eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Hydrocele, Filarial: Treatment

Author: Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Coauthor(s): Joe Miller, MD, Staff Physician, Division of Urology, Southern Illinois University Affiliated Hospitals; Rizk El-Galley, MD, Director of Clinical Research, Assistant Professor, Department of Surgery, Division of Urology, University of Alabama
Contributor Information and Disclosures

Updated: Jul 2, 2009

Treatment

Medical Therapy

In 1997, the World Health Assembly (WHA) passed a resolution calling for the initiation of lymphatic filariasis–elimination programs by the governments of endemic areas. By 2005, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) had reached nearly 50% of the at-risk world population with mass drug administration of the 2-drug regimens (DEC plus albendazole or ivermectin plus albendazole) or administration of DEC-fortified salt. Epidemiological studies indicate that several countries have demonstrated a near-total absence of transmissions as a result of mass drug administration. Programs aimed at alleviating and preventing disability from lymphatic filariasis are also underway.

Subclinical cases should be treated to prevent lymphatic damage because most patients develop full clinical disease. Young adults in endemic areas should be screened for the presence of the parasite and treated if test results are positive.

  • DEC is effective against both microfilariae and adult worms and is considered the drug of choice. It clears the blood of microfilariae, reduces the opportunity for mosquito-borne transmission of the parasite, and reverses filarial-associated hematuria and proteinuria.
    • DEC does not reverse existing lymphatic damage and does not change the course of pathology in patients with established disease. Patients should be tested every 6-12 months for the presence of the parasite, and patients whose test results are positive should be re-treated.
    • DEC is only partially effective against adult worms; therefore, ultrasonography of the scrotum 1 month after treatment shows any residual worms, which is an indication for re-treatment.
    • Recommended schedules are 6 mg/kg/d for a total of 72 mg/kg for W bancrofti infection and 4 mg/kg/d for a total of 60 mg/kg for infection with B malayi.
    • DEC causes allergic reactions (Mazzotti reactions), especially in patients with high microfilarial counts. Headache, fever, nausea, vomiting, local pain, and swelling over lymph nodes and along lymphatic vessels have been reported. Therefore, patients with heavy infection should start with low doses (3 mg/kg body weight/d) and gradually increase the dose.
  • Ivermectin is a newer antiparasitic drug that causes fewer adverse effects. It has proven to be an effective microfilaricide after a single oral dose of 20-25 mcg/kg of body weight. Because of its low cost, single oral dose, and few adverse effects, it is becoming the drug of choice for early filarial infection. However, ivermectin does not affect adult filarial worms.
  • Foot care and skin care are essential in patients with lymphedema. Patients should be encouraged to use antiseptic soap to clean their skin daily. Early infections should be treated vigorously.

Surgical Therapy

Various surgical procedures have been developed to remove the edematous tissue in patients with genital elephantiasis. The principles of these operations follow general plastic-surgery principles.

  • The penile and scrotal skin and subcutaneous tissues can be excised and reconstructed using a partial-thickness graft from normal skin in the upper part of the body without lymphedema. Unmeshed grafts yield a better cosmetic appearance to the penis, while meshed grafts are preferred for scrotal reconstruction. In females, split-thickness grafts can be used to reconstruct the vulva and the perineal skin.
  • Filarial hydroceles are more difficult to excise surgically than idiopathic hydroceles because of scarring and fibrosis. The ideal procedure is to excise the hydrocele completely with an intact sac. In some cases, this is impossible, and partial excision and eversion of sac edges behind the testis is sufficient.

Preoperative Details

Antibiotics should be initiated the night prior to surgery and continue for a total of 5 days. Analgesics in the form of nonsteroidal anti-inflammatory drugs or oral acetaminophen should be administered as appropriate.

Postoperative Details

Standard postoperative care applies. Most patients may be discharged home the same day. Patients with undue swelling, pain, or oozing from the wound or those in whom a drain has been placed should be observed for 24-48 hours.

Follow-up

Patients should return for a follow-up visit within 7-10 days.

Complications

Wound healing is slow and complicated in patients with filariasis because of the lymphedema and chronic scarring. Patients who require excision and grafting of the scrotal or penile skin are at higher risk for graft failure. Wound infections are also common in these patients.

More on Hydrocele, Filarial

Overview: Hydrocele, Filarial
Workup: Hydrocele, Filarial
Treatment: Hydrocele, Filarial
Follow-up: Hydrocele, Filarial
Multimedia: Hydrocele, Filarial
References

References

  1. Sherchand JB, Obsomer V, Thakur GD, Hommel M. Mapping of lymphatic filariasis in Nepal. Filaria J. Mar 19 2003;2(1):7. [Medline].

  2. Lammie PJ, Cuenco KT, Punkosdy GA. The pathogenesis of filarial lymphedema: is it the worm or is it the host?. Ann N Y Acad Sci. Dec 2002;979:131-42; discussion 188-96. [Medline].

  3. Taylor MJ. A new insight into the pathogenesis of filarial disease. Curr Mol Med. May 2002;2(3):299-302. [Medline].

  4. Bernhard P, Magnussen P, Lemnge MM. A randomized, double-blind, placebo-controlled study with diethylcarbamazine for the treatment of hydrocoele in an area of Tanzania endemic for lymphatic filariasis. Trans R Soc Trop Med Hyg. Sep-Oct 2001;95(5):534-6. [Medline].

  5. Approaches to the urogenital manifestations of lymphatic filiariasis. Geneva, Switzerland: World Health Organization; 2002.

  6. Bosworth W, Ewert A. The effect of Streptococcus on the persistence of Brugia malayi and on the production of elephantiasis in cats. Int J Parasitol. Dec 1975;5(6):583-9. [Medline].

  7. Cohen LB, Nelson G, Wood AM, Manson-Bahr PE, Bowen R. Lymphangiography in filarial lymphoedema and elephantiasis. Am J Trop Med Hyg. Nov 1961;10:843-8. [Medline].

  8. Dreyer G, Norões J, Figueredo-Silva J, Piessens WF. Pathogenesis of lymphatic disease in bancroftian filariasis: a clinical perspective. Parasitol Today. Dec 2000;16(12):544-8. [Medline].

  9. Eigege A, Richards FO Jr, Blaney DD, Miri ES, Gontor I, Ogah G. Rapid assessment for lymphatic filariasis in central Nigeria: a comparison of the immunochromatographic card test and hydrocele rates in an area of high endemicity. Am J Trop Med Hyg. Jun 2003;68(6):643-6. [Medline].

  10. Hussein O, El Setouhy M, Ahmed ES, Kandil AM, Ramzy RM, Helmy H, et al. Duplex Doppler sonographic assessment of the effects of diethylcarbamazine and albendazole therapy on adult filarial worms and adjacent host tissues in Bancroftian filariasis. Am J Trop Med Hyg. Oct 2004;71(4):471-7. [Medline].

  11. Nielsen NO, Bloch P, Simonsen PE. Lymphatic filariasis-specific immune responses in relation to lymphoedema grade and infection status. I. Cellular responses. Trans R Soc Trop Med Hyg. Jul-Aug 2002;96(4):446-52. [Medline].

  12. Ottesen EA. The human filariases: New understanding, new therapeutic strategies. Curr Opin Infect Dis. 1994;7:550-8.

  13. Ottesen EA, Vijayasekaran V, Kumaraswami V, Perumal Pillai SV, Sadanandam A, Frederick S, et al. A controlled trial of ivermectin and diethylcarbamazine in lymphatic filariasis. N Engl J Med. Apr 19 1990;322(16):1113-7. [Medline].

  14. Tobian AA, Tarongka N, Baisor M, Bockarie M, Kazura JW, King CL. Sensitivity and specificity of ultrasound detection and risk factors for filarial-associated hydroceles. Am J Trop Med Hyg. Jun 2003;68(6):638-42. [Medline].

  15. Weekly epidemiological record. Geneva, Switzerland: World Health Organization; 2006.

  16. Weil GJ, Lammie PJ, Weiss N. The ICT Filariasis Test: A rapid-format antigen test for diagnosis of bancroftian filariasis. Parasitol Today. Oct 1997;13(10):401-4. [Medline].

Further Reading

Keywords

filarial hydrocele, scrotal lymphedema, filarial worms, filaria, filariae, Filaria bancrofti, F bancrofti, Wuchereria bancrofti, W bancrofti, Brugia malayi, B malayi, Filaria malaya, F malaya, Culex pipiens, C pipiens, parasitic disease, parasitemia, parasite infection, filariasis, mosquito bite, lymphatic filariasis, nematode, roundworm, round worm, lymphangiectasia, filarial infestation, scrotal filarial infestation, skin sclerosis, elephantiasis, tropical eosinophilia, eosinophilic interstitial pneumonitis, chyluria, bancroftian filariasis, acute filarial lymphangitis, AFL, filarial dance sign, FDS

Contributor Information and Disclosures

Author

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Joe Miller, MD, Staff Physician, Division of Urology, Southern Illinois University Affiliated Hospitals
Joe Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Rizk El-Galley, MD, Director of Clinical Research, Assistant Professor, Department of Surgery, Division of Urology, University of Alabama
Rizk El-Galley, MD is a member of the following medical societies: American Urological Association, Royal College of Surgeons of England, and Southwest Oncology Group
Disclosure: Nothing to disclose.

Medical Editor

Edmund S Sabanegh Jr, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Edmund S Sabanegh Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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