Case Reports

Elephantiasis of Penis and Scrotum

NASEHI A, AZADI SH

Department of Urology,  Aiatollah Kashani Hospital, Tehran, Iran

KEY WORDS: elephantiasis, penis, scrotum, lymphedema

55

Urology Journal

UNRC/IUA

Vol. 2, 55-57 Spring 2004

Printed in IRAN

Introduction

Lymphedema of penis and scrotum is rarely seen

in countries in which filariasis is not endemic. The

abnormal accumulation of lymphatic fluid in sub-

cutaneous tissue of penis and scrotum could lead

to swelling, pain, dysuria, and sexual dysfunction

(impotency and erectile dysfunction).

Lymphedema may be idiopathic or secondary to

inflammation, surgery, malignancies, trauma, radi-

ation, hypoproteinemia, and other medical disor-

ders. Lymphatic obstruction is limited to penis

and scrotum and is not seen in adjacent organs

such as lower extremities, abdomen, and but-

tock.(1) Regardless of the cause of scrotal and

penile elephantiasis, this disease can lead to phys-

ical and spiritual weakness and its treatment is

difficult particularly in the aged.(2)

Case Report

A 16-year-old boy was referred to our hospital

because of painless swelling of penis and scrotum

(fig. 1). He reported a history of swelling since his

childhood, which had been intensified during the

past year.

No history of irradiation, surgery, trauma, or

infection was reported. Penis and scrotum was

swelling and non tender. Testes in the scrotum

were palpable with difficultly. Mild lower extremi-

ties edema was present. Other systems were nor-

mal. Ultrasonography of testes and lower urinary

tract were normal. 

Abdominal and pelvic CT scan, as well as CBC,

U/A, ESR and blood biochemical tests were nor-

mal. Serologic study was negative for filariasis.

With the diagnosis of idiopathic elephantiasis of

penis and scrotum, surgery was planned in which

extensive debridement of the involved tissue, scro-

toplasty by the use of skin flaps of 1/3 of the pos-

terior scrotum, and Z plasty by applying extra skin

of penis region to repair its cover were to be per-

formed (fig. 2, 3, 4).

Pathology report was diffuse dermal edema with

chronic inflammation around vessels, compatible

with arteriovenous malformation (fig. 5).

Our patient had primary or idiopathic penile or

scrotal lymphedema. In one year follow-up after

reconstructive surgery, recurrence was not seen

Accepted for publication in January 2003

FIG. 1. Lymphedema or elephantiasis of penis and

scrotum



ELEPHANTIASIS OF PENIS AND SCROTUM

and he had a normal sexual function.

Discussion

Genital elephantiasis is mostly developed in trop-

ical regions. Degreef believes that about 20% of

males in tropical regions develop penile and scro-

tal elephantiasis.(3)

Lymphedema has two types: Primary and sec-

ondary. Primary lymphedema is subdivided into

three categories: 1. congenital-inherited (Milory

syndrome), 2. praecox (with early onset), and 3.

tarda (with late onset).(1)

Secondary lymphedema has four subtypes: 1.

obstructive (secondary to neoplasm, radiation, sur-

gical intervention, mechanical trauma, and chemi-

cal agents injection), 2. inflammatory (parasitic,

bacterial, and fungal infections), 3. phlebitis, and

4. angioneurotics.(1)

Penile and scrotal lymphedema mostly occurs

following an infection or as a reaction to trauma.

Idiopathic lymphedema is rarely seen and is

caused by a primary obstruction of lymphatic ves-

sels of scrotum.(1)

No effective medical treatment has been intro-

duced; instead, different surgical methods for the

treatment of chronic genital lymphedema have

been reported in the literature. Two main methods

are as follows:

1. Physiologic methods or lymphangioplasty

through which lymphatic discharge from

involved regions to new lymphatic channels is

obtained.

2. Lymphangiectomy with reconstructive sur-

gery.(2)

Lymphangioplasty is used in the cases of recur-

rent lymphedema; however, this method can not be

successful in the cases of chronic fibrosis or lym-

phedema caused by radiation because of the lack

56

FIG. 2. Freeing of testes and spermatic cord from

the surrounding involved tissue through a horizon-

tal incision on posterior part of the scrotum

FIG. 3. Testes, spermatic cord and penis have been

separated from the surrounding involved tissue

through two longitudinal and spiral incisions.

FIG. 4. Scrotoplasty and Z plasty in order to con-

struct the cover of penis following extensive

debridement of the involved tissue

FIG. 5. A microscopic image from the involved tis-

sue that shows diffuse edema in dermis, interstitial

tissue, and muscle fibers



ELEPHANTIASIS OF PENIS AND SCROTUM

of appropriate lymphatic channels.(2)

Lymphangiectomy includes the removal of super-

ficial lymphatic network, which is located above

the Buck's fascia which is derived from median

raphae and prepuce lymphatics. These lymphatics

drain to superficial posterior lymphatic channels.

A deeper system is located beneath the Buck's fas-

cia and is drained into deep inguinal lymph

nodes.(4)

This method of drainage leads to the success of

this surgical method. It is essential to remove

involved skin and subcutaneous tissue completely

(reduction scrotoplasty) to prevent lymphedema

recurrence followed by reconstructive surgery of

penis and scrotum.(5,6)

Different surgical techniques are used in lym-

phangiectomy and repair of penis and scrotum

which include Jourdan and Meller,(1) Dlepech,(2,5)

Larrey,(5) Cadogan and Anderson,(7) Raghaviah,(8)

Vaught,(9) Dandapat,(3,5) Morey,(10) Apesos,(2) and

Malloy.(1)

Surgical complications of elephantiasis or geni-

tal lymphedema include hemorrhage, hematoma,

urethral injury, infection, painful erection,

decrease of sensation, and scar in suture line.

These complications could be reduced by using a

proper incision, use of Z plasty instead of longitu-

dinal suture, separating of testes and cord by an

external incision in scrotum before taking any

measure, and removal of involved tissue.(2,3)

References

1. Malloy TR, Wein AJ, Gross P. Scrotal and penile lymphede-

ma: surgical consideration and anagement. J Urol 1983;

130: 263.

2. Apesos J, Anigian G. Reconstruction of penile and scrotal

lymphedema. Ann Plast Surg 1991; 27: 570.

3. Dandapat MC, Mohaparto SK, Patro SK. Elephantiasis of

the penis and scrotum (a review of 350 cases). Am J Surg

1985; 149: 686.

4. Brown WL, Woods JE. Lymphedema of the penis. Plast

Reconstr Surg 1977; 59: 68-71.

5. Prpic I. Severe elephantiasis of penis and scrotum. Br J

Plast Surg 1966; 19: 173-8.

6. Ketterings C. Lymphedema of penis and scrotum. Br J

Plast Surg 1968; 21: 381-6.

7. Anderson BB, Cadogan CA. Scrotal lymphedema praecox:

disease and treatment. J Natl Med Ass 1982; 74: 387.

8. Raghavaiah NV. Reconstruction of scrotal and penile skin

in elephantiasis. J Urol 1977; 118: 128.

9. Vaught SK, Litvak AS, McRoberts JW. The surgical man-

agement of scrotal and penile lymphedema. J Urol 1975;

113: 204.

10. Morey AF, Meng MV, McAninch JW. Skin graft reconstruc-

tion of chronic genital lymphedema. Urology 1997; 50: 423.

57