Giant scrotal elephantiasis secondary to long-standing scrotal hidradenitis suppurativa: a case report

Background: Scrotal elephantiasis, an advanced, irreversible form of chronic lymphedema, is an uncommon but serious side effect of long-term hidradenitis suppurativa (HS). Recurrent infections, inflammation, and advancing fibrosis risk lymphatic blockage, marked functional compromise, and significant reconstructive challenges. Case presentation: We report the case of a 48-year-old man who developed significant scrotal elephantiasis after 9 years of severe HS (Hurley stage II–III) with recurrent abscesses, fistulae, and an unclear diagnosis that confounded his clinical course. Imaging revealed lymphatic congestion and widespread thickening of the scrotal wall without active infection. Early histopathologic findings of non-necrotizing granulomatous inflammation prompted consideration of alternative diagnoses; however, a comprehensive workup excluded systemic granulomatous illnesses. The final course of treatment involved release of the buried penis, extensive local excision of diseased scrotal tissue while preserving both testes, and regional flap reconstruction using posterior scrotal skin. Postoperatively, the patient reported improved quality of life and satisfaction with the surgical outcome. Discussion: Diagnostic challenges may arise when granulomatous changes in HS mimic systemic granulomatous disorders. In advanced HS cases, medical therapy alone is often insufficient, with definitive management requiring radical excision and reconstruction. Early recognition of HS-associated lymphedema and avoidance of potentially aggravating local therapies are critical to prevent irreversible morbidity. Conclusion: Although rare, HS itself should be considered as a possible cause of scrotal elephantiasis in a patient with genital HS. Early detection, avoidance of potentially exacerbating local therapies, and a multidisciplinary approach combining definitive surgical excision, reconstruction, and biologic therapy are essential for achieving optimal functional outcomes.