforator Flap Transfer (CHASCIP)." Microsurgery. 2025;45(5):e70075. doi:10.1002/micr.70075

18. Laman M, Tavul L, Karl S, et al. "Mass Drug Administration of Ivermectin, Diethylcarbamazine, Plus Albendazole Compared With Diethylcarbamazine Plus Albendazole for Reduction of Lymphatic Filariasis Endemicity in Papua New Guinea: A Cluster-Randomised Trial." Lancet Infect Dis. 2022;22(8):1200–1209. doi:10.1016/S1473-3099(22)00026-3

19. McNeely ML, Al Onazi MM, Bond M, et al. "Essential Components of the Maintenance Phase of Complex Decongestive Therapy." Med Oncol. 2024;41(11):289. doi:10.1007/s12032-024-02442-1

20. Borman P, Noble-Jones R, Thomas MJ, Bragg T, Gordon K. "Conservative and Integrated Management of Genital Lymphoedema: Case Reports for Men." J Wound Care. 2021;30(Sup12a):6–17. doi:10.12968/jowc.2021.30.Sup12a.6

21. Koudou GB, Bjerum CM, Ouattara FA, et al. "Moxidectin Combination Therapies for Lymphatic Filariasis: An Open-Label, Observer-Masked, Randomised Controlled Trial." Lancet Infect Dis. 2025;25(10):1075–1083. doi:10.1016/S1473-3099(25)00111-2

22. Torio-Padron N, Stark GB, Földi E, Simunovic F. "Treatment of Male Genital Lymphedema: An Integrated Concept." J Plast Reconstr Aesthet Surg. 2015;68(2):262–8. doi:10.1016/j.bjps.2014.10.003

23. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. "A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures." Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875

24. Abdelfattah U, Elbanoby T, Hamza F, et al. "Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer." Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006