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Best practice in managingscrotal lymphoedemaJustine WhitakerJustine H'hitak'i-r is the RCN Nursing Standard, Nurse of the Year. Justine is a Macmiilan Lymphoedema

C^tii)icat Specialist for East Lancashire Eniiiihiustiiif.ii'liituher^rastlancspct.nhs.uk

The diagnosis, treatment and long-term manage-ment of upper and lower limb lymphoedema areregularly described in current hterature. (Badger

et al, 2004). There is less information available on lym-phoedema affecting the mate genitals. Lymphoedema ofthe external genitalia ha.s been suggested by McOoug-al tobe either transient or persistent and that it can occur at anyage (McDoug-.ll. 2003). What causes oedema of the scro-tum and penis is the same as for any other part of the body.(Haldar and Cranston. 2000). McDougal (2003) provides asimple classification for male genital oedema. Classifyingthis area can assist in treatment selection when comid-ering individual patients and their differential diagnosis.(McDougal. 2003). He classifies into two main areas withsubsequent subcategories; firstly congenital or primarylymphoedema with age of onset, how sporadic it is andinheritance, and secondly acquired, neoplastic, infectious,grainilomatous. reactive, disorders of fluid balance and idi-opathic, see Table 1 (McDougal, 2003).

Genital lymphoedemaAU the causes of McDougal's clas.sificadon can if a swellingis evident for three months or longer, result in the condi-tion becoming chR>nic (Green and Mason, 2006). In theearly stages of chronic oedema the tissues will 'pit' whenpressure is applied (Williams, 2003). When examining apatient with lymphoedema of the scrotum it is often veryobvious that pitting oedema is present due to indentationson the skin caused by underwear seam lines or where thepenis has displaced fluid while pressed against the tissuesduring encasement in underwear

Green and Mason (2006) discuss the later stages ofthronic oedema as the accumulation of fluid and wasteproducts in the tissues and as they remain there, they buildup causing thickening and fibrosis. (Green and Mason,2006). The number of niale.s atTected with lymphoedemaof the scrotum across all classifications has not been quanti-fied in the literature, although it is thought to affect onegroup of patients with the condition secondary to theparasitic disea.se Filarisis in large numbers. Around 120million people are affected by lymphatic filariasis. witharound 90% of those living in India. (Anitha and Shenoy,2001).The global alliance to eliminate lymphatic Filariasisestimates that glob.illy around 27 million boys and menhave scR)tal oedema due to this disease (global alliance toeliminate lymphatic Filariasis, 2007).

More commonly in v '̂estern society scrotal oedema ispresent due to neoplasms (McDougal, 2003). Prostate can-cer is the second most common cancer affecting men inthe UK and is responsible for around 13% of male deathsdue to cancer with an increasing incidence (Thompson etal, 2007).

The National Institute of Clinical Excellence in 2002published a document outlining guidance for urologicalcancers (NICE, 2002). Part of the document says thatall patients should have access to specialist palliative care.These guidelines include provision for lyniphoedemamanagement. Thompson et al (2007), also highlight thatthe policy firamework for commissioning cancer services(Calman-Hine Report, 1994), should allow integrationbetween cancer treatment services and paUiative care serv-ices. This can only strengthen the opportunity for patientswith scrotal oedema in having access to appropriate serv-ices locally, as regional cancer networks implement thesestrategies.

Clinical presentationThe chnical presentation, physiological causes and psycho-logical impact should be taken into consideration when apatient presents v/ith oedema of the scrotum. It could bejustified to assume that when the scrotum swells to exces-sive amounts that the patient would be suffering frompsychological distress. Ridner (2004) analysed the conceptof psychological distress within the nursing literature. Shefound that the term 'psychological distress* was commonlyused, however it was repeatedly ill defined and the defini-tion had not been well articulated. It is a common problem

ABSTRACT ^ _ _ _ _ _ _ _ _ _ _ _Managing lymphoedema of the male genitals is challenging, distressing

and potentially life-threatening if not managed appropriately. Consideration

is made of the classification, clinical presentation, lymphatic anatomy

and management of genital lymphoedema in clinical practice. The article

addresses the Issues raised when caring for patients suffering from this

condition. A case history demonstrates the use of a novel innovation.

The Whitaker Pouch, which can relieve and manage symptoms facilitating

self-management and appropriate best practice.

KEYWORDSgenital oedema • Lymphatic anatomy Empowerment • Management

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Table 1. Classification of genital lymphoedemaalso just of the scrotum,able figures.

no evidence of the quantifi-

Congenital

Age of onset

Sporadic

nherited

Acquired

MeoplasticIdiopathic

Source: McDougal, 2003

Birth infancyPrepubertal/pubertalAdult onset

Lymphoedema congenitalLymphoedema praecoxLymphoedema tarda

Milroy's diseaseMeig's disease

Infectious granulomatous reactiveDisorders of fluid balance

•

which is highly debatable as to whether it is addressed at alevel adequate to offer the patients the appropriate vehicleto begin to address this component oftheir condition.

An undentanding of the anatomy and physiology of thelymphatics allows us to appreciate that abnormalities of thelymphatic system; and how it contributes to the forma-tion of excess intentitial fluid, which ovt-r time becomeschronic and thus lymphoedema occurs (Bates, Levick etal, 1993). Browse et al in 2003 describe the scrotum as adependent organ, which doesn't have any direct externalcompression and that due to the shape of the organ hasa narrow passage at the top anatomically just below thecrest of the pubis, where the lymphatic vessels collecttogether to continue on their drainage pathway (Browseet al, 2003).

Not all patients who present with scmtal oedema willhave oedema of the penis. Browse et al (2003) suggestthat in the group of patients whose oedema is caused bycongenital or hereditary factors, 65% will have oedemaof both the scrotum and penis and around 30% will haveswellijig of the scrotum alone. The palliative care settingpresents patients with both scrotal and penile swelling, but

Figure 1. The correct application of tbe Whitaker pouch.The penis sits hetween the loops.

Lymphatic anatomyAnatomically the lymph nodes in the groin and pelvic areaare the immediate drainage pathways to drain both the penisand the scrotum. Browse et al (2003) describe in detail fix>mthe results of lymphographic studies, these drainage path-ways and discuss the 'lymphatic chain' Figure J.

The lymphatic chain incorporates the inguinal, iliac andpara-aortic nodes. All the lymphatic vessels from the lowerlimbs, perineum, externiil genitalia. lower abdomen .mdbuttock drain into the inguinal nodes. Inguinal nodes aresplit into superficial and deep and are usually around 10-20 in number. The medial inguinal nodes are responsiblefor most of the genitalia drainage. The vessels leaving theinguinal nodes drain into the iliac nodes. The inguinal,iliac and the para-aortic nodes are subdivided into theexternal, medial and internal anatomical positions, hencethe lymphatic chain. The medial inguinal nodes generallydrain into the medial iliac nodes which in turn drain intothe medial para-aortic glands (Browse et al, 2003). Patientswho present with para-aortic or pelvic lymphadenopathyin the palliative care setting therefore may present or be atrisk of developing scrotal and or penile oedema.

Scrotal oedema managementThe management of scrotal oedema can be both conserva-tive and surgical (Haldar and Cranston, 2000; Browse etal, 2003). Haldar and Cranston describe two approachesto surgical management, those being firstly to attempt tocorrect the underlying lymphatic dysfunction anatomicallyand secondly to surgically de-bulk the thickened fibrosedtiaue of the scrotum (Haldar and Cranston, 2000). Browseet al (2003) demonstrated reasonable immediate controlof the oedema using this technique; however report thataround half of the patients operated on are likely to have aslow gradual recurrence of the oedema resulting in furthersurgery (Browse et al, 2003).

Conservative approaches mirror those used to managelymphoedema of the limbs for example bandaging, manuallymphatic drainage (MLD) and compression garments.Bandaging of the scrotum and penis should begin with lowlevels of compression and Giiltig in 2(K)5 suggests that thistechnique should be carried out in specialist lymphoedemaclinics and in combination with manual lymphatic drain-age (Gultig,2005).

The use of compression hosiery or garments is very welldocumented in general to manage and control lymphoede-ma of the limbs (Partsch and Junger, 2006). An increasingrange of speciiilist compression garments are now availablefor patients with truncal oedema (Doherty et al, 2006).When considering garments for oedema of the scrotumthe anatomy of the lymphatics needs to be taken into con-sideration avoiding a tight band at the top of the garmentdue to the narrow anatomical structure of the neck of thescrotum, thus further restricting lymphatic flow.

One garment which is available is called the 'Whitaker

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Inferiormesentericnodes

Common iliacnodes

Externaliliac nodes

Internal iliac nodes

Figure 3. Anatomical positions of the lymphatic chain.

Figure 4. Male wearing a Whitaker Pouch MB: peniswould normally he visihie hetween pouch and strap.

Figure 2. The person assisting the application turns thepouch inside out ensuring the seam is on the underside.

Pouch' and is produced by Medi Bayreuth. {Figure 1,2and 4). The Whitaker Pouch is made of a soft fine elasticcircular knit fabric which when tested exerts compressionof around a Class 1 RAL standard. RAL standard compres-sion is the German method of testing the pressures exertedby a garment when tested in-vitro conditions. R^L class 1amounts to 18-21inmHg of compression. Other standardswhich produce lower levels of compression at class 1 arethe British Standard and the French Standard (Clark andKrimmet,20n5).

Self managementProviding a compression garment to manage lymphoedemanot only controLs the swelling biic also empowers patientsto become self-managing. The following example outlinesa case study on how the Whitaker Pouch contributed togaining control over Mr X's scrotal oedema.

Case HistoryMr X a 68 year old man was diagnosed with prostatecancer four years prior to his disease becoming meta-static. Metastases affected his left hip and he was treatedwith radiotherapy and chemotherapy. Three months laterfollowing a CT scan he was diagnosed with extensivelymphadenopathy affecting his iliac and para-aortic nodecham.A month later he presented to clinic with extensivescrotal, penile and left leg oedema. Socially he lived withhis wife who supported him and he was a very motivatedproactive individual who embraced self-managenicnt ofhis condition, including his long-term urinary catheter.Assessment of the scrotum included measurement, whichalthough somewhat subjective, was repeatable.

Two measurements were taken of the scrotum; thefirst was taken from the underneath point of the base ofthe penis where it protrudes from the torso, through tothe posterior aspect of the scrotum where it forms the

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CLINICAL FOCUS

Figure 5. Mr X's initial presentation.

perineum, secondly the horizontal measurement of thecircumference or girth, at the widest part of the scrotumwas taken. It is this second measurement which is neededto gauge the correct size of the Whitaker Pouch for appro-priate fitting. The measurements indicated a considerablesized scrotum: the first being 22cm in length and the sec-ond being 35cm in length.

Whitaker PouchA Whit-iker I'ouch was fitted and the patient was instruct-ed on how to apply the garment daily (Figure 1). Due tohis strong internal locus of control he took on this respon-sibility with no objection, also it was appropriate to teachhim a daily routine of simple lymphatic drainage (SLD),which is a modified self treatment derived from manuallymphatic drainage (MLD). Three weeks later Mr X hada repeat CT scan to monitor his disease progress and itresulted in an increase in size to the iliac and para-aorticnodes. Despite this, the size and condition of his scrotumimproved enough to fit him with the next size down ofthe Whitaker Pouch. His first measurement had decreasedby 5.5cm to 16.5cm and iiis second measurement haddecreased by 8cm in girth to 27cm.

Management of his swollen penis was also done by thegentleman himself and this included daily self-bandag-lng with a 4cm wide cotton mesh conforming bandage.Although measurements of the penis girth were not takena visible reduction wxs noted and the patient managed tomaintain the results of his intervention.

ConclusionAlthough managing lymphoedema of the male genitaliacan be quite a challenge, and in some instances the problemmay be beyond the u.se of a simple compression garment,other techniques such as bandaging, MLD and on occasionsurgery can assist to gain control. Once this has occurred thelong-term objective to manage and prevent deteriorationwill ultimately result in the consideration of a compressiongarment. The Whitaker Pouch can offer this long-terminauagement and continue to reduce the symptoms whilefacilitating the individual to gain self caring strategies tomanage their own chronic condition (Figure /).

A thorough understanding of the underlying diseaseprocess and a diagnosis is an essential component of anypadents prescription of care to etisure they receive appropri-ate management at the first point of contact. Patients wherepossible should have access to a lymphoedenia specialistservice in order to facilitate this. When a patient is unableto self manage for a multitude of reasons, carers, communityand hospitiil based staff can assist in the application of theWhitaker Pouch (Figure 2). Knowing appropriate garmentsare available can aid professionals to broach the subject ofgenital swelling and also allow the patient comfort in that itis not unheard of and that appropriate equipment is availableto address their individual problem. BJCN

AniEha K, Shenoy R.K, (2(M)1).Trcattnent of Ivmpharic Slanxiis: CurR-ni Cn-ndi.tndiiinj Drniiati'l Venerfol Lepwl 67(2); bi\~S

Badger C . Prt-ston N. Sters K. Mortimer P (2004) Aaiihiolia I ami-injlamniatorus

for rediidng MMI! injhmmaii'ry episi'des in lymphoedema of the limbs (Cochnine

RcMew). iniThe Cochranc Ubrat7 (issue 3)Bates D. Levick J, Mortimer P (199.1) Change in inai;romoleciiLir compcwiimn

of iiireritii)^ fluid ftani swollen arms alter bn-ast caiict-r trcatmem. and itsunplicarioiis Ctin S<i 85(6): 737-46

Browse N, Burnand K. Mortimer P (eds) (2003) Diseases fot the lymphalia.Hodder Arnold. London

Ciark M, Krininiel 0 (2006) LYmpkoeJemn and the conslmclion and cliissificalion ofcompression hi'siery. L>iiiplioedema Framt-wiirk. Template tor Practice: ironi-pression hosiery in lyniphoedeiiu. MEP Ltd. London

Doherty D, Morgan 1'. MoffaH C (2(K)6] Roir ,<f hosiery in hun timh lymphoedemd.Lymphoedema Framework. Template for PraL-tice: compression hosiery inlyniphoedem.i. MEP Led. London

Green T. Mason W (2006) Chronic aedemas: identification and referral pathways.BrJ Cmmmmiiy Nurs ll(4):S8,S1(Mi

Global Alliance to Eliminate Lymphatic Filariasis (2(MI7) www.filariasis,orglast acces.sed 16/09/07

Giiing O (200S) Lymphoedema bandaging for the head, bn-ast jiid gt-iiitalia.Lympboedema bandaging in practice. EWMA Focus dnciiinont. MedicalEducation Partnership Ltd

Haldar N, C^nuistoii D (2l)0()) Male Grnital Lyinphoeitema. itnTwycroM k.Jenin K,Todd J (2000) Lymphoedema. Radcliffe Medical Pres-S. Ojtfoni

McDougil W (2203) Lymphoedema of the external genitalia. / Vrol 170711-16

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Partsch H,J nger M. (20(16). Ei>idnKC for the use ^compression hosiery in tymphotde-

ma. Lyniphoedvma Framework. Template for Practice: compression hosiery inlymphoedema, MEP Ltd, London

Ridner S (20(M) Psychological distress: eonccpt analysis / Ad Nurs 45(5):

Tliompsoii J. Wood J. Feuer D (2I.HI7) Prostate cancer: palliative care and paitirelief. Br Med Hull (Epub ahead of print)

Williams A (2003). An overview of non-cancer rebted chronic oedema - a UKperspective. www.worldwidewouiid5.coni/20l)3/ipril/Wiliiaim/Chtonn:-Oedcma.htnil. Ust accessed

KEY POINTS• Managing lymphoedema of the male genitals is

challenging, distressing and potentially life-threatening

if not managed appropriately.

• The clinical presentation, physiological causes

and psychological impact should be taken into

consideration when a patient presents with oedema of

the scrotum.

• An understanding of the anatomy and physiology

of the lymphatics allows us to appreciate that

abnormalities of the lymphatic system; and how it

contributes to the formation of scrotal oedema.

The Lymphoedema Supplement, October 2007 S21