Filarial Hydrocele - Causes, Symptoms, Diagnosis, and Treatment

What Is a Filarial Hydrocele?

Filarial hydrocele is a scrotal enlargement caused by a parasitic infection with Wuchereria bancrofti, found in tropical places worldwide. Males who are impacted by this ailment suffer from physical and mental suffering due to the condition's influence on their fertility, mobility, and even their ability to earn a living. Even though hydrocele is often a painless mass, it can cause psychological difficulties that result in sexual dysfunction and infertility.

How Is Filarial Hydrocele Caused?

The adult worms of Wuchereria bancrofti are the causative organisms that demonstrate a preference for the intrascrotal lymphatic vessels, and obstruction of the lymphatic vessels can result in a fluid collection within the tunica vaginalis of the scrotal cavity. In endemic places, hydrocele is the most prevalent sign of chronic W. bancrofti infection in males, and it is also the most serious. Fluid collections along the canal of Nuck can similarly form in females.

In Which Population Is Filarial Hydrocele Seen?

• Regional Estimates: Bancroftian filariasis is a parasitic disease that is seen in tropical places all over the world. Immigration from these locations may bring the condition to the United States, and military personnel returning from extended deployments in these regions have been documented to be infected. According to the World Health Organization, more than 1.3 billion people in 83 countries and territories are contracting microfilaria. W.bancrofti is responsible for more than 90 percent of the projected 120 million infections, with hydrocele accounting for 26.79 million of those cases. With more than 550 million individuals at risk of contracting this disease, India bears the heaviest burden of the disease.

• Race: There has been no evidence of a racial predisposition to filarial infection.

• Sex: According to the World Health Organization report, the prevalence of filarial infection varies by location, probably due to differences in cultural or employment patterns that result in exposure to mosquito vector species.

• Age: Microfilarial infection is widespread and can affect people of all ages. The prevalence of lymphatic filariasis and its associated symptoms and acute presentations increase with age. The majority of filarial hydrocele rises with age, as does the risk of developing it.

How Does Filariasis Spread?

Mosquito bites are the primary cause of the transmission and spread of filariasis. When a mosquito bites a person with filariasis, the filarial worms in the person's blood infect the mosquito, spreading the disease to other people. When the infected mosquito bites another person, the worms are carried into the other person's bloodstream by the insect. The lymphatic system is where these worms migrate after entering the bloodstream. There, they develop into fully grown worms. Adult worms can survive for up to seven years in their natural environment. Millions of filarial worms are released into your bloodstream as a result of the filarial worms' reproduction.

What Are the Symptoms of Filarial Hydrocele?

• Many people who have filarial infections suffer from fever as a result of their immune system's response.

• Experiential fever coupled with lymphangitis, lymphadenitis, and funicular epididymitis (inflammation of the spermatic cord and epididymis).

• Transitory edema and tiny hydroceles are observed in patients.

• A fever and a purulent response (discharge of pus) are common symptoms of secondary infections.

• Lymphedema is the defining feature of the disease.

• It is possible for patients in the prepatent period (50 to 150 days) to develop acute lymphedema of the scrotum, which will resolve on its own or with medical treatment.

• The lymphatic tissues of these patients exhibit the regular alterations associated with filarial infection. However, adult worms are rarely seen in the lymphatic tissues.

• On the other hand, patients with established infections acquire irreversible lymphatic scarring, which leads to increasing lymphedema over time. The genitalia, as well as the lower extremities, are the most usually affected sites.

How Is Filarial Hydrocele Diagnosed?

The diagnostic laboratory tests for detecting hydrocele are as follows:

• Complete Blood Cell Count (CBC): Patients with filarial infection usually exhibit significant eosinophilia (having higher amounts of eosinophils).

• Serum Immunoglobulins: Elevated serum levels of immunoglobulins are reported with microfilarial infection.

• Enzyme-Linked Immunoassay (ELISA): Og4C3 monoclonal antibody-based ELISA gives a quantitative measure of circulating filarial antigen (CFA).

• Immunochromatographic Testing (ICT): Dipstick testing of whole blood with ICT cards, which utilize monoclonal antibody is a qualitative test for circulating filarial antigen (CFA) that is frequently used in the field as a screening test for lymphatic filariasis.

• Hydrocele Fluid Examination: CFA (circulating filarial antigen) may be discovered in hydrocele fluid, and microfilariae may be found in cytology.

• Urine Examination: Chyluria (a rare condition in which lymphatic fluid leaks into the kidneys and turns the urine milky white) may be found macroscopically, and microfilariae may be detected via microscopic analysis of voided urine; proteinuria and hematuria may also be noticed with microfilariae infection with renal involvement.

• Peripheral Blood Examination: Infections with microfilariae can be detected through microscopic examination of peripheral blood; microfilariae have a circadian pattern that differs depending on the endemic region, necessitating serum sampling that coincides with periods of activity; activity can be induced with the administration of Diethylcarbamazine citrate (DEC).

How Is Lymphatic Filarial Hydrocele Treated?

1. Medical Therapy:

The medical therapy includes treatment through drugs like Diethylcarbamazine [DEC], Albendazole, or Ivermectin plus Albendazole.

• Diethylcarbamazine - DEC (diethylcarbamazine) is effective against both microfilariae and adult worms, and it is often regarded as the medication of choice in this situation. It removes microfilariae from the bloodstream, lowers the chance for mosquito-borne transmission of the parasite, and reverses filarial-associated hematuria and proteinuria. DEC (diethylcarbamazine) does not repair existing lymphatic damage and does not alter the course of pathology in patients who have already been diagnosed with a chronic condition. Patients should be checked for the existence of the parasite every 6 to 12 months, and those who test positive should be re-treated if the results are positive. When treating mature worms, DEC (diethylcarbamazine) is only partially effective; thus, ultrasonography of the scrotum should be done one month following treatment; the existence of any residual worms is an indication for re-treatment.

• Ivermectin: Ivermectin is modern anti-parasitic medicine that has fewer side effects than older anti-parasitic drugs. Receiving a single oral dose of 20 to 25 mcg/kg of body weight is efficient for microfilaricide, according to the research. It is inexpensive, requires only a single oral dose, and has few side effects, making it the medicine of choice for early filarial infection. On the other hand, Ivermectin has no impact on adult filarial worms.

2. Surgical Therapy:

Many surgical methods have been developed to remove the edematous tissue in patients suffering from genital lymphedema.

• Antibiotics should be started the night before surgery and continued for five days after completion.

• It is recommended that analgesics in nonsteroidal anti-inflammatory medicines (NSAIDs) or oral Acetaminophen be taken as needed.

• Because of scarring and fibrosis, filarial hydroceles are more difficult to excise surgically than idiopathic hydroceles, making surgical excision more challenging. The most efficient method is to remove the hydrocele while leaving the sac intact. However, this is not possible in some circumstances, and a partial excision and eversion of the sac margins behind the testis are sufficient procedures.

• Filarial hydrocele is treated with surgery, which is the preferred approach. The following are some of the reasons to have hydrocele surgery:

  • Ineligibility for medical treatment due to untreated hydroceles.

  • Interference with one's occupation.

  • Interference with the performance of the sexual function.

  • The patient's family suffers as a result of this.

  • Lingering discomfort and pain.

  • Post-operative care is provided following surgery. Most of the patients will be able to return home the same day. Patients who have excessive swelling, pain, seeping from the site, or those who have had a drain implanted, should be monitored for 24 to 48 hours after the procedure. Patients should return for a follow-up visit within seven to ten days of their initial appointment.

What Strategies Are Developed to Contain Filarial Hydrocele?

The World Health Assembly (WHA) passed a resolution in 1997 which called for the establishment of lymphatic filariasis–elimination strategies by the governments of countries with endemic populations. Within three years of its launch, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) had successfully implemented mass drug administration of two-drug regimens (Diethylcarbamazine [DEC] plus Albendazole or Ivermectin plus Albendazole) or administration of DEC-fortified salt in 60 countries around the world. Because of the initiative, 6.2 billion doses of medicine have been sent to 1 billion people since its commencement in the year 2000.

What Are the Possible Side Effects of Anti-Parasitic Drugs?

Anti-parasitic drugs have the potential to inflict side effects. Some of these adverse effects are as follows:

• Dizziness.

• Fever.

• Headache.

• Pain in the muscles or joints.

• Nausea.

What Are the Complications of Filarial Hydrocele?

Because of the lymphedema and chronic scarring associated with filariasis, wound healing is slower and more complex in these patients. Patients who require scrotal or penile skin removal and grafting are at a higher risk of graft failure than the general population. In addition, wound infections are common in these patients.

How to Prevent and Control the Spread of Disease?

Avoiding mosquito bites is the most effective method of preventing lymphatic filariasis. It is usually between the hours of dark and dawn that the mosquitoes that carry the microscopic worms bite people. If you reside in a region where lymphatic filariasis is prevalent, you should take the following precautions:

• At night, either sleep in an air-conditioned room or sleep with a mosquito net.

• Between the hours of dusk and dawn, dress in long-sleeved shirts and pants.

• Apply mosquito repellent to exposed skin to keep mosquitoes away.

• Another prevention method involves distributing medicine to entire communities that kill microscopic worms and suppress mosquito populations. Annual mass therapy reduces the level of microfilariae in the blood, reducing the spread of the infection to other people.

Conclusion:

Within 10 to 15 years after visible clinical symptoms, established filarial lymphedema progresses and takes on a more steady course. No medical treatment effectively reverses this condition; consequently, early detection and treatment are of the utmost significance. Consult your doctor or reach out to icliniq if you have any concerns regarding this filarial hydrocele.