A Mechanism for Chronic Filarial Hydrocele with Implications for Its Surgical Repair

Chronic hydrocele is the accumulation of fluid around the testis leading to an increase in the volume of the scrotal contents. Depending on the volume of fluid, hydrocele can be disfiguring and even incapacitating. Chronic hydrocele has multiple etiologies, but irrespective of the cause, surgery is the standard form of treatment and this can be done using different surgical techniques. The prevalence of chronic hydrocele in bancroftian filariasis endemic areas—a parasitic disease transmitted by mosquito—is very high and represents the most common clinical manifestation of bancroftosis, following by swollen legs of lower limbs or lymphedema among women. In Greater Recife, northeastern, Brazil, a bancroftian filariasis endemic area, a pioneering, prospective surgical study proposes a new mechanism for filarial-induced hydrocele and presents evidence that the filarial hydrocele fluid may damage the testis. Thus, based on the findings presented, the authors propose that in bancroftian filariasis endemic areas hydrocele patients should be operated on using a specific surgical technique in order to avoid recurrence of the disease, and consequently, additional damage to the testicle

Posterior recurrence.

<p>Left recurrent hydrocele in a 36 year-old patient from G2. (A) Posterior recurrent hydrocele sac (arrow heads) and anterior surface of the testis (asterisks); (B) and (C) different views of opened posterior recurrent hydrocele sac showing multiple cavities and irregularity of its inner surface (<b>+</b>).</p

Quilúria Chyluria

A ruptura ou fistulização de vasos linfáticos para o interior do sistema excretor urinário dá origem à quilúria, que tem na bancroftose a sua principal etiologia. Pode ser, raramente, também causada por neoplasia, malformação linfática, traumatismo abdominal, assim como outras doenças infecciosas como a tuberculose. Os autores propõem as diretrizes gerais para a condução do portador de "urina leitosa" em áreas endêmicas e não endêmicas de filariose bancroftiana. Ressaltam a importância dos exames de triagem e de outros mais sofisticados para uma investigação etiológica a partir da realização de anamnese e de exame físico criteriosos. Enfatizam a necessidade de que a doença deve ser conduzida através de uma abordagem mais abrangente, que compreenda, além da médica, a assistência social e a nutricional. Na grande maioria dos casos, o controle da quilúria está basicamente fundamentado na educação e na adequação do paciente a uma dieta hipolipídica/hiperprotéica e rica em líquidos.<br>The rupture or fistulization of lymph vessels into the urinary system, known as chyluria (milky urine), is caused mainly by bancroftian filariasis. On rare occasions chyluria may also be caused by neoplasia, lymphatic malformation, abdominal trauma, as well as other infectious diseases such as tuberculosis. The authors proposed general guidelines to manage patients suffering from milky urine in Bancroftian filariasis endemic and non-endemic areas. They emphasized the importance of a careful diagnostic process accomplished using screening procedures, evaluating a detailed history of illness and performing a careful physical examination, targeting on the most suitable diagnostic tools for each case. In addition, they emphasized the need to manage the patient from a broader perspective, which goes beyond the medical aspect, involving also social and nutritional contexts. In the great majority of cases, controlling chyluria is fundamentally based on patient education and adjustment to a low lipid, high protein diet in addition to increased fluid intake

Terapia complementar em área endêmica de filariose bancroftiana, pelos Clubes da Esperança

Em 1997, a Organização Mundial de Saúde anunciou um ambicioso projeto de eliminação global da filariose linfática como problema de saúde pública. Esse projeto baseia-se em dois pilares: interrupção da transmissão e controle da morbidade. Experiência em Recife-Brasil, área endêmica de filariose bancroftiana, mostrou que a criação pioneira de Clubes da Esperança pode contribuir, a baixo custo, como terapia coadjuvante importante na melhoria da qualidade de vida dos portadores de linfedema e de quilúria. Os pacientes compreendem os fundamentos básicos e os utilizam na prevenção dos episódios agudos bacterianos de pele (erisipelas) e na manutenção da urina sem o componente quiloso. Eles sentem que não estão sós e, através de ações especializadas e do trabalho em grupo, readquirem o potencial para o trabalho produtivo, realizando também mudanças substancialmente positivas dentro de suas comunidades, agindo, assim, como amplificadores do processo

Mixed recurrence.

<p>Right recurrent hydrocele in a 29 year-old patient from G2. (A) Recurrent hydrocele sacs situated anterior (black arrow heads) and posterior (white arrow heads) to the testis (asterisks). (B) Emptied anterior recurrent hydrocele sac (black arrow head); aspiration of posterior recurrent hydrocele sac (white arrow head). (C) Opened, anterior (right forceps) and posterior (left forceps) recurrent hydrocele sacs; anterior surface of abnormal testis (arrow heads) is seen.</p

Lymphatic Endothelial Cell in Endemic Bancroftian Filariasis: A Focus on the Lymphatics of the Tunica Vaginalis Testis

Background. In endemic areas, lymphangiectasia is the fundamental alteration to live Wuchereria bancrofti adult worms which, in adult males, are usually found in the lymphatic vessels of the spermatic cord; accordingly, hydrocele/filaricele is the most common clinical manifestation of bancroftian filariasis. The pathogenic role of the lymphatic endothelial cells (LECs) and the status of mesothelial cells (MCs) samples of the parietal layer (PL) of the tunica vaginalis testis were examined. Methods. The PL of thirty-two patients, excised for different reasons, was examined by histology and immunohistochemistry using the D2-40 monoclonal antibody for identification of LECs and CK-7 antibody for recognition of mesothelial cells (MCs). Results. The most important findings were (a) marked lymphangiectasia, especially in hydroceles with minor evolution time; (b) the first report of lymphatic stomata and submesothelial lacunae in filarial acute hydrocele; (c) the likely participation of LECs in filarial granuloma; (d) the potential phenotypic transition of LECs into myofibroblasts in severe chylocele; and (e) mesothelial reactive hyperplasia, a hallmark of filaricele, varying in intensity from mild to severe, sometimes mimicking a mesothelial neoplasia. Conclusion. The data suggest that LECs have an active role in the pathogenesis of bancroftian hydrocele and, possibly, in other clinical forms of lymphatic filariasis

Anterior recurrence.

<p>Left recurrent hydrocele in a 31 year-old patient from G2. (A) Previous hydrocelectomy scar. (B) Recurrent hydrocele sac situated anterior to the testis (asterisk). (C) Aspiration of clear, straw colored fluid from anterior recurrent sac. (D) Opened recurrent hydrocele sac showing the anterior surface of the testis covered by tunica albuginea and visceral layer of tunica vaginalis (asterisk). By gross appearance the testicle is abnormal in shape and size. The sac wall (forceps) and testicular tunicas appear thick and with irregular surfaces.</p

Comparison of age, lymphangiectasia, testicular abnormality findings, hydrocele volume, and hydrocele recurrence in Group-1, Control Group and Group-2 patients.

<p>*Fisher's exact test comparing groups 1 and 2.</p><p>**Geometric mean.</p>†<p>t-test.</p><p>***Fisher's exact test comparing group 1 and comparison group.</p