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Background and Aims Genital edema is a frequent complication in those patients who are on peritoneal dialysis, generally secondary to the increase in intra-abdominal pressure that it entails. It occurs late after the implantation of the peritoneal catheter (after 30 days of implantation). The typical clinical manifestation of this condition is basically subcutaneous edema in the genital area, accompanied by pain and UF failure. The diagnosis must be made by using an imaging test, mainly CT-peritoneography. Method A series of clinical cases of PD patients who consulted for genital edema is reviewed, analyzing the role of peritoneography Results CASE 1 A 76-year-old male, 15 days after the start of the technique, consulted for right scrotal edema. It was decided to suspend CAPD and start hospital intermittent IPD with low volumes. A CT-peritoneography was requested, which revealed a right peritoneal-vaginal duct and a left inguino-scrotal leak. Surgical correction of the anatomical defect was performed without incident, with subsequent return of the patient to CAPD. CASE 2 A 78-year-old man, 15 days after the start of the technique, consulted for bilateral scrotal edema. A CT-peritoneography was performed, which showed that the leak of peritoneal fluid to the scrotum was due to bilateral inguinal hernia. Subsequently, inguinal hernioplasty of the surgical defect was performed without complications. Conclusion Genital edema, as a complication of patients with CAPD, appears in approximately 4-10% of them. CT-peritoneography is the diagnostic technique of choice. To do this, 150 ml of nonionic iodinated contrast, with a concentration of 300 mg/ml, are diluted in approximately 2 liters of dialysis solution, which are introduced into the peritoneal cavity of the patient 2 h before performing the CT. Subsequently, a CT scan of the abdomen and pelvis including the perineum is performed, in the supine position and craniocaudal direction.

Diagnostic paracentesis is a routinely practiced, typically safe procedure performed in the emergency department. Genital swelling post-paracentesis is a rare complication with few documented case reports. We report a case of isolated penile edema after a diagnostic paracentesis performed in the emergency department. The patient is a 63-year-old male who came to the emergency department with a two-day history of isolated penile swelling after undergoing a diagnostic paracentesis in the emergency department as part of his workup during a recent hospital admission. On exam, the paracentesis site was noticeably low, beneath the inguinal ligament on the right side. His genital exam showed a circumcised penis with significant soft tissue swelling that involved the entire penile shaft sparing the glans and scrotum. There was no penile tenderness on palpation or urethral discharge. The testicles and scrotum revealed no signs of edema or tenderness, hernias, or abnormal lie. Of note, the patient reported that he had a less severe episode of penile swelling approximately one year ago after a paracentesis in a similarly low site, which resolved spontaneously. The features and timing of this presentation, added to the patient's previous episode over a year ago, pointed to this being a sequela of the paracentesis he had undergone during his last hospital stay. After evaluation and consultation with the urology service, he was discharged home with expectant management and outpatient follow-up. His symptoms resolved spontaneously after one week. To our knowledge, there have been no published reports of isolated penile edema after a diagnostic paracentesis. This case could be used when teaching the proper technique for performing a paracentesis and its potential complications.

Congenital penile lymph edema is a rare anomaly of unknown cause of the lymphatic vessels. Lymphedema is often the shortage of lymphatic collecting ducts, lymphatic hypoplasia, hyperplasia, as a result of aphasia or lymph node fibrosis associated with the pathological development of lymphatic vessels. Lymphedema is generally a permanent condition and surgical treatment is necessary. Here we present the case of a newborn at 26 weeks via caesarean section with congenital penile edema, and no detection of chromosomal anomalies.

Background: We present the case of an adolescent girl with prominent clitoral swelling as the first symptom when she presented to the emergency department, and who was subsequently diagnosed with nephrotic syndrome. Case: A 14-year-old adolescent girl was admitted with painless clitoral swelling. She denied recent masturbation, itching, or discharge. She was within the last few days of menstruation. Physical examination revealed clitoral edema without erythema or genital edema. Urine dipstick test and microscopic evaluation revealed protein 2+, blood 3+, abundant erythrocytes and 9-10 leukocytes. A few days later, additional clinical findings, such as pretibial and facial edema, were diagnosed as nephrotic syndrome. Summary and Conclusion: This case is a reminder that clitoral swelling is to be considered a sign in the diagnosis of nephrotic syndrome, even when it occurs alone. C1 [Girisgen, Ilknur; Yuksel, Selcuk] Pamukkale Univ, Sch Med, Dept Pediat Nephrol, Denizli, Turkey. [Pekal, Yucel; Pekal, Busra] Pamukkale Univ, Sch Med, Dept Pediat, Denizli, Turkey.

Cutaneous edema is the accumulation of extracellular fluid in skin. Lymphedema is the accumulation of lymph, an extracellular fluid rich in protein. Edema or lymphedema of male genitalia may involve the glans, foreskin, penile shaft, scrotum or the whole external genitalia.

Summary Hereditary angioedema (HAE) is a primary complement factor deficiency, characterized by recurrent submucosal/subcutaneous swelling episodes. SERPING1 gene defects encoding C1 esterase inhibitor (C1INH) are responsible from the disease. Fifteen patients with HAE are retrospectively evaluated in this study. All patients (n = 15) had HAE type I, 13 were from the same family, other two from two different families. Median age at onset of symptoms was 7 years (2-20); median age on diagnosis, 12 (0,5-41) and median delay in diagnosis, 3 years (0-33). Clinical symptoms were extremity edema(92,3%), facial edema(46%), abdominal pain (46%), genital edema (46%), and laryngeal edema (23%). Some patients suffered from recurrent abdominal pain, had been empirically given colchicine with familial mediterranean fever (FMF) when they admitted. One presented with bullous skin eruption, soon after developed extremity edema. Both resolved spontaneously after C1INH concentrate therapy. Two females suffered from recurrent genital edema after sexual activity. One patient experienced compartment syndrome-like swelling of extremity after playing football. One patient diagnosed with panic attack due to fear of death by asphyxiation, and was diagnosed with HAE disease. A nonsense mutation in exon 8, a missense mutation in exon 2 in SERPING1 gene was present in Family 1 and another patient (P14) from the other family, respectively. Sporadic/autosomal dominant inheritance ratio was 2/3 in the families present in our series. Patients with HAE presents with a large spectrum of symptoms. In mediterranean countries, patients with abdominal attacks may be misdiagnosed with FMF. Thus, health-care professionals should be alert, and put HAE in the first line of differential diagnoses when the disease symptoms are present. Consequently, morbidity/mortality will decrease with effective treatment options.

Background Penile and scrotal swelling can occur as an extraintestinal manifestation of Crohn's disease (CD) and is thought to be an uncommon form of metastatic CD (MCD). Because of the rarity of this manifestation, much is unknown concerning the presentation, treatment, and response to therapy in children with genital MCD. Methods Boys ages 1 to 17 years presenting with genital edema and a confirmed diagnosis or strong suspicion of CD who were evaluated at the Mayo Clinic between 1996 and 2014 were included for review. We sought to characterize the clinical and pathologic features of genital MCD and response to treatment in our cohort of patients. Results Eight patients with genital MCD were identified from our institution (mean age 11.4 yrs, range 7-16 yrs). Seven (88%) patients experienced cutaneous symptoms before a formal diagnosis of CD was made, and two of the seven had no adverse gastrointestinal symptoms at that time. Patients were prescribed an average of 3.4 medications (topical and systemic) for management of their gastrointestinal CD and MCD. Conclusions Penile and scrotal swelling can occur as an extraintestinal manifestation of CD and is thought to be an uncommon form of MCD. In boys, genital swelling typically precedes intestinal CD. Treatment of the underlying CD with systemic medications was most helpful in this series. An evaluation for CD is necessary in all patients presenting with unexplained genital swelling.

Acute genital edema (AGE) is an infrequent but disruptive complication in patients on continuous ambulatory peritoneal dialysis. It is a common manifestation of dialysate leakage caused by inguinal, umbilical, femoral, or incisional hernias; peritoneal tears; leaks around the dialysis catheter; trauma; fluid overload; and malignancy. The evaluation of AGE begins with a history and physical exam. However, the physical exam in these patients is often indeterminate. Several diagnostic measures exist to evaluate and guide management of AGE occurring during continuous ambulatory peritoneal dialysis but little agreement exists on an optimum method. We have conducted a review of the literature on the evaluation and management of AGE and present a summary of the data. CT peritoneography and peritoneal scintigraphy have been used extensively to evaluate AGE although no comparative studies exist. MRI peritoneography has also been described. CT peritoneography offers more anatomical detail but may not be as sensitive as peritoneal scintigraphy in detecting a peritoneal fluid leak as the cause for AGE. CT is also more costly and subjects the patient to more radiation. MRI is a noncontrast study without radiation risk, but has not been studied to the same degree. If testing is equivocal or bilateral hernias are suspected, diagnostic laparoscopy is helpful and can be combined with hernia repair. Whether the etiology is a leak or tear, low-volume peritoneal dialysis (PD) or cessation of PD for two to four weeks will allow closure. However, hernias almost always require operative repair with mesh usually without disrupting PD.

The etiology of acute scrotal edema can vary from a benign process such as post-trauma hydrocele, allergy, hypoproteinemia, appendicular torsion, or epididymo-orchitis to an emergent process such as an incarcerated inguinal hernia, testicular torsion, or rupture. Rarely, unexplained penile or scrotal swelling occurs as a chemical contact. Here, we reported a case of acetochlor contact presenting as acute genital edema of initial symptom.

A 52-year-old African American male with a long history of poorly controlled hypertension presented to the emergency department (ED) with two days of genital edema and pain. During ED work-up, the patient developed sudden onset of non-pitting, non-pruritic, and non-urticarial upper lip edema. Review of his antihypertensive medication list revealed that he normally took benazepril, highly suggestive of a diagnosis of angiotensin-converting-enzyme inhibitor-related angioedema (ACEI-RA). We present the first reported case of penile ACEI-RA that progressed to involve the oropharynx. The ED management of the condition and some of the newer treatment options available for ACEI-RA is also briefly discussed.

Therapists certified in lymphedema management are skilled and prepared to address male genital edema mainly through manual lymphatic drainage and compression bandaging. That being said, there remains a need to further develop and establish treatment protocols in this area of edema management, especially in inpatient, acute care hospital settings. Many individuals who are hospitalized for various conditions may experience acute genital edema. Acute genital edema is a painful and self-limiting condition, which is difficult to treat. Early diagnosis and proper conservative management is essential to success and can even prevent surgery. At present, in circumstances when acute male genital edema (AMGE) is acknowledged, treatment methods are typically limited to medical intervention with use of medications such as diuretics, or compression slings are provided by therapists during acute hospital stays. This article describes a strongly effective, conservative method of reducing and resolving genital edema

We present a case of congenital lymphedema in a 7-year-old boy in Sierra Leone with active filarial infection and penile edema. The genital edema with onset at 6 months of age may have been due to a congenital abnormality in lymphatic drainage. Other possible causes of childhood lymphedema, including Milroy's disease, are discussed.

BACKGROUND Genital lymphedema (GL) causes irritating symptoms such as urinary troubles due to genital edema and genital lymphorrhea, which deteriorate patients' quality of life. Indocyanine green genital lymphography has been reported to be useful for severity evaluation of GL but is not available in all medical settings. More convenient and simple severity evaluation methods are required in clinical practice. METHODS Thirty-two female secondary lower extremity lymphedema patients with GL were evaluated using the genital lymphedema score (GLS) based on patients' symptoms related to GL (score from 0 to 9; higher is worse) and the genital dermal backflow (GDB) stage based on indocyanine green lymphography findings. The GLS was compared according to GDB stage. RESULTS The GLS ranged from 1 to 9 (mean, 3.0), and GDB stage ranged from I to IV (9 in GDB stage I, 13 in GDB stage II, 8 in GDB stage III, and 2 in GDB stage IV). There was a significant difference between GLS in GDB stage I, GDB stage II, GDB stage III, and GDB stage IV [1.2 (0.4), 2.4 (0.5), 4.8 (0.9), and 8.0 (1.4), respectively; P < 0.001). CONCLUSIONS The GLS was well associated with pathophysiological GL severity staging system and increased with progression of GDB stage. Because GLS is more convenient and simple than GDB stage, GLS is useful for primary evaluation of GL.

Crohn's disease is an inflammatory intestinal disease that primarily causes abdominal pain and diarrhea. We report a male patient who presented with penile and scrotal lymphedema and inguinal fistulas as the first manifestations of Crohn's disease. Extraintestinal or metastatic Crohn's disease initially presenting as genital lymphedema with fistula formation is rare. Skin lesions in extraintestinal Crohn's disease typically show non-caseating, sarcoidal granulomas with numerous foreign body- and Langhans-type multinucleated giant cells, which are separated from intestinal involvement by normal skin. Treatment options are limited and include multi-immunosuppressant medications.

Scrotal swelling in young boys is a common problem. The differential diagnosis includes testicular torsion, epididymoorchitis, and idiopathic scrotal edema. We report the unusual case of a 17-year-old boy who presented with recurrent episodes of penile and scrotal edema as extraintestinal manifestations of Crohn's disease. Genitourinary complications of Crohn's disease are not uncommon; however, they more typically present in the form of nephrolithiasis, obstructive uropathy, and enterovesical fistulization. Few reports have described Crohn's disease presenting with isolated genital edema in the absence of associated intestinal or systemic symptoms.

The incidence of prostatic abscess is 0.5% in relation to all prostate pathologies and usually occurs in patients with diabetes or with some degree of immunosuppression. The case of a male patient, 84 years old, with a history of arterial hypertension and mild renal failure, presenting high fever, prostate syndrome, genital edema and constipation is reported. He was diagnosed with prostate abscess via transrectal ultrasonography (TRUS). Treatment was started with empirical meropenem and a puncture of the abscess was performed transperineally under TRUS guidance placing an 8-Fr nephrostomy tube for 36 h. The patient was discharged 48 h after the puncture with a good prognosis. TRUS-guided transperineal drainage is a safe, adequate and effective treatment for prostate abscess, and allows the placement of drainage for several hours thereby avoiding the communication between the abscessed cavity and the urethra or rectum. Therefore, after having reviewed the literature, we consider this approach suitable for drainage.

Although rare in developed countries (0.2 cases cases/100 000 men) (1), penile cancer (PC) is com-mon in underdeveloped countries. In Brazil, Paraguai, Angola and India, the incidence of PC varies from 2.3 to 8.3 cases/100 000 men) (2,3). In Brazil annually around 1000 penile amputations are reported. In some Brazilian regions, prevalence of PC is similar to prostate cancer, affecting young males (3.53% < 26 years; 3.88% 27 - 35 years, 12% 36- 45 years and 18.7% 46 - 55 years old) (4). In a strict epidemiological and bureaucratic point of view, the health authorities of those coun-tries don’t consider PC a public health problem in view of several other more prevalent diseases. Apart from epidemiological and statistical data, we disagree and believe that PC prevention is imperious in these nations. When dealing with the humanitarian and clinical aspects of PC, we conclude that the medical and scientific community such as the urological society and government agencies must pay attention to this disease:- PC when diagnosed and treated precociously is highly curable and with low toxicity. When treated in more advanced phases, its treatment is costly and with bad outcome (3).- Primary lesion treatment, even conservative, involves some degree of genital mutilation, with sensitivity alterations and even total loss of the ability for sexual activity. Amputations may also compro-mise self-esteem and corporal image, difficult or avoid orthostatic micturition, result in loss of masculinity (in a society centered in the phallus) and may also result in urethral strictures.- There are very few studies about the delayed sequelae of inguinal iliac lymphadenectomies: lymphoceles and repeated erysipela. Very few studies are available regarding treatment of lower limb chronic lymphedema. Usually this condition prevents labor and sports activities. There is no definite cure for genital edema.

Chronic penile swelling in prepubertal boys is an uncommon problem. The differential diagnosis includes primary and secondary lymphedema, trauma, previous penile surgery, and extraintestinal metastatic Crohn's disease. We report a 6-year-old boy who presented with persistent penile edema as an extraintestinal manifestation of Crohn's disease. In this case, the penile edema preceded the overt bowel symptoms associated with Crohn's disease, and a high index of suspicion led to the underlying diagnosis. Few previous reports have reviewed the different treatment options and their associated outcomes for Crohn's disease in prepubertal boys with genital edema.

Treatment for limb lymphedema is challenging. The recent development of the super-microsurgical technique has made lymphaticovenular (LV) anastomosis an easier and more accurate surgical method for lymphedema. A summary of our experience as well as recent developments in surgical treatments for lymphedema are described. Methods and Results: Ultra-microstructural analysis demonstrated that dysfunction of the lymphatics in lymphedema was caused by the degeneration and incomplete regeneration of smooth muscle cells and valve insufficiency in the lymphatic channel. ICG and infrared ray examinations have been proposed as new means of assessment of lymphatic function. LV anastomosis is suitable for genital edema, arm edema with severe phlegmone with leg edema, and early stage leg edema. Although pre- and postoperative compression therapy is generally required for limb edema, some cases do not require postoperative compression due to remaining or regenerated smooth muscle cells. As new methods of treatment, the vascularized lymphadiposal flap has been effective for progressive cases with LV anastomosis. LV anastomosis is also effective for congenital chyloabdomen. (*English Translation of J Jpn Coll Angiol 2008; 48: 173–178.)

Objective Metastatic Crohn's disease is a rare and complex inflammatory condition distinguished by cutaneous granulomatous lesions outside the gastrointestinal tract. Genital involvement is rare; with less than 10 cases reported involving isolated penile lymphedema. Here, we present a case of isolated lymphedema of the penis as a consequence of extra-intestinal Crohn's disease. Case report The patient is an 18-year-old African American male with a complex history of inflammatory bowel disease, who initially presented with a chief complaint of 6 weeks of swelling of his penis at age 13. A modified circumcision and lymphangectomy of the penis were performed; histopatholgy demonstrated a granulomatous infiltrate and interstitial edema of the distal penis. Conclusion Surgical intervention is an applicable therapeutic alternative and last-line therapy for treatment of isolated penile lymphedema in select patients with appropriate pathology, and can be a suitable adjunct to medical management in these cases.

We have determined that immunization with a detergent extract of the mouse pneumonitis agent of Chlamydia trachomatis fails to induce a protective inflammatory immune response following genital infection by C. trachomatis. We demonstrated that mice immunized with the detergent extract have increased cutaneous delayed-type hypersensitivity and increased splenic T-cell proliferation in response to the chlamydial extract. After genital infection by C. trachomatis, extract-sensitized mice had significantly increased genital inflammation (P = 0.044) compared with controls. The inflammation was characterized by significantly increased eosinophils in the genitalia (P < 0.0005) and increased genital edema (P < 0.0005). However, the increased genital inflammation of extract-sensitized mice provided no increase in protection against infection (P = 0.92).

Cutaneous-mucosal lesions constitute one of the most frequent extraintestinal manifestations of Crohn's disease and in some cases may be the first symptom of intestinal disease. We describe the case of a 45-year-old female patient who sought medical help for genital tumefaction of 20 years' evolution. For the previous 15 years, she had been experiencing digestive symptomatology attributed to irritable bowel syndrome. Two months before the consultation, and coinciding with aggravation of the condition, the patient had been diagnosed with colonic Crohn's disease. Skin biopsy of the labia minora revealed sarcoid granulomas. The results of microbiological studies (staining for microorganisms and cultures) were negative. A diagnosis of metastatic vulvar Crohn's disease was made and, treatment with metronidazole was started, which improved the genital edema after 2 months. Genital lymphedema is an exceptionally rare manifestation of metastatic Crohn's disease that may appear several years before intestinal symptomatology develops. Treatment with metronidazole seems to be a good therapeutic option.

Introduction: Peritoneal fluid leaks are frequent in continuous ambulatory peritoneal dialysis (CAPD) patients and may manifest as subcutaneous or genital edema or as apparent ultrafiltration (UF) failure. Genital swelling in CAPD patients is often due to dialysate leak through a small clinically-undetectable inguinal hernia, and may require herniorrhaphy. If imaging studies exclude an associated hernia or patent processus vaginalis, a conservative approach may be adopted. Case report: An 80 year-old bed-ridden male developed gross bilateral scrotal swelling (without cough impulse) and apparent UF failure shortly after initiation of CAPD. Computed tomography peritoneography (CTP) showed bilateral scrotal fluid collections without a hernia or patent processus vaginalis. An attempt to maintain the patient on CAPD by reducing the dialysate volume, scrotal elevation and adopting a supine position was not successful; CAPD was substituted with temporary hemodialysis (HD) for four weeks. Scrotal swelling reversed after one week of CAPD cessation and did not recur when supine PD with intermittent dry periods was reinstituted a few weeks later. Satisfactory UF could also be easily attained. This was compatible with caudal fluid migration through peritoneal defects being the underlying cause. The patient had been successfully maintained on CAPD for the last 18 months. Conclusion: Fluid dissection through soft tissues can result in gross genital edema and apparent ultrafiltration failure in CAPD patients. Supine PD, scrotal elevation with intermittent dry periods may be a practical alternative management in the absence of automated dialysis facilities. The severity of dialysate leak does not preclude a satisfactory response to this conservative management. Keywords: peritoneal dialysis, dialysate leak, genital edema, ultrafiltration failure

Continuous ambulatory peritoneal dialysis (CAPD) is a useful and practical modality for the treatment of end-stage renal disease (ESRD). In the properly selected patient this method is well-tolerated with minimal complications. We report a case of intermittent massive genital edema secondary to patent processus vaginalis in a patient receiving CAPD. The diagnosis of patent processus vaginalis, which was strongly suggested by the intermittent nature of the symptoms, was confirmed by computerized tomography (CT) peritoneography.

A 36-year-old woman presented with chronic recurring dermatitis of the vulva, perineum, and lips. The genital lesions had a 3-year history and were associated with slight pruritus and occasional pain. The lesions of the upper lip had a history of 6 months. The patient had been treated with cycles of antimycotics and topical steroids which only partially controlled the symptoms during treatment. Dermatologic examination showed erythematous, infiltrative dermatitis with edema of the labia majora and persistent edema of the upper lip (Fig. 1a,b). Routine blood chemistry, urine analysis, and chest X-ray were normal. Microscopic examination and cultures of vaginal swabs did not reveal any pathogenic bacteria or fungi. Histologic examination of a biopsy of vulval lesional skin showed lichenoid lymphocytic infiltration of the papillary dermis and small, nonnecrotic epithelioid granulomas in the deep dermis (Fig. 1c,d). No microorganisms, including acid-fast bacilli or fungi, were identified. Culture was negative for fungi. Polymerase chain reaction was negative for the mycobacterial genome. Histologic examination of a biopsy from the upper lip showed similar results. The pathology reports of both regions were compatible with a diagnosis of granulomatous cheilitis and vulvitis. To investigate concomitant asymptomatic inflammatory bowel disease, the patient underwent colonoscopy with retrograde ileoscopy and gastroscopy, which were both negative. The patient refused radiographic examination of the small intestine with a barium meal. The patient was treated with systemic metronidazole (500 mg/day). After 6 months of therapy, the upper lip showed significant improvement and erythema and desquamation in the genital area showed slight improvement, but genital edema was unaffected.

Lymphedema is the swelling of a body part due to the accumulation of excessive amounts of regional interstitial fluid and decrease or blockage of lymphatic transport.1 Secondary lymphedema is the most common form and usually results from surgical, traumatic or inflammatory disruption or obstruction of the lymphatic pathways. Acute genital lymphedema usually resolves spontaneously but occasionally becomes chronic and may require surgical treatment.2 We report a case of severe acute postoperative genital edema following radical retropubic prostatectomy and bilateral pelvic lymphadenectomy that was successfully managed with 2 weeks of manual lymphatic drainage (MLD) therapy. To our knowledge this is the first case reported in the urological literature of postoperative genital edema treated with decongestive lymphatic therapy. CASE REPORT A 71-year-old man with a prostate specific antigen of 4.5 ng/ml and clinical stage T2a Gleason grade 5 4 9 adenocarcinoma of the prostate underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Lymphadenectomy included removal of all the tissue from the obturator fossa and along the hypogastric vessels bilaterally. Both neurovascular bundles were excised widely around the prostate because of high volume, poorly differentiated tumor. Final pathological evaluation revealed bilateral Gleason grade 5 4 9 adenocarcinoma of the prostate confined within the prostatic capsule, with all surgical margins, seminal vesicles and lymph nodes negative for tumor. Postoperative hospital stay was uneventful, and the patient was discharged home on postoperative day 3. At postoperative day 11 the patient complained of severe debilitating swelling and pain in the penis and scrotum that interfered with sitting and walking. Physical examination demonstrated the genitalia to be markedly edematous with the scrotum the size of a grapefruit. There was mild penile edema that was not troublesome, and there was no lower extremity edema. There was no evidence of cellulitis. Venous duplex ultrasonography showed no evidence of either deep venous thrombosis or venous obstruction in the lower extremities or pelvis, and pelvic computerized tomography revealed no evidence of a pelvic fluid collection. During the next week the genital edema persisted and was refractory to the usual treatments of genital support and diuretics. Three weeks postoperatively daily decongestive therapy was started, consisting of MLD, lower extremity stretching exercises and overlapping circumferential compressive wrappings to the scrotum that transmitted low pressure compression (20 to 30 mm Hg). MLD was initiated in the inguinal region, moving cephalad, with the goal of transferring lymph from the edematous tissues to nonedematous cutaneous sites. Nonelastic compressive wrappings were applied after each session of MLD and worn continuously between treatments. Each daily therapy session of MLD lasted 3 to 4 hours. Between therapy sessions the patient was also instructed to wear tight briefs or an athletic supporter continuously. After several days of therapy the genital lymphedema and pain improved considerably, and after 2 weeks of treatment it had resolved completely. The patient was able to return to normal activities of daily living without sequelae. He was instructed to continue to wear tight supportive undergarments at home for 2 weeks. At 3 months postoperatively he was doing well, with no residual genital edema, and with excellent urinary control and an undetectable serum prostate specific antigen. DISCUSSION

The pediatric urological involvement of Crohn's disease is not widely appreciated. We report a case of prolonged genital edema in a child with Crohn's disease who presented with genital edema prior to the diagnosis of Crohn's.

Edema confined to the genitalia is a common occurrence with intrascrotal or penile pathology. It is less commonly secondary to local pelvic pathology, primary scrotal lymphed- ema or idiopathic scrotal edema. Rarely, systemic diseases such as Henoch-Schonlein purpura may cause genital edema. We report a case of Crohn's disease with associated genital edema. CASE REPORT A 36-year-old man was referred with a 1-year history of painless genital edema. The patient denied any constitu- tional symptoms, previous urological abnormalities or changes in bowel habits. Three years previously he had been assessed by a general surgeon for an anal fistula with a small bowel follow-through and colonoscopy, both of which were normal. The fistula was attributed to trauma caused by an indwelling rectal thermometer that had been placed during a university experiment investigating cold tank induced hypo- thermia. Physical examination revealed a healthy man with genital edema (fig. 1). Routine blood and urine investigations and testing for sexually transmitted diseases were negative. Cys- tourethroscopy was unremarkable. Abdominopelvic comput- erized tomography revealed a thickened segment of terminal ileum. Scrotal skin biopsy showed multiple noncaseating ep- ithelioid granulomas in the dermis (fig. 2, A). Ziehl-Neelsen stain, silver stain and periodic acid-Schiff with diastase stain were negative for organisms. A diagnosis of metastatic Crohn's disease of the genitalia was made. Subsequent ileal biopsy demonstrated noncaseating ulceration with poorly de- fined granulomas (fig. 2, B), confirming the clinical diagnosis of Crohn's disease. The patient was started on prednisone 60 mg. daily, tapered during 4 months, with no improvement in the edema.

Genital edema was seen as a complication of continuous ambulatory peritoneal dialysis (CAPD) in 18 patients, who accounted for 4 per cent of all patients on CAPD. In the majority of patients, the swelling developed suddenly and painlessly in the scrotum, penis or labia majora. Some of the patients noticed ultrafiltration failure. In the majority of these patients, this was a result of fluid leakage through the patent processus vaginalis. In one female patient, fluid leaked through the implantation site of the catheter. A computed tomographic scan using contrast media is a useful diagnostic tool in identifying the side of the defect in patients with generalized scrotal or penile edema. Surgical repair of the hernia and the hole in the processus vaginalis or hernia sac prevented recurrence. A trial of temporary discontinuation of CAPD or intermittent peritoneal dialysis using small volumes of dialysis fluid prevented recurrence while reinstituting CAPD in patients with normal findings from contrast studies. Intermittent peritoneal dialysis using low volumes of dialysis fluid with stepwise increase prevented recurrence while reinstituting CAPD two to three weeks after surgical repair.

Treatment morbidity associated with definitive radiotherapy is analyzed in a group of 267 patients treated between 1967 and 1978. Minimum follow-up is 2 years, median is 4 years. The majority (82%) of the patients were treated with 22 MV photon beam to a pelvic dose of approximately 5000 rad followed by a boost to gradually reduced fields to a total of 6500–7000 rad to the prostate. The most frequent complications were urethral stricture (5.2% of the patients), proctitis (4.5%), bladder injuries (3.4%) and leg edema (3.0%). The incidence of radiation-induced complications did not correlate with the total dose, previous transurethral resection or patients' age. Pelvic lymphadenectomy was associated with a 25% incidence of leg and genital edema. Small bowel obstruction developed in 2 of 3 patients who had transperitoneal laparotomy prior to treatment. Symptoms secondary to bladder and rectal injuries were reversible in over 50% of patients within the first year after the onset.

Localized genital edema occurred in 8 of 81 patients (10 per cent) undergoing continuous ambulatory peritoneal dialysis. Underlying causes included defects in the inguinal canal and noninguinal peritoneal leaks that were localized with clinical, radiographic and scintigraphic techniques. Management included temporary cessation of continuous ambulatory peritoneal dialysis exchanges in half of the patients, particularly those with recently inserted catheters. Surgical repair was recommended in all cases when inguinal defects were identified. Edema resolved permanently in 6 patients and all patients were able to remain on continuous ambulatory peritoneal dialysis.

Severe genital edema is a well-described complication of continuous ambulatory peritoneal dialysis (CAPD). Leakage of dialysate fluid from defects in the peritoneum may occur from clinically detectabl

ResumenEl tratamiento del linfedema genital ha sido abordado generalmente por la cirugía plástica y reconstructiva.La intención de este trabajo es presentar una técnica alternativa para el tratamiento del linfedema peneano con un abordaje urológico con intención funcional y estética.Se trata de un paciente masculino con antecedente de tumor testicular izquierdo, orquiectomía radical izquierda, radioterapia inguinoescrotal, linfedema peniano y escrotal secundario y reservorio linfático inguinal izquierdo. Presenta deformación importante del pene, dificultad miccional y balanopostitis de repetición, se decide realizar la resección del linfedema peniano y la reconstrucción correspondiente.No se reportaron complicaciones durante ni posteriores al procedimiento y se observó una buena cicatrización y disminución del linfedema peniano.Existen distintos tratamientos tanto conservadores como quirúrgicos con resultados variables.Resulta importante el manejo de estas técnicas por parte de los urólogos, buscando un abordaje integral junto con otros especialistas para el mayor beneficio del paciente y mejores resultados.AbstractGenital lymphedema has generally been treated through plastic and reconstructive surgery.The aim of this article was to present an alternative technique for the functional and esthetic treatment of penile lymphedema with a urologic approach.A male patient had a past history of left testicular tumor, left radical orchiectomy, inguinoscrotal radiotherapy, secondary penile and scrotal lymphedema, and a left inguinal reservoir to palliate the scrotal lymphedema. He presented with an important deformation of the penis, micturition difficulty, and repeat balanoposthitis and so the decision was made to perform resection of the penile lymphedema and the corresponding reconstruction.There were no complications during or after the procedure and good cicatrization and reduced penile lymphedema were observed.The different conservative as well as surgical treatments that exist offer variable results. The management of these techniques is important for the urologist so that an integrated approach with other specialists can be carried out that will provide the patient with the best results.

Eighteen patients with complications secondary to continuous ambulatory peritoneal dialysis underwent peritoneal scintigraphy utilizing Technetium-99m sulfur colloid. Patients were divided into three groups. Group 1 patients (11) had dialysate leaks leading to abdominal-wall edema, genital edema, or exit-site drainage. Scintigrams were abnormal in nine patients in this group and frequently provided localizing information that aided in the management of leaks. Group 2 patients (five) had recurrent peritonitis. Two of these patients had abnormal scintigrams. In one instance, scintigraphy detected multiple abdominal-wall hernias that may have been responsible for recurrent peritonitis, which resolved following corrective surgery. Group 3 patients (two) had inadequate ultrafiltration but no clinical evidence of a dialysate leak. Scintigrams were negative in this group, eliminating consideration of an underlying structural defect in the peritoneum. Scintigraphic imaging is possible for several hours following instillation of labeled dialysate. This capability is important, since scintigrams that were initially negative frequently became positive after several hours of ambulation. Postdrainage images were also helpful in confirming extraperitoneal leakage. This study demonstrates that peritoneal scintigraphy is a useful diagnostic tool in the management of complications of continuous ambulatory peritoneal dialysis.

Two patients who developed massive genital edema while on CAPD were investigated by peritoneal scintigraphy with Tc99m-glucoheptonate. In one the genital swelling was due to an umbilical hernia and in the other it was due to an abdominal-wall hernia. After the hernia was repaired CAPD could be continued. We recommend peritoneal scintigraphy as a technique for the investigaiton of leakage of peritoneal fluid in patients undergoing CAPD. Recently genital swelling has been described as a complication of CAPD (I, 2). In one patient an isotope technique demonstrated an open processus vaginalis (1), and in four patients (2) scrotal or labial edema was due to an inguinal hernia. This communication describes two patients with genital edema which was due to an umbilical hernia in one, and to an abdominal wall hernia in the other.

In a patient on continuous ambulatory peritoneal dialysis with localized abdominal and genital edema, the site of extraperitoneal dialysate leakage was determined by computerized tomographic scanning with intraperitoneal contrast enhancement. No adverse effects were encountered. The source of fluid leakage should be sought in CAPD patients with localized (i.e. genital) edema, because often they may have an undetected hernia or other peritoneal defect. Removal of the peritoneal dialysis catheter would not solve such a problem. In such cases, intraperitoneal contrast-enhanced CT scanning may represent an effective technique for identifying the site of dialysate leakage. Abdominal and inguinal hernias are well-recognized complications of con tinuous ambulatory peritoneal dialysis (CAPD). Dialysate may escape from the peritoneal space through such hernias; also the development of genital edema in a CAPD patient may indicate the presence of an inguinal hernia, which otherwise may be impossible to detect clinically (I). In CAPD patients who have had multiple abdominal operations, there may be numerous possible sites of hemia development and dialysate leakage, so that it may prove difficult to identify and repair the defect. We describe a patient in whom contrast-enhanced computerized tomographic scanning was used to identify the site of extraperitoneal dialysate leakage.

The two patients in this case series had experienced long-term difficulty controlling lymphedema at home. Both patients had used numerous home therapies, including older-generation intermittent pneumatic compression devices, without success. The Flexitouch® system, an advanced pneumatic device, was prescribed to assist them with in-home efforts by providing therapy to their affected limbs in addition to the lower trunk area for the patient with lymphedema of the lower extremity; and the trunk, chest wall, and shoulder areas for the patient with lymphedema of the upper extremity. Both patients achieved successful home maintenance of lymphedema, as judged by limb volume, clinical observations, and subjective patient impressions, after incorporating the Flexitouch® system. Neither patient experienced the deleterious effects (worsening genital edema; fibrotic cuff development) that they had experienced with the older-generation intermittent pneumatic compression devices they had previously used. Incorporating the Flexitouch® system as part of maintenance may improve success for lymphedema patients who have previously struggled with in-home management.