Practical Insights on Treating Genital Lymphedema and Its Complications

Early conservative treatment for genital lymphedema is a very important aspect of care to reduce the risk of infections and skin changes (like fibrosis or papillomas), limit the involvement of the edema, reduce the need for surgical interventions, and/or improve surgical outcomes.^1–3
 
Typically, complete decongestive therapy (CDT) entails manual lymphatic drainage (MLD); compression (bandages and garments); specific exercises; skin care, education; and a newer aspect, weight management.^2–8
 
The external genital portions are considered part of the medial thigh lymphotome and should be addressed with manual lymphatic drainage as part of the proximal thigh.⁹ It is important to address the genitals with compression bandaging and/or garments whenever edema is present and/or may develop (like with bilateral leg involvement). Compression can also facilitate improving the elasticity of the external genitals for hygiene, cosmetic concerns, and/or improved surgical outcomes.² Applying appropriate compression to the genitals can be difficult, even for experienced health care providers (HCPs), due to anatomical aspects, toileting needs, activities of daily living (ADL) such as gait, and for those who have trouble achieving comfort in the sensitive area.^2,5–7
 
As with other areas, compression bandaging typically results in a greater reduction in edema than garments; yet, correctly bandaging and/or patient adherence is often worse.^5,6,10 According to Aulia and Yessica, “Conservative therapy may produce good results, but the ef­fects are temporary without maintenance and continued com­pression.”³
 
The exercises for genital lymphedema need to include the pelvic floor muscles, the abdominals, gluteals, and other hip/pelvic muscles to achieve the desired impact with muscle pumps to assist in fluid reduction. Education needs to include possible signs of infection, proper skin care/hygiene, importance of compliance with CDT, intimacy concerns, and on surgical options if appropriate.^5–8,11 Along with conservative CDT therapy a patient may need prophylactic antibiotics as part of the regimen to reduce the risk of infections.¹¹

When Genital Lymphedema Patients Need Surgery

If conservative therapy is not initiated or is initiated after irreversible tissue changes (significant fibrosis or adipose) from frequent infections occur, surgical intervention may be necessary.^2,3 A study by Garaffa and colleagues found 60% of males with genital lymphedema were able to “successfully manage” with early/consistent conservative treatment (CDT and prophylactic antibiotics) and did not require surgical intervention.¹²
 
Surgical intervention for both sexes can encompass excision and debulking of the involved tissue from the external genitalia, including the lymph vessels, adipose tissue, fibrosclerotic/fibrotic tissue, and layers of the skin.^13–16 Complications from this type of surgery can consist of delayed wound healing, infection (1.4-20.7%), seroma/hematoma/lymphocele (2.0-8.2%), necrosis of skin flaps (4.7%), pain (on urination, defecation, intimacy, ADL), testicular thermoregulation/fertility concerns, DVTs (0.7%), and/or worsening/recurrence of lymphedema (3.3-20%).^13–16 If the penis is debulked in the surgery, the skin graft will need to be able to expand to assist with erections and will need to be stretched frequently as part of the healing process to minimize scar tissue.
 
The excisional surgery does not address the underlying lymphatic dysfunction, resulting in the high likelihood of additional surgical interventions in the future.^{12–14,17–19} According to Zvonik, Födi, and Felmerer, “the high rate of recurrence suggests that the resection operation is only palliative.”¹¹ The main benefits of this type of surgery are possible reduction of erysipelas or cellulitis episodes, improved cosmesis, and/or improved ADL.^11,17
 
Another possible surgical intervention is the microsurgery lymphovenous anastomosis (LVA), in which lymph vessels are connected to venules to assist with removal or rerouting of lymphatic fluid out of the area and/or in reducing the backflow into the genitals from the trunk and/or lower extremities. This intervention is recommended for early stages of lymphedema when no or minimal tissue changes have occurred. The complications are much fewer for LVAs as compared to the debulking surgeries, especially with infections.^3,15,21 Unfortunately, both surgical interventions may result in the recurrence of lymphedema in the genital region. The chance of recurrence for both surgery options can be reduced with continuation and/or initiation of CDT post-surgery, especially compression, for the remainder of their lives.^2,15,20,21

Complications of Genital Lymphedema

Infections (cellulitis, erysipelas, and/or lymphangitis) are a significant concern with genital lymphedema. The environment of the genitals (warm, moist, near orifices with high bacteria counts, and thin tissue) alone significantly increases the risk of infections and wounds as compared to other body segments, like legs or arms, prior to adding in an altered immune system and increased stagnant lymphatic fluid. Infections can create a brutal cycle of increased edema, tissue changes (fibrosclerotic or adipose tissue), the risk for future infections, skin breakdown, and/or wounds in the genital regions.^11,13,22,23
 
A study by Zvonik and colleagues found 85% of males and females with genital lymphedema had 1 or more infections a year and 23% of these patients had 6 or more infections a year.¹¹ The leakage of lymphorrhea and/or wound drainage can also increase the risk of additional skin breakdown and infections. Other contributing factors can include smoking, diabetes, acne inversa, psoriasis, fungal infections, sexual intercourse (lack of cleaning before/after, aggressive intimacy), hygiene, stress, chafing, sexually transmitted diseases, and lack of CDT components (especially compression).^{8,11,13,22,23}
 
Infections in the genital region need to be addressed early and prophylactic antibiotics are frequently recommended.¹³ The unique unconfined structural design of the genital tissue can allow the antigens to travel more freely and can lead to spreading of the infection and even sepsis.²² It can be difficult to apply wound dressings in the genital region, especially if the person is don/doffing compression garments. The wound/incision may also be too painful to wear appropriate compression over the dressing. The lack of recommended compression can allow increased edema, further slowing the closure of the wound/incision.
 
Maceration with wounds can also slow healing and lead to additional wounds in the genitals.²³ It is important to ensure proper skin care, including barriers for moisture, with genital wounds/incisions to obtain optimal healing. The genital skin heals mainly with atrophic scars and the mobility of the tissue needs to be maintained to allow for flow of nutrients and expansion with intimacy.²² Overall, it is important for the patients and HCPs to closely monitor infections and wounds/incisions in the genital region.

In Conclusion

Genital lymphedema is too often underrepresented in research and overlooked in health care. The stigma and unease in discussing/addressing the genital region by patients and/or HCPs has made progress in the last several decades, yet still has room for improvement.^5–8 A study by Noble-Jones and colleagues found HCPs with more genital specific training/education were more like to include all aspects of CDT for conservative treatment than those with less training/education. The study also found majority of HCPs involved in the international study still felt there was a need for more education/training on medical interventions, compression, and patient assessment.^5–7
 
The keys to success with genital lymphedema are early and continued conservative therapy, skin care, availability of prophylactic antibiotics, and an open discussion between the HCPs and the patients.

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Dr. DiCecco founded LymphEd in 2017. Her research and dissertation was on treatment techniques for females with genital lymphedema with or without lower extremity involvement. Dr. DiCecco completed her Lymphology Association of North America (LANA) Certification in 2013 and her training as a Casley-Smith International Certified Instructor in 2016. Dr. DiCecco is also certified by the Lymphoedema Training Academy in the Fill and Flush Technique for lymphedema treatment. Dr. DiCecco developed the lymphedema and pelvic floor service lines for the Sports Rehabilitation Center in Atlanta, where she is currently Director of the two programs. Dr. DiCecco recently joined the faculty as an Assistant Professor at the Georgia campus for the Philadelphia College of Osteopathic Medicine in the Physical Therapy Department. Dr. DiCecco joined the board for a non-profit organization, the Lighthouse Lymphedema Network (LLN) in 2002 and she is the lead grant writer for the organization. Dr. DiCecco contributed a chapter in the LLN’s book on lymphedema, The Puzzle. She is a member of the American Physical Therapy Association and its Oncology, Women’s Health, and Education Sections. Dr. DiCecco is a member of the Lymphology Association of North America, the Lymphoedema Association of Australia, the Casley-Smith International Group, and the lymphedema round table for therapists in Atlanta.

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References
1. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. Reconstructive surgery of the scrotum: a systematic review. Int J Impotence Res. 2022; 34(2):359–368.
2. Torio-Padron N, Stark GB, Földi E, Simunovic F. Treatment of male genital lymphedema: an integrated concept. J Plast Reconstr Aesthetic Surg. 2015; 68(2):262–268.
3. Aulia I, Yessica EC. Surgical management of male genital lymphedema: A systematic review. Arch Plast Surg. 2020; 47(1):3–8.
4. Földi M, Földi E, Strößenreuther R, Kubik S, eds. Földi's Textbook of Lymphology: for Physicians and Lymphedema Therapists. 3rd Edition. Elsevier Health Sciences, 2012.
5. Noble-Jones R, Thomas MJ, Gabe-Walters M. The education needs of health professionals conservatively managing genital oedema: UK survey findings. Br J Nursing. 2021; 30(9):S18–S26.
6. Noble-Jones R, Thomas MJ, DiCecco S, Gabe-Walters M, Moffatt C. Contextual factors affecting the education needs of lymphoedema health professionals regarding genital oedema. J Wound Care. 2021; 30(Suppl 2):28–38.
7. Noble-Jones R, Thomas M, Bose R. The Lymphoedema Genitourinary Cancer Questionnaire in urology follow-up clinics. Int J Urol Nurs. 2018; 13(5):5–12.
8. DiCecco S. Let’s talk genital lymphedema. Pathways. 2021; 5–9.
9. Casley-Smith J, Caslley-Smith J. Modern Treatment for Lymphoedema. Adelaide, S. Australia: Lymphoedema Association of Australia, 1997.
10. King M, Deveaux A, White H, Rayson D. Compression garments versus compression bandaging in decongestive lymphatic therapy for breast cancer-related lymphedema: a randomized controlled trial. Support Care Cancer. 2012; 20(5):1031–1036.
11. Zvonic M, Foldi E, Felmerer G. The effects of reduction operation with genital lymphedema on the frequency of erysipelas and the quality of life. Lymphology. 2011; 44(3):121–130.
12. Garaffa G, Christopher N, Ralph DJ. The management of genital lymphoedema. BJU International. 2008; 102(4):480–484.
13. Bakar Y, Tuğral A. Lower extremity lymphedema management after gynecologic cancer surgery. Ann Vasc Surg. 2017; 44, 442–450.
14. Halperin TJ, Slvin SA, Olumi AF, Borud LJ. Surgical management of scrotal lymphedema using local flaps. Ann Plast Surg. 2009; 59(1):67–72.
15. 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.
16. Eswara JR, McDougal WS. Long-term outcomes of surgical management for nonmalignant perineal disease. J Urol. 2013; 190(6):139–2143.
17. Yao K, Tu H, Li YH, et al. Modified technique of radical inguinal lymphadenectomy for penile carcinoma: morbidity and outcome. J Urology. 2010; 184(2):546–552.
18. Atta A, El Basiouny MS, Abass SM. Surgical treatment of scrotal lymphedema: modified surgical technique. Lymphology. 2018; 51(1):38–43.
19. Liguori G, Papa G, Boltri M, et al. Reconstruction of penile skin loss using a combined therapy of negative pressure wound therapy, dermal regeneration template, and split-thickness skin graft application. Int J Impotence Res. 2021; 33(8):854–859.
20. Hara H, Mihara M. Lymphaticovenous anastomosis and resection for genital acquired lymphangiectasia (GAL). J Plastic Reconstr Aesthetic Surg. 2018; 71(11):1625–1630.
21. Giacalone G, Yamamoto T, Hayashi A, et al. Lymphatic supermicrosurgery for the treatment of recurrent lymphocele and severe lymphorrhea. Microsurgery. 2019; 39(4):26–331.
22. Téot L, Mustoe TA, Middelkoop E, Gauglitz GG. Textbook on Scar Management: State of the Art Management and Emerging Technologies. Springer International Publishing, 2020.
23. Fife CE, Farrow W, Hebert AA. Skin and wound care in lymphedema patients: a taxonomy, primer, and literature review. Adv Skin Wound Care. 2017; 30(7):305–318.