Filarial Hydrocele

What is Filarial Hydrocele?

Hydrocele is a condition that causes a painless swelling in the scrotum, usually in adult men, due to buildup of fluid in a layer of the scrotum known as the tunica vaginalis. Chronic hydrocele, a long-lasting form of this condition, can have various causes, including testicular cancer or a filarial infection. This condition is particularly common in areas where filariasis, a parasitic disease spread by mosquitoes, is common. The disease-causing agent is typically a parasite called Wuchereria bancrofti.

When filariasis causes hydrocele, it’s known as filarial hydrocele, a condition that usually shows up as a chronic and late symptom of the disease. It’s estimated that in areas where filariasis is endemic, or commonly found, more than 40 million people suffer from chronic, physically-altering symptoms of filariasis. This includes over 27 million men with filarial hydroceles, lymph scrotum (also known as chylocele) or elephantiasis of the scrotum. These genital conditions often manifest as hydrocele, resulting from a blockage or malfunction of the lymphatic vessels – the network of tubes that help maintain fluid levels in the body.

Filarial hydrocele can be not only physically disabling, but also has significant economic impact due to the large number of adult males affected in the tropical and subtropical regions where the disease is common.

What Causes Filarial Hydrocele?

Lymphatic filariasis is a disease caused by three types of parasitic worms, namely Wuchereria bancrofti, Brugia malayi, and B. timori. However, Wuchereria bancrofti is most frequently linked to the long-term condition known as hydrocele.

In our bodies, these worms (both male and female) live in the lymph nodes. After they mate, the worms produce numerous smaller worms called microfilariae. These small worms move around the body from the lymph system to the blood vessels.

When a female mosquito of the species Culex, Aedes, or Anopheles (depending on where in the world it lives) bites an infected person, it drinks up the blood – along with some of these microfilariae. In about 10 to 12 days, these larvae grow and change inside the mosquito to become more active and infectious. These larvae then move and gather in the mosquito’s proboscis – the long tube it uses to feed.

The next time the mosquito bites a person, the mosquito deposits the larvae into the bite. From there, they enter the bloodstream, and eventually, travel to the lymph vessels and lymph nodes, where they grow into adult worms.

Sometimes, some of these adult worms end up in the lymph vessels in the scrotum, causing conditions like acute filarial lymphangitis, lymphangiectasia, and acute hydrocele. These may cause temporary symptoms like pain or lumps. However, repeated inflammation over time can lead to chronic hydrocele. So, many men with lymphatic filariasis eventually experience symptoms of hydroceles.

Risk Factors and Frequency for Filarial Hydrocele

Non-communicating hydrocele, a condition often related to the tropical infection lymphatic filariasis, is rare in the United States. It is most often seen in immigrants or those who have travelled to places where the infection is more common. The main cause of this infection is a mosquito-borne parasite called Wuchereria bancrofti. It’s especially prevalent in low and middle-income tropical regions.

This condition affects both men and women. However, only men can develop a non-communicating hydrocele because the parasite often resides in the lymphatic system of the spermatic cord. This causes scrotal nodules, leading over 50% of infected men to develop chronic hydrocele over time. It’s most prevalent in male adults aged 20 and above who live in over 70 tropical and subtropical countries across Africa, Asia, the Caribbean, Pacific, and South America. More than 27 million men in these regions are estimated to be affected.

It’s been observed that around 5% of men with scrotal nodules will develop a hydrocele that may persist for 18 months or longer. Notably, an Egyptian study found that, from 16 men infected with the parasite, 14 had detectable fluid in their scrotal sac even after treatment. Of these, at least three developed the chronic form of hydrocele.

Few studies indicate that, following mass drug administration for filariasis management, individuals may develop conditions like lymphedema and/or hydrocele. However, other studies don’t establish such associations. Moreover, there’s an underestimation of true hydrocele prevalence and associated disability from surveys due to personal modesty issues. People with minor hydroceles often ignore their symptoms, especially during survey data collection. Therefore, the reported incidence based on clinical examination may not accurately represent the disease’s actual extent.

Signs and Symptoms of Filarial Hydrocele

When a patient potentially has filarial hydrocele (a condition where the scrotum swells due to fluid), it’s important for them to provide a detailed personal history and undergo a thorough physical examination. Key questions will focus on where the patient has lived, as well as any travel history, since this condition often develops due to an infection during early life. Without the right treatment, filarial hydrocele can drastically affect a person’s daily life, including their sexual function, physical abilities, work productivity, and emotional well-being.

There are two types of filarial hydroceles: acute and chronic. An acute hydrocele is indicated by painful lumps in the scrotum, which may or may not be accompanied by an enlarged scrotal sac due to fluid build-up. The lumps are believed to be caused by the death of the adult filarial worms and the resulting inflammatory response. This sometimes happens after medical treatment for filariasis.

The chronic form of this condition primarily manifests as painless swelling in one or both sides of the scrotum. The size of the swelling can vary significantly. Some people may find the swollen scrotum uncomfortable due to its weighty feel. In the majority of cases, patients recall having filariasis years ago and experiencing some episodes of painful lumps in the scrotal area, which resolved on their own within a week.

If severe inflammation of the lymph vessels occurs, pain may be experienced. On physical examination, the genitals may reveal variously sized hydroceles. Some can be significantly large and alter the normal appearance of the area. Other signs could include a thickened spermatic cord and numerous firm lumps in the epididymis. In chronic cases, calcification (hardening due to calcium deposits) may occur, and this can be felt during physical examination or seen in imaging studies.

Testing for Filarial Hydrocele

When assessing a condition known as filarial hydrocele, which is a swelling in the scrotum due to infection with a parasite, several tests are typically performed. These often include a complete blood count to check for a high number of a specific type of white blood cell called eosinophils, which might signal an active filariasis infection (which is caused by parasitic worms). A peripheral blood examination may also be done to look for the parasites in the blood. However, by the time a chronic hydrocele has developed, the active infection usually isn’t present any longer.

Urine tests can be helpful for detecting signs of the disease including chyluria (fat droplets in urine), proteinuria (excess protein in urine), or hematuria (presence of blood in urine). In some rare cases, parasites may be detected in urine samples. These are common for patients with filarial hydrocele.

The most sensitive method to diagnose lymphatic filariasis, a major cause of filarial hydrocele, involves detecting certain proteins (circulating filarial antigens or CFA) of W. bancrofti DNA in the blood using laboratory tests like ELISA immunoassay. There are also rapid field tests available in some locations.

Another test using a fine needle to sample fluid from the hydrocele may also be used, as parasites or even adult worms might be identified from the fluid.

Different blood tests can also be done to check for increased levels of proteins produced by the immune system (immunoglobulins) and compounds that signal inflammation in the body (interleukins). These can help determine the body’s response to the parasite infection. It’s also now possible to detect circulating filarial antibodies against W. bancrofti antigens in the blood by using newly developed lab testing techniques. Since some people could carry the infection without showing symptoms, these tests can be particularly useful in diagnosing and treating patients.

For imaging studies, ultrasound (US) is commonly used. It’s helpful in detecting even small amounts of fluid collection in the tunica vaginalis, which is the lining of the testicle. It can also help visualize blockages in the lymphatic system. Ultrasound examinations are used to see the scrotal lymph vessels, testes size and shape, epididymis for lumps, spermatic cord for lumpiness, and layers of the tunica vaginalis for any fluid. More so, ultrasounds can detect moving adult worms in the lymphatic vessels, termed the “filarial dance sign”. This imaging method is also used to monitor the effectiveness of treatment.

Treatment Options for Filarial Hydrocele

The World Health Organization (WHO) initiated a program in 2000 to eliminate lymphatic filariasis, a kind of parasitic infection. Part of this plan involved using mass medication programs in places where the disease is common, administering a combination of specific medicines. Some additional medicines have been used in certain countries as well. This medical treatment is most effective if the infection is detected early, and helps reduce the spread of the disease. However, if patients have already developed a kind of swelling called filarial hydrocele, medications alone may not be completely effective. In these cases, surgical treatment is usually necessary. In fact, taking medications can sometimes lead to developing hydrocele. Yet, certain antibiotics have been found to help manage the symptoms of filarial hydrocele by eliminating some of the worms causing the disease, particularly if used in the early stages of hydrocele development.

Surgery is the primary treatment for filarial hydroceles. However, there are not many standardized guidelines on how to manage such surgeries. This includes uncertainty on the antibiotics to use, surgical approaches, dressings, and overall care throughout the surgical process. The aim of these surgeries is to remove the hydrocele and prevent it from recurring. The surgery may be challenging due to potential scarring and structural changes. During the surgery, the surgeons strive to remove or repair damaged lymph vessels if feasible.

There are several different surgical methods available to treat hydrocele. The exact procedure depends on patient’s specific condition, the severity of the hydrocele, and if there are any long-term complications such as scarring. For example, some surgeries may involve reshaping the scrotum, removing a portion of the skin, and in some cases, reconstructing the penis if it’s affected. There may be a need for reconstruction surgery when the skin of the scrotum is thickened or oozing a lymphatic fluid known as “lymph scrotum.” In rare instances, if there is testicular damage, surgical removal of the testicle might be required.

In a basic surgical procedure, an incision is made in the scrotum, the hydrocele fluid is drained, and then part of the tissue is removed. After ensuring there’s no damage to the testicle and stopping any possible bleeding, the wound is stitched closed. Depending on the condition of the testicle and other tissues, other procedures might be necessary, including possible reconstruction. The type of surgery chosen may depend on many factors, including the severity and size of the hydrocele, and the surgeon’s comfort and experience with the procedure.

The hydrocele sac, or the fluid-filled swelling, can be wholly or partially removed during surgery. Complete removal usually leads to better results, reducing the chances of the hydrocele recurring and post-surgery infections or complications. In surgeries where abnormal channels (lymph fistulae) are found contributing to the hydrocele, removing the whole sac and these channels leads to better outcomes. Regular training for the surgical teams helps improve these outcomes further.

Access to good surgical care is critical for patients with filarial hydroceles. Without it, some patients may resort to improper ways of draining their hydroceles, which could lead to infections and damage to the testicles. Successful surgical repair helps patients return to healthy lives, enhance their sexual function, and improve their chances of finding employment. Some studies found the overall benefits of surgery far outweigh the costs. However, potential complications after surgery could include blood accumulation (hematoma), infection, poor wound healing, and recurrence of the original hydrocele.

What else can Filarial Hydrocele be?

When investigating the cause of an enlarged scrotum or a mass in the scrotum, doctors need to rule out several conditions that could be causing it. They do this by taking a thorough medical history of the patient, conducting a physical exam, and using an ultrasound as needed. Here are some common conditions that they may need to rule out:

• Non-infectious hydrocele (a fluid-filled sac around a testicle)
• Inguinal hernia (when a part of the intestine or fat pushes through a weak spot in the abdominal wall)
• Spermatocele (a cyst in the epididymis that’s filled with sperm)
• Varicocele (an enlargement of veins in the scrotum)
• Epididymal cyst (a cyst on the tube that carries sperm from the testicle)
• Testicular tumors
• Appendix testis (a small pouch of skin present at birth and located on the upper or lower pole of the testis)

In addition, they should also consider the possibility of idiopathic scrotal edema, which is unexplained swelling in the scrotum. For instances where the enlarged scrotum is also causing pain, physicians will also need to consider conditions like testicular torsion (when a testicle becomes twisted), and infections such as epididymo-orchitis or orchitis, both of which can cause inflammation in the testicle.

What to expect with Filarial Hydrocele

Filarial hydrocele, as covered in earlier sections, can have a severe impact on a person’s mental and social health. Without treatment, the condition generally worsens with time, affecting various parts of a patient’s life. If a long-term (chronic) hydrocele forms and no treatment is provided, a person can face physical, social, psychological, and financial difficulties.

Men with chronic hydrocele often struggle with sexual issues and physical disabilities due to the growth and disfiguration caused by the hydrocele. If it’s left untreated, the hydrocele can pose a risk of infection if the skin of the scrotum breaks down and ulcers appear. Conditions like lymph scrotum can lead to discharge, which in turn can cause frequent infections. These multiple infections can eventually lead to a condition called scrotal elephantiasis and long-term inflammation of the inguinal glands—the glands in the groin area.

Men affected by this condition may isolate themselves socially due to the pain, physical disability, and mobility limitations. Participating in family and community activities or performing physical labor can become more difficult. The increasing size of the hydrocele can make simple tasks like lifting and carrying items, walking, and standing difficult. Along with the financial strain, this disease can also decrease the chances of marriage and often leads to poor sexual functioning.

Possible Complications When Diagnosed with Filarial Hydrocele

If filarial hydrocele, a condition resulting from a certain type of parasitic infection, is not treated, complications could occur. These might involve fertility issues, heightened risk of infection, scrotum skin damage leading to ulcers, physical disability and lower mobility. The affected individuals might rely more on others for personal care and they could also lose chances of employment or actual jobs. The condition could make them face social stigma and negatively affect their mental health.

Furthermore, several issues related to male reproductive and urinary systems can arise, such as inflammation in the penis, scrotum, groin lymph nodes and it can also cause scrotal elephantiasis, a severe condition where the scrotum becomes extremely enlarged. Lower leg swelling, also known as lower extremity lymphedema, is another complication of filarial infection and it can be observed in those with filarial hydrocele as well.

Potential complications:

• Infertility
• Increased risk of infection
• Scrotum skin leading to ulcers
• Physical disability
• Decreased mobility
• Greater dependency for self-care
• Loss of employment opportunities and loss of work
• Social stigma
• Negative impact on mental health
• Inflammation of the penis, scrotum, and groin lymph nodes
• Scrotal elephantiasis
• Lower leg swelling (lower extremity lymphedema)

Preventing Filarial Hydrocele

Programs designed to control mosquitos, along with plans like WASH (which stands for water, sanitation, and hygiene), have been effective in certain areas where illnesses caused by mosquitos are common. These programs are usually supervised by global health organizations, such as the World Health Organization (WHO). They aim to decrease the spread of mosquito-borne diseases and eliminate infections caused by filaria, a type of parasite that’s spread by mosquitos. They’ve made a lot of progress in reaching these goals.

Public health education programs can also be helpful. By teaching residents about how infections spread and the importance of good hygiene, we can improve the health outcomes in these regions. It’s also beneficial to teach patients and the community about these diseases to remove any associated stigma. If people are aware and understand the disease, they will seek treatment sooner and reduce the overall health impact caused by filarial hydrocele, a condition caused by filarial infection where the scrotum swells due to fluid accumulation.