Skip to main content

Primary Closure of the Scrotum

Primary closure is the preferred wound-closure strategy for scrotal defects, exploiting the scrotum's redundant, elastic, well-vascularized skin. Up to ~50% of the scrotal envelope can be resected and closed primarily with appropriate mobilization, and aggressive component separation extends this further — including in Fournier's gangrene, where ~57% of patients can be closed primarily after early component separation, with a ~64% reduction in wound-convalescence time versus secondary intention.[1][2][3] This page focuses on the technical maneuvers, indications, and outcomes specific to primary closure. The broader reconstructive ladder is covered in Scrotal Reconstruction Techniques.

Anatomy Relevant to Closure​

The scrotal wall consists, from superficial to deep, of skin, dartos muscle / fascia, external spermatic fascia, cremasteric muscle and fascia, internal spermatic fascia, and tunica vaginalis.[1][4] Three features make the scrotum uniquely amenable to primary closure:

  • Skin — thin, rugated, hair-bearing, and highly elastic.
  • Dartos fascia — a smooth-muscle-containing layer loosely adherent to the underlying tunica vaginalis, dissectable in an avascular plane to release the skin envelope from the testicular coverings.[1]
  • Vascular redundancy — paired inferior external pudendal (femoral) and perineal (internal pudendal) territories interanastomose richly within the dartos, allowing wide undermining and septal division without devascularization.[5]

Indications​

SettingBest for / indications
Elective scrotal surgeryOrchiectomy, hydrocelectomy, spermatocelectomy, epididymectomy — standard layered closure.[6]
Scrotal traumaBlunt, penetrating, avulsion, or battlefield wounds after debridement and tunica-albuginea repair, when contamination and tissue viability permit.[7][8]
Fournier's gangrene / NSTIClean granulating bed after serial debridement — achievable in ~40–57%; ~64% shorter convalescence than secondary intention.[2][3]
Hidradenitis suppurativa / wide local excisionUp to ~50% scrotal resection — exploit native dartos elasticity.[1]
Penoscrotal lymphedema / MLLAdjacent healthy-skin closure feasible in nearly all — Wisenbaugh 10/11; Torio-Padron 51/51 without flaps or grafts.[9][10]

Standard Layered Closure​

After elective scrotal surgery or small reconstructive defects:[6][11][12]

  • Dartos closed as a separate layer with 3-0 or 4-0 absorbable braided suture (e.g., polyglactin), interrupted or running, to obliterate dead space and achieve hemostasis.
  • Skin closed with absorbable suture (4-0 chromic gut or polyglactin, running subcuticular or interrupted) — absorbable preferred to avoid removal in a sensitive area.
  • Drain (Penrose or small closed-suction) selectively placed to prevent hematoma / seroma after hydrocelectomy or in the setting of trauma.
  • Tunica albuginea (in testicular rupture): debride nonviable seminiferous tubules and close with absorbable suture; if the defect is too large for primary closure, bridge with an ipsilateral tunica vaginalis flap.[7][8]

Maneuvers for Closure of Larger Defects​

Used in combination, these maneuvers frequently convert defects that initially appear too large for primary closure into tension-free closures without grafts or flaps.[1][2][13]

1. Division of the Scrotal Septum (Median Raphe)​

Dividing the midline fibrous partition continuous with the dartos converts the bilateral compartments into a single unified cavity, allowing contralateral skin to be recruited across the midline. Often the first and simplest maneuver, particularly for predominantly unilateral defects.[1]

2. Dartos Mobilization Off the Tunica Vaginalis​

Dissection of the dartos off the tunica vaginalis in an avascular plane releases the skin–dartos envelope from the testicular coverings, generating substantial laxity without compromising flap perfusion (analogous to undermining elsewhere).[1]

3. Gubernacular Division​

Division of the gubernaculum frees the inferior pole of the testis from its fixed attachment to the scrotal floor, allowing superior repositioning. Safe — testicular vasculature runs through the spermatic cord, not the gubernaculum.[1]

4. Spermatic Cord Mobilization + Orchidopexy at the Penoscrotal Junction​

After gubernacular division, the cord can be further mobilized proximally; testes are then secured at the penoscrotal junction with absorbable sutures. Redundant cord is coiled and tucked under the abdominal wall, reducing the vertical dimension of scrotal contents and the surface area requiring coverage.[1][11]

5. Component Separation / Wide Genital Tissue Mobilization​

Adapted from abdominal-wall reconstruction principles: extensive subcutaneous undermining of scrotal, perineal, inguinal, and lower-abdominal / inner-thigh skin to allow primary approximation. In Sandberg's Fournier's series, early component separation achieved primary closure in 57% (48/84), reduced wound-convalescence time by 64%, and had a secondary-procedure rate similar to wounds left open (6.3% vs 11%, p = 0.67). STSG was needed only when suprapubic / penile involvement exceeded 50% — scrotal and perineal wounds were generally closable with mobilization alone.[2]

6. Delayed Primary Closure​

When contamination precludes immediate closure, DPC after serial debridements is highly effective. Kumar reported DPC in 16 Fournier's patients with mean defect area 119 cm² (range 44–346 cm²) at a median of 6.5 days after initial debridement: 50% closed with scrotal advancement alone, the rest with thigh / lower-abdominal / perineal advancement flaps; 63% discharged directly home; Clavien-Dindo III complications 25% (partial flap necrosis, dehiscence, bleeding); none required STSG.[13]

7. Rapid Intraoperative Tissue Expansion​

For defects approaching ~75% scrotal skin loss, Kwon described a single-stage expansion technique: bilateral subcutaneous pockets dissected in residual lateral scrotal / medial thigh skin, round 300 cc expanders inflated over ~20 minutes, then removed for tension-free primary closure. In 3 patients followed for 12 months, the technique produced a cosmetically appealing scrotum with complete testicular coverage and no complications.[14]

8. Two-Stage Tissue-Expanded V-Y Scrotoplasty​

For extensive skin loss, Rapp described placement of a tissue expander in residual scrotal / adjacent tissue, serial expansion over several weeks, then a second-stage V-Y advancement scrotoplasty using the expanded native tissue.[15]

9. Expanded Superthin Groin Flap​

For total scrotal skin loss, Atik described a tissue expander placed through an inferolateral groin incision, serially inflated over 3 weeks, then dissected as a thin subfascial flap and rotated to cover the scrotal defect with the donor closed primarily — addressing the common criticism that conventional regional flaps are too bulky for the scrotum.[16]

10. Temporary Testicular Thigh Pouches as Natural Tissue Expanders​

When >50% of scrotal skin is lost and the testes cannot be covered, Okwudili relocated the testes into anteromedial thigh pouches to allow primary closure of the residual scrotal wound; testes were then gradually massaged back into the residual pouch over 3–8 months, acting as natural tissue expanders. In 12 patients, normal testicular volume was maintained (mean 19.0 ± 3.2 cm³) and no specialized reconstructive surgery was required. Testes must be placed anteriorly in the thigh to avoid sitting pain.[1][17]

Technique Selection by Defect Size​

DefectPreferred ApproachKey Consideration
Elective / smallLayered closure (dartos + skin), ± drainHemostasis to prevent hematoma / edema[6]
≤ 50% scrotal skin lossPrimary closure with septum division + dartos mobilization + gubernacular division + orchidopexy at penoscrotal junctionTension-free closure is the over-riding principle[1]
50–75% loss, clean fieldComponent separation / wide mobilization ± delayed primary closureSandberg 57% primary closure rate; 64% faster healing[2]
50–75% loss, contaminatedSerial debridement → delayed primary closure at median ~6.5 dKumar 16 patients; mean 119 cm² closed; 63% home from index admission[13]
~75% loss, selected casesRapid intraoperative tissue expansion (~20 min, bilateral pockets)Single-stage, complete testicular coverage[14]
Extensive loss, stable patientTwo-stage tissue-expanded V-Y scrotoplasty / expanded superthin groin flapNative-quality expanded skin[15][16]
> 50–75% loss, immediate closure not feasibleTemporary thigh pouches → natural expansion → delayed primary closurePosition testes anteriorly to avoid sitting pain[17]

Outcomes vs Alternatives​

Cosmesis​

Primary closure preserves the native rugated, pigmented, elastic envelope. STSG produces "acceptable" cosmesis (Alwaal: 52/54 [96%] with >90% take and good cosmetic outcome) but lacks the rugation and elasticity of native skin and may remain visibly meshed; grafting onto the tunica albuginea rather than the tunica vaginalis produces a fixed, unnatural appearance and should be avoided.[1][18] A two-stage wrap-around STSG with neoscrotum shaping (Konofaos) improves cosmesis over single-stage STSG but still falls short of native tissue.[19] Pedicled flaps (DIEP, medial thigh, ALT) generally provide good appearance but can be excessively bulky.[20]

Spermatogenesis and Thermoregulation​

The scrotum's thin skin, dartos smooth muscle, and cremaster maintain testicular temperature 2–4 °C below core — a prerequisite for spermatogenesis. Primary closure preserves this apparatus intact. In Demir's animal model, STSG produced significantly diminished spermatogenesis (lower testicular weight, shorter germinal epithelium, lower Johnsen score) compared with both controls and flap reconstruction; flaps were comparable to controls.[21] In humans, grafted skin has persistently impaired cutaneous vasodilation and sweating for ≥4–8 years (possibly permanent), while vasoconstrictor responses are preserved — meaning grafted scrotal skin cannot effectively dissipate heat.[22][23] A small penoscrotal-avulsion series found normal sperm quality and no contracture after free skin grafting at long-term follow-up, so the clinical magnitude of this concern remains incompletely characterized.[24]

Sexual Function and Quality of Life​

After Fournier's gangrene, ~65% of patients report deterioration in sexual function regardless of reconstructive method, and SF-36 physical functioning scores remain below population norms.[25] Genital graft complications — contractures, hypertrophic scars, hypersensitivity, sensory alteration — directly impair sitting, voiding, and intimacy.[26] In the DIEP-flap series, mean CSFQ-14 was 41.47 ± 19.96 (male dysfunction cutoff 47), indicating persistent dysfunction even after successful flap reconstruction.[20] Long-term sexual-function data after primary closure specifically remain a gap in the literature.

Convalescence and Operative Burden​

Primary closure has the shortest convalescence (Sandberg: ~64% reduction vs secondary intention), same-admission definitive closure, and the lowest secondary-procedure rate (6.3% vs 11% for wounds left open, p = 0.67).[2] STSG requires 1–2 weeks of granulation before grafting and a 5–7 day bolster.[11] Flap reconstruction is single-stage but with longer operative time and a higher complication burden (DIEP series: partial necrosis 3/17, 18%).[20]

Complications​

ComplicationNotes
Hematoma / edemaMost common; mitigated by meticulous hemostasis, layered dartos closure, supportive dressing.[6]
Wound dehiscenceHigher in obese, diabetic, and post-lymphedema patients; usually managed with local wound care.[9]
Tension necrosis / testicular displacementAvoid by aggressive mobilization rather than closure under tension; reposition cord and divide gubernaculum as needed.[1]
Partial flap necrosis (with component separation / DPC)25% Clavien-Dindo III in Kumar's DPC series; rarely required regrafting.[13]
Sitting pain (thigh-pouch bridge)Position testes anteriorly in the thigh.[17]

Cross-references​

References​

1. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary update on genital hidradenitis suppurativa: a review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

2. Sandberg JM, Warner HL, Flynn KJ, et al. "Favorable outcomes with early component separation, primary closure of necrotizing soft tissue infections of the genitalia (Fournier's gangrene) debridement wound defects." Urology. 2022;166:250–256. doi:10.1016/j.urology.2022.03.042

3. Lauerman M, Kolesnik O, Park H, et al. "Definitive wound closure techniques in Fournier's gangrene." Am Surg. 2018;84(1):86–92.

4. Raad G, Massaad V, Serdarogullari M, et al. "Functional histology of human scrotal wall layers and their overlooked relation with infertility: a narrative review." Int J Impot Res. 2023;35(5):428–438. doi:10.1038/s41443-022-00573-5

5. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps." BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

6. Oesterling JE. "Scrotal surgery: a reliable method for the prevention of postoperative hematoma and edema." J Urol. 1990;143(6):1201–1202. doi:10.1016/s0022-5347(17)40224-2

7. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. "Urotrauma guideline 2020: AUA guideline." J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408

8. Williams RJ, Fries CA, Midwinter M, Lambert AW. "Battlefield scrotal trauma: how should it be managed in a deployed military hospital?" Injury. 2013;44(9):1246–1249. doi:10.1016/j.injury.2013.02.023

9. Wisenbaugh E, Moskowitz D, Gelman J. "Reconstruction of massive localized lymphedema of the scrotum: results, complications, and quality of life improvements." Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063

10. 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):262–268. doi:10.1016/j.bjps.2014.10.003

11. Hayon S, Demzik A, Ehlers M, et al. "Orchidopexy and split-thickness skin graft for scrotal defects after necrotizing fasciitis." Urology. 2021;152:196. doi:10.1016/j.urology.2021.02.007

12. Byrne M, Aly A. "The surgical suture." Aesthet Surg J. 2019;39(Suppl_2):S67–S72. doi:10.1093/asj/sjz036

13. Kumar SS, Sun HH, Tay K, et al. "Favorable safety outcomes of delayed primary closure of large Fournier's gangrene skin defects." Urology. 2023;180:270–277. doi:10.1016/j.urology.2023.07.028

14. Kwon EO, Pareek G, Fracchia JA, Armenakas NA. "Scrotal reconstruction using rapid intraoperative tissue expansion: a preliminary report." J Urol. 2008;179(1):207–209. doi:10.1016/j.juro.2007.08.129

15. Rapp DE, Cohn AB, Gottlieb LJ, Lyon MB, Bales GT. "Use of tissue expansion for scrotal sac reconstruction after scrotal skin loss." Urology. 2005;65(6):1216–1218. doi:10.1016/j.urology.2005.02.006

16. Atik B, Tan O, Ceylan K, Etlik O, Demir C. "Reconstruction of wide scrotal defect using superthin groin flap." Urology. 2006;68(2):419–422. doi:10.1016/j.urology.2006.04.003

17. Okwudili OA. "Temporary relocation of the testes in anteromedial thigh pouches facilitates delayed primary scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin — experience with 12 cases." Ann Plast Surg. 2016;76(3):323–326. doi:10.1097/SAP.0000000000000505

18. Alwaal A, McAninch JW, Harris CR, Breyer BN. "Utilities of split-thickness skin grafting for male genital reconstruction." Urology. 2015;86(4):835–839. doi:10.1016/j.urology.2015.07.005

19. Konofaos P, Hickerson WL. "A technique for improving cosmesis after primary scrotum reconstruction with skin grafts." Ann Plast Surg. 2015;75(2):205–207. doi:10.1097/SAP.0000000000000066

20. Yalçın C, Doğan B, Manav S, Karamürsel S. "Reconstruction of large penoscrotal defects following Fournier's gangrene using pedicled vertical DIEP flap: case series and evaluation of long-term results." Ann Plast Surg. 2025;95(5):553–558. doi:10.1097/SAP.0000000000004510

21. Demir Y, Aktepe F, Kandal S, Sancaktar N, Turhan-Haktanir N. "The effect of scrotal reconstruction with skin flaps and skin grafts on testicular function." Ann Plast Surg. 2012;68(3):308–313. doi:10.1097/SAP.0b013e318214534f

22. Crandall CG, Davis SL. "Cutaneous vascular and sudomotor responses in human skin grafts." J Appl Physiol (1985). 2010;109(5):1524–1530. doi:10.1152/japplphysiol.00466.2010

23. Davis SL, Shibasaki M, Low DA, et al. "Sustained impairments in cutaneous vasodilation and sweating in grafted skin following long-term recovery." J Burn Care Res. 2009;30(4):675–685. doi:10.1097/BCR.0b013e3181abfd43

24. Wang DL, Luo ZJ, Sun GF, Wei ZR. "Long-term prognosis of free skin-grafted penoscrotal avulsion injuries in two patients." J Plast Reconstr Aesthet Surg. 2009;62(3):385–387. doi:10.1016/j.bjps.2008.04.039

25. Czymek R, Kujath P, Bruch HP, et al. "Treatment, outcome and quality of life after Fournier's gangrene: a multicentre study." Colorectal Dis. 2013;15(12):1529–1536. doi:10.1111/codi.12396

26. Tremblay C, Edger-Lacoursière Z, Schneider G, et al. "Rehabilitation evaluation and treatment for skin graft complications of the genitalia." J Burn Care Res. 2026;47(3):868–878. doi:10.1093/jbcr/irag016