Abstract A patient with massive lymphedema of the pe-
nis and scrotum is reported. After radical excision of the
elephantoid tissues a reconstruction with a posterior
scrotal flap and a skin graft was performed. The surgical
options and the literature are reviewed. Good cosmetic
and functional results were obtained with a one-stage
Key words Genital lymphedema · Treatment ·
Lymphangiectomy · Reconstruction · History
Lymphedema arises from the abnormal retention of lym-
phatic fluid in the subcutaneous tissues. Aberrant lym-
phatic drainage may be idiopathic or secondary to parasit-
ic infection, radiation, malignancy, surgery, tuberculosis,
syphilis, leprosy, and lymphogranuloma. The problem of
lymphedema involving the genitals and perineum occurs
frequently where filariasis is endemic, in countries such
as India. In developed countries, the main causes are
elective lymph node dissection and radiotherapy.
Regardless of the cause, chronic lymphedema can be
extremely debilitating. Massive lymphedema or elephan-
tiasis of the penis and scrotum produces a very ugly de-
formity with considerable physical disability. It causes
problems during walking, troublesome urination and
sexual intercourse, this results in extreme mental anguish
and social problems.
Despite the fact that there is no reliable or consistent
treatment for lower extremity lymphedema, there are sat-
isfactory surgical solutions for genital lymphedema.
Even so, penoscrotal lymphedema still presents a diffi-
cult management problem. It is necessary to emphasize
that therapy is mainly surgical, with conservative medi-
cal management being of little value except in the mild-
est cases . The two main principles of operative treat-
ment are lymphangioplasty and lymphangiectomy .
Lymphangioplasty to establish new lymphatic drain-
age patterns is technically difficult and unreliable; it is,
therefore, not often performed [3–6].
The most effective treatment is excision of the in-
volved tissue followed by reconstruction of the resulting
defect. This involves excision of skin, subcutaneous tis-
sue and superficial lymphatics, with preservation of pe-
nis, cord structures and testes. There are many options
for coverage of the penoscrotal defects: scrotal flaps ,
fasciocutaneous thigh flaps [8–10], and skin grafts .
A 73-year-old man was referred with increasing scrotal swelling
over 20 years. There was no history of overseas travel or irradiation.
On examination the scrotum measured approximately 60×45×14
cm, the skin was hard and thickened, and there was massive nonpit-
ting edema. The penis was buried within the scrotum. The testes and
cord structures were not palpable, and there was no obvious lym-
phadenopathy. There was associated lymphedema of the lower ex-
tremities and the patient had two longitudinal scars on the medial
side of the upper thighs (Fig. 1); the reason for this was not known.
Ultrasonography confirmed the presence of two normal testes,
bilateral hydroceles and no hernia.
A vertical midline incision was made in the scrotum down to the
penile “tunnel” and the penile shaft was uncovered. A Foley cath-
eter was placed. The involved skin of the penile shaft and prepuce
was excised. The vertical incision was extended by two lateral in-
cisions, in order to bilaterally expose the spermatic cord and testes
(Fig. 2). The hydroceles were repaired. The remainder of the scro-
tal mass was excised (Fig. 3).
The testes were covered with a posterior scrotal flap. The shaft
of the penis was covered with a split-thickness skin graft taken
from the left forearm. Penrose drains were placed, and antibiotics
prescribed. The patient was initially placed on bed rest and al-
A. Costa-Ferreira (
Rua São João Bosco, 383 3 A, 4100 Porto, Portugal
A. Costa-Ferreira · A. Martins · J. Amarante · A. Silva · J. Reis
Department of Plastic
and Reconstructive Surgery São João University Hospital,
Eur J Plast Surg (1999) 22:397–399 © Springer-Verlag 1999
A. Costa-Ferreira · A. Martins · J. Amarante
A. Silva · J. Reis
Giant penoscrotal elephantiasis
Received: 16 April 1999 / Accepted: 1 June 1999