What is the initial workup and management for penile lymphedema?

Initial Workup and Management of Penile Lymphedema

The initial workup for penile lymphedema should include a thorough physical examination documenting the morphology and extent of swelling, followed by ultrasound or MRI assessment, with referral to a specialized multidisciplinary team including lymphedema therapists for comprehensive management. 1

Physical Examination

• Document the diameter of swelling, location, morphology (papillary, nodular, ulcerous, or flat), and relationship to other structures 2
• Assess for bilateral or unilateral involvement and evaluate for potential involvement of scrotum or lower extremities 3
• Evaluate for signs of underlying infection or inflammation that may be contributing to the lymphedema 4

Imaging Studies

• Ultrasound is recommended as first-line imaging to assess soft tissue changes and can guide fine-needle aspiration cytology (FNAC) if needed 1
• MRI or magnetic resonance lymphangiography (MRL) provides more detailed assessment of lymphatic channels and extent of lymphedema 3
• 18FDG-PET/CT should be reserved for cases where malignancy is suspected as a cause of lymphedema 1, 2

Laboratory Evaluation

• Consider serology for filariasis in endemic areas or if travel history suggests possible exposure 4
• Basic laboratory tests to rule out infection or systemic conditions that may contribute to lymphedema 5

Differential Diagnosis Considerations

• 30-50% of palpable inguinal lymphadenopathy may be due to inflammatory changes rather than malignancy 6
• For palpable inguinal nodes, fine-needle aspiration is the standard initial diagnostic approach 6
• A negative FNA should be confirmed with excisional biopsy or followed with careful surveillance 6

Management Approach

• Refer to a specialized multidisciplinary team including urologists specializing in penile conditions, lymphedema therapists, and other specialists as needed 2

• Initial conservative management includes:

  • Thorough hygiene and skin care to prevent infection 7
  • Custom compression garments made of cotton-polyester for the affected region 7
  • Elevation and manual lymphatic drainage techniques 7

• For cases not responding to conservative measures, surgical options include:

  • Excision of lymphedematous tissue with reconstruction using skin flaps 8
  • Modified Charles procedure for severe cases, involving removal of affected skin followed by reconstruction 8
  • Preservation of scrotal septum and subcutaneous lymphatic tissue flaps during reconstruction to improve outcomes 3

• For acute phase with rapid progression and signs of inflammation:

  • Consider low-dose systemic corticosteroids to prevent progression 5
  • Antibiotics if there are signs of infection 4

Follow-up and Monitoring

• Regular follow-up every 3 months for the first 2 years 2
• Physical examination at each visit to assess for recurrence or progression 2
• Ultrasound may be used during follow-up to evaluate treatment response 2
• Assess for impact on sexual function and quality of life at each visit 2

Complications and Special Considerations

• Sexual dysfunction is common and may require additional interventions 7
• Erectile dysfunction may persist even after resolution of lymphedema and may require specific medications (e.g., sildenafil) 7
• Surgical complications can include hematoma (2.5%) and poor wound healing (5%) 3
• Recurrence is possible, particularly in cases associated with malignancy or radiation therapy 8

Prognosis

• With appropriate surgical management, recurrence rates are low in primary lymphedema 3
• Conservative management can provide significant improvement in mild to moderate cases 7
• Surgical treatment allows for better hygiene, easier ambulation, improved sexual function, and better quality of life 8