Megan M. Merrill, DO
BASICS
DESCRIPTION
Pitting or nonpitting edema of 1 or both sides of the penile shaft and scrotal skin due to the accumulation of transudative fluid in the dartos (scrotal) or subcutaneous layer of the penile skin
EPIDEMIOLOGY
Incidence
The incidence is not well documented
Prevalence
Prevalent condition in nursing home and hospitalized patients
RISK FACTORS
• Chronic liver disease
• Congestive heart failure
• Epididymo-orchitis
• Genital trauma or penile fracture
• Hypervolemia
• Indwelling Foley catheter
• Lymphoma
• Medications known to cause lymphedema
• Paraphimosis
• Pelvic or inguinal surgery
• Peritoneal dialysis
• Radiation to the pelvic or inguinal region
• Retroperitoneal surgery
• Squamous carcinoma of the penis
Genetics
• Fragile X Syndrome—mutation in FMR-1 on X chromosome
– Physical manifestation of macro-orchidism/scrotal edema that becomes more apparent in puberty (1)
PATHOPHYSIOLOGY
• Accumulation of transudate within the subcutaneous tissue of the penile shaft and scrotal skin
– May be localized to the genital region or part of more extensive lower extremity edema or massive body edema (anasarca)
In generalized edema capillary hemodynamics are altered and fluid moves from vascular space to interstitium according to Starling’s law (2)
Net filtration = LpS × (Δ Hp - Δ Op)
Lp = permeability of capillary wall
S = surface area for fluid movement
Hp = hydraulic pressure
Op = oncotic pressure
Hypoalbuminemia contributes to change in oncotic pressure and worsens edema (2)
– Transient lymphedema can be seen after pelvic surgery, such as radical prostatectomy or radical cystectomy
– Often is localized to the peno-scrotal region
• Rarely, sexually transmitted diseases (STDs) such as lymphogranuloma venereum (LGV) or donovanosis (granuloma inguinale) may cause lymphangitis and lymphatic genital obstruction resulting in chronic fibrosis (elephantiasis) (3)
ASSOCIATED CONDITIONS
• Advanced prostate cancer
• Anasarca
• Ascites/hepatic failure
• Congestive heart failure
• Fournier gangrene
• Lymphatic obstruction (lymphangitis filariasis)
• Lymphoma
• Pelvic or inguinal surgery (eg, pelvic or ilioinguinal lymphadenectomy)
• Paraphimosis
• Renal insufficiency/peritoneal dialysis
• Retroperitoneal lymphadenectomy
• Testicular torsion
GENERAL PREVENTION
• Maintenance of euvolemia
• Foley catheter care
DIAGNOSIS
ALERT
• Edema of the penis and scrotum in an uncircumcised male may indicate paraphimosis, which requires immediate foreskin reduction to avoid glans penis vascular compromise (3).
• Edema of the scrotum with areas of necrosis or devitalized skin may indicate Fournier gangrene and requires emergent urologic consultation and surgical debridement.
HISTORY
• Acute vs. chronic condition
• Acute scrotal pain in a child or young adult may indicate torsion.
• Circumcision: Severe paraphimosis can compromise the glans penis
• Trauma
• Recent inguinal, pelvic or retroperitoneal surgery
• History of lower extremity lymphedema
• History of STDs
• Peritoneal dialysis: Dialysate can leak through inguinal hernias into the scrotum
• Medication history:
– Pantoprazole, sirolimus, and mycophenolate can cause lymphedema.
– Angiotensin-converting enzyme (ACE) inhibitors: Angioedema of the genitals reported
• Indwelling Foley catheter
– BPH or indwelling Foley catheter patients can develop epididymo-orchitis.
PHYSICAL EXAM
• Examine for anasarca
• Evaluate for lower extremity edema
• Pitting or nonpitting edema of the penile shaft and/or scrotal skin
• Note the presence/correct placement of an indwelling Foley catheter
• Reduce foreskin in uncircumcised males
• Inspect for skin integrity
• Bruising or induration with crepitance seen in Fournier gangrene
• Foul odor associated with Fournier gangrene
• Examine testis and epididymis for signs of epididymo-orchitis
• Examine scrotum/ spermatic cord in supine and standing position for presence of varicocele
• Transilluminate the scrotum for hydrocele
• Examine external inguinal ring for herniation
• Cremasteric reflex test for testicular viability
• Evaluate for the presence of inflatable penile prosthesis (IPP), artificial urinary sphincter (AUS), or other foreign body
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• No specific lab tests
• Urinalysis may suggest infection/epididymo-orchitis
• Elevated brain natriuretic peptide (BNP) associated with hypervolemia
• Fractional sodium excretion may suggest fluid overload
• Albumin/pre-albumin levels assess nutritional status
Imaging
• Scrotal ultrasound (US) confirms thickened subcutaneous tissue and may suggest etiology.
• CT may suggest retroperitoneal etiology.
Diagnostic Procedures/Surgery
Physical exam significant for pitting edema of the genital skin
Pathologic Findings
Edematous subcutaneous tissue of the scrotum and penile shaft with possible areas of devitalized skin or necrosis
DIFFERENTIAL DIAGNOSIS
• Acute idiopathic scrotal edema
• Angioedema of the genital skin
• Cellulitis
• Chemical or allergic dermatitis
• Elephantiasis
• Epididymo-orchitis
• Fournier gangrene
• Hydrocele
• Idiopathic scrotal edema (usually children)
• Inguinal hernia
• Paraphimosis
• Retroperitoneal mass
• Squamous carcinoma of the penis
• Testicular torsion
• Varicocele
TREATMENT
GENERAL MEASURES
• Scrotal elevation
• Genital or scrotal compression NOT recommended
• Meticulous care of skin breakdown
• Correction of hypervolemia
• Dialysis if due to severe hypervolemia
• Evaluate for urinary retention—Foley catheter if indicated
• Immediate postoperative edema usually resolves spontaneously
MEDICATION
First Line
• Limited utility
• Diuretics may be of some utility
• Chemotherapy for lymphoma
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Indicated to address the etiologic process: Testicular torsion, inguinal hernia, penile fracture, or Fournier gangrene
• Manual reduction of foreskin or dorsal slit if necessary to address paraphimosis
• Rarely, radical excision with gracilis flap may be required for severe refractory cases
ADDITIONAL TREATMENT
Radiation Therapy
While this can be a cause of genital lymphedema, it may have a role in primary palliative treatment of prostate, penile, and retroperitoneal malignancies causing scrotal edema.
Additional Therapies
Supportive undergarments/briefs for patient comfort
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Depends on etiology
COMPLICATIONS
• Skin breakdown/ulceration
• Urinary retention/difficulty voiding
• Genital and scrotal compression is NOT recommended
FOLLOW-UP
Patient Monitoring
• Physical exam for resolution
• Monitor underlying condition, appropriate labs, nutritional status
Patient Resources
Sterns RH. Patient information: Edema (swelling) (Beyond the Basics). In: UpToDate, Basow DS, ed. UpToDate. Wolters Kluwer, Philadelphia (www.uptodate.com, accessed August 8, 2014).
REFERENCES
1. Lachiewicz AM, Dawson DV. Do young boys with fragile X syndrome have macroorchidism? Pediatrics. 1994;93:992–995.
2. Sterns RH. Pathophysiology and etiology of edema in adults. In: UpToDate, Basow DS, ed. UpToDate. Wolters Kluwer, Philadelphia (www.uptodate.com, accessed August 8, 2014).
3. Weinberger LN, Zirwas MJ, English JC 3rd. A diagnostic algorithm for male genital oedema. J Eur Acad Dermatol Venereol. 2007;21(2):156–162.
ADDITIONAL READING
Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin N Am. 1995:22(1):101–105.
See Also (Topic, Algorithm, Media)
• Edema, Lower Extremity, Urologic Considerations
• Fournier Gangrene
• Testicular Torsion
• Paraphimosis
• Edema, External Genitalia (Lymphedema, Peno-Scrotal Edema) Image 
CODES
ICD9
• 605 Redundant prepuce and phimosis
• 607.83 Edema of penis
• 608.86 Edema of male genital organs
ICD10
• N47.1 Phimosis
• N48.89 Other specified disorders of penis
• N50.8 Other specified disorders of male genital organs
CLINICAL/SURGICAL PEARLS
• Determine the patient’s fluid status to rule out hypervolemia as the cause of genital edema.
• Acute scrotal pain, swelling, lack of cremasteric reflex, and a high-riding ipsilateral testis could indicate testicular torsion.
• Evaluate for paraphimosis in uncircumcised males.
• Crepitance, induration, necrosis, and foul odor suggest Fournier gangrene and require emergent surgical debridement.
• Complications of edema may include urinary retention and skin breakdown—these should be evaluated for and treated accordingly.