Filarial Hydrocele

Stephen Leslie; Preeti Rout; Jyotsna Pandey

Filarial Hydrocele

Author: Stephen W. Leslie Author: Preeti Rout Editor: Jyotsna Pandey Updated: 8/3/2025 12:20:13 AM

Introduction

Hydroceles result from the accumulation of fluid within the tunica vaginalis inside the scrotum.[1] This common condition, typically observed in adult males, results in painless enlargement of the scrotum.[1] Chronic hydroceles have multiple etiologies and may occur secondary to other disorders, such as testicular malignancy or infection. There is a remarkably high incidence of chronic hydroceles in parts of the world where filariasis is endemic, and Wuchereria bancrofti is by far the most common causative agent in these regions.[2]

Filariasis is a mosquito-transmitted parasitic disease. Filarial hydroceles are a late, chronic manifestation of W bancrofti filariasis in men. Late-stage manifestations of lymphatic filariasis—including elephantiasis, filarial hyodrceles, and severe lymphedema—occur later in life and can lead to disfiguring sequela, reduced mobility, social isolation, mental health problems, increased poverty, and permanent disability.[3][4] Genital deformities often lead to social stigma and isolation, mental health issues, job loss, reduced employment opportunities, decreased mobility, and increased medical expenses for patients and their caregivers. These consequences contribute to a severe socioeconomic burden, particularly in regions already affected by poverty, limited employment opportunities, and suboptimal medical care.[3][4]

In men, genital pathology manifests most often as a large, chronic hydrocele due to blockage or dysfunction of the scrotal lymphatic vessels that have become clogged, scarred, or damaged by nematodes.[5][6] Filarial hydroceles are the most common manifestation of W bancrofti filariasis in men. In contrast, the most common clinical findings in women include swollen legs, lower limb lymphedema, and elephantiasis.[3][6][7][8] A filarial hydrocele is not only debilitating and disabling to the individual, but also has significant regional economic implications due to the huge numbers of affected adult males throughout the tropical and subtropical regions and countries where the disease is endemic.[3][4]

Etiology

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Etiology

Lymphatic filariasis is caused by 3 species of parasitic roundworms (nematodes)—W bancrofti, Brugia malayi, and Brugia timori.[9][10] Among these, W bancrofti is most commonly associated with the chronic disease manifestation of filarial hydroceles.[3][11]

In the human body, adult worms, both male and female, reside in the lymph nodes and reproduce, producing huge numbers of larvae called microfilariae, ranging from 10,000 to 50,000 per day. These larvae migrate between the lymphatic system and blood channels to reach the peripheral blood vessels.[8] The adult worms can live for years in the body and, during their lifetime, produce millions of immature larvae (microfilariae) that circulate in the blood.[8]

When female mosquitoes—such as Culex, Aedes, and Anopheles, depending on the region of the world—ingest a blood meal from an actively infected person, they consume microfilariae with the blood.[8] The Anopheles mosquito is mainly found in rural areas, the Culex variety is commonly observed in urban and semi-urban areas, and the Aedes mosquito is endemic to islands in the Pacific.[12] The larvae grow and molt repeatedly in the mosquito to produce the highly active infective microfilariae in about 10 to 12 days.

The infective larvae then migrate and accumulate in the mosquito's proboscis.[8] When the mosquito bites a human host, the larvae are deposited on the skin and enter the bloodstream through the bite wound. As they move through the human body, they migrate to the lymphatic vessels and lymph nodes, where they mature into adult worms that can live for 6 to 8 years.[8]

Eventually, adult worms migrate to the inguinal and scrotal lymphatic vessels, where they cause acute filarial lymphangitis, lymphangiectasia, and acute hydroceles.[8] These early manifestations may result in transient symptoms such as pain or palpable nodularity. Repeated cycles of inflammation over time may lead to lymphatic damage, obstruction to lymph flow, and, ultimately, a chronic hydrocele.[8] Thus, a majority of men with untreated lymphatic filariasis eventually develop symptomatic hydroceles.[5][8][13][14][15][16][17][18] The lymphatics of the testicles are particularly susceptible to damage from filarial parasites such as W bancrofti, as they have no collaterals, drain against gravity, have no surrounding muscle, and are relatively long.[19]

Epidemiology

Lymphatic filariasis is a rare disease in the United States, with most cases occurring in immigrants or travel-acquired infections. In tropical and subtropical regions around the world, mainly in low- and middle-income countries, lymphatic filariasis is the most significant risk factor for the development of filarial hydroceles.[17]

In approximately 90% of cases, lymphatic filariasis is typically caused by infection with the mosquito-borne roundworm parasite W bancrofti.[3][11] Approximately one-third of infected individuals eventually develop clinical symptoms.[20] Although both men and women are affected by this parasitic infection, only males can develop scrotal hydroceles due to W bancrofti's penchant for residing in the spermatic cord and scrotal lymphatics, causing scrotal nodules that progress in more than 50% of infected men to chronic filarial hydroceles over time.[5][21][22]

Bancroftian filariasis is the second most common cause of infectious disability in the world after leprosy.[8]

Initial infection with W bancrofti is often at a young age, with filarial hydroceles developing later in life.[8] Initial infections typically occur in children who are typically asymptomatic until after puberty.[7][23][24] Filarial hydroceles are observed in adult males aged 20 or older, who live in over 72 tropical and subtropical countries in Sub-Saharan Africa; Asia; the Caribbean; South Pacific Islands, especially Samoa; and South America. India alone accounts for about 40% of the world's total lymphatic filariasis cases.[25]

According to the World Health Organization (WHO), more than 650 million people in 39 countries around the world are at risk of lymphatic filariasis, with filarial hydroceles affecting over 27 million men globally, mostly in endemic tropical and subtropical regions.[3][20][26][27]

Worldwide, about 70 million people have lymphatic filariasis, with W bancrofti accounting for over 90% of cases.[8][28][29]
In endemic areas, over 40 million people suffer from the chronic disfiguring manifestations of filariasis, and in highly affected areas, up to 40% of men have hydroceles.[30][31]
Overall, about two-thirds of all patients affected by lymphatic filariasis live in Asia.[6][32]

Population-based and household surveys consistently underestimate the true prevalence of filarial hydroceles and the disability they cause. Personal modesty and cultural factors may be responsible for many hydroceles to be ignored by patients and unreported, especially when data are collected through surveys. Therefore, the reported incidence depends mainly on clinical examinations and may be imprecise in determining the true extent of the disease, which is likely seriously underestimated.[33][34][35][36]

Pathophysiology

A filarial hydrocele refers to the accumulation of fluid in the scrotum due to true hydrocele (fluid), chylocele (lymph), or hematochylocele (blood with lymph). The term filaricele encompasses all three variations and has been suggested as a comprehensive term in recent years.

The hydrocele may be communicating or non-communicating. Non-communicating hydroceles develop in association with filarial infections and may present as either an acute or chronic condition. In filarial infections, the migration of adult worms, the lymphatic damage that they cause, and their persistence in the scrotal lymphatic drainage system result in a non-communicating filarial hydrocele.[17]

A chylocele may result from the rupture of lymphatic vessels inside the scrotal cavity, leading to a lymphocele (lymph) or chylocele (milky) fluid collection, which may contain variable amounts of red blood cells (hematochylocele).

Acute Hydroceles

Acute hydroceles typically develop following the death of these worms, often after medical therapy.[37][38][39][40] The release of filarial antigens may trigger acute filarial lymphangitis, a rapidly developing lymphatic inflammatory condition characterized by the sudden onset of fever, pain, and swelling of affected lymphatic vessels.[37] This condition can also lead to epididymitis, funiculitis, or orchitis, followed by temporary clogging of the lymphatics by the inflammatory reaction to disintegrating filarial worms.[37][38][39][40] Chronic hydroceles may develop following about 5% of these events.[41]

Painful lumps or nodules in the scrotum are typically present, which are caused by the inflammatory response to dead parasitic worms. This reaction occasionally occurs after medical treatment for filariasis. The acute response typically resolves within days to weeks, but most cases subside in less than 1 week.[5][41] Acute filarial lymphangitis rarely causes chronic lymphedema.

Chronic Hydroceles

Chronic hydroceles develop due to the poor functioning of the lymphatic system, as adult worms migrate to the scrotal lymphatics and form scrotal nodules.[42] There is a 22% incidence of acute filarial hydrocele formation following a single scrotal nodule event, either spontaneously or induced by treatment.[41] Chronic filarial hydroceles may also damage the testes.[30]

Approximately 90% of men with filarial hydroceles demonstrate adult W bancrofti in scrotal lymphatic channels.[30][43][44]

While the adult nematodes are alive, non-obstructive dilation of the lymphatic vessels is observed without inflammation.[30][38][39][45]
Acute filarial hydroceles result from a sudden obstruction of lymphatic flow in the tunica vaginalis, caused by granulomas and blockages from dead nematodes.[30][41][46]

Depending on the extent and severity of lymphangiectasia and other cofactors, such as the total adult filarial burden, and the location of mature nematodes in the scrotal lymphatic system (for instance, in the spermatic cord or the testicular sac area), hydroceles and chyloceles can develop even years after the initial infection.[30]

The development of hydroceles and chyloceles can occur even years after the initial infection, depending on the extent and severity of lymphangiectasia and other factors, such as the total adult filarial burden, and the location of mature nematodes within the scrotal lymphatic system, for example, in the spermatic cord or testicular sac. In some cases, chyluria may also be observed.[47]

Regular and repeated exposure (inoculations) to W bancrofti microfilariae is necessary to maintain the high levels of nematodes necessary for patients to develop clinical disease manifestations.[48] Consequently, individuals typically need prolonged stays in endemic regions to acquire a clinically significant infection. The disorganized urbanization common in endemic areas hinders mosquito control and eradication programs, leading to higher disease prevalence.

Evidence suggests that a superimposed bacterial infection may play a role in triggering the immune response due to the death of the parasite. Wolbachia is an essential, obligatory intracellular symbiotic bacterium in the W bancrofti filarial parasite, which is released upon the death of the nematode.[49][50] The Wolbachia endosymbionts produce inflammatory cytokines, such as tumor necrosis factors and vascular endothelial growth factors, which are essential for the development of filarial hydroceles. Upon the death of the nematode, these endosymbionts are released, contributing to the host's inflammatory response.[17]

The release of bacteria triggers an immune response, resulting in an increase in the patient's blood levels of interleukin (IL)-6, IL-10, and tumor necrosis factor-alpha receptors.[49] Although the exact role of this response in the pathogenesis of filarial hydroceles remains unclear, it is thought to act as a catalyst for immune activation following the death of adult worms.[49][51][52]

Additionally, familial and genetic predispositions may influence an individual's susceptibility to filarial infection and disease progression.[51][53][54]

Prenatal exposure to W bancrofti tends to reduce that individual's immune reaction to the parasite.[55] This immunological tolerance explains why patients infected in endemic areas are frequently asymptomatic until late in the disease process, when the nematode burden is very high. In contrast, individuals with normal immune systems and outsiders often exhibit much more severe clinical symptoms, even with mild or early infections.[55]

W bancrofti and Brugia secrete abundant amounts of certain microRNAs, which can jeopardize the integrity of human endothelial cells.[56][56] These findings suggest that these parasites may be directly involved in damaging these cells, thereby contributing to their pathogenicity.[56]

The host response to infection by filarial parasites is complex and multifaceted, involving both adaptive and innate responses.

A parasite antigen-specific response mounted by the Th2 cells, involving an expansion of CD4⁺ T cells that produces IL-10.[18][57][58]
Concurrently, the Th1 response is suppressed, which contributes to the persistence of the parasites.[18][57][58]
- Whether this suppression of the host's protective immune response is the main reason for the persistence of infection remains unclear.[18][57][58]
- Notably, it is the host response to the infection that primarily leads to the clinical signs and symptoms of the disease.[18]

Histopathology

Histologically, affected lymph nodes become fibrotic with lymphatic obstruction and adult parasites, although collateral channels may develop. Repeated inflammatory episodes of lymphatic filariasis cause lymphatic infiltration with eosinophils, macrophages, and plasma cells, which stimulate lymphatic endothelial hyperplasia, causing thickened lymphatic vessel walls.[17] These thickened walls, together with the presence of adult nematodes, result in obstructed lymphatic flow with damage to the lymphatic drainage system and chronic leakage of high-protein lymph fluid into the surrounding tissues, causing lymphedema, thickened scrotal wall tissue, and filarial hydroceles.[17]

History and Physical

Obtaining a detailed history and performing a thorough physical examination are essential. Inquiring about the region a patient lived in and any relevant travel history is crucial. A detailed history often reveals staggering effects on a patient's life, including poor sexual function, disfigurement, loss of social standing, isolation, physical disability, inability to work leading to significant economic loss, decreased self-esteem, mental illness, and depression.[3][4][20][42][59] For example, filariasis-related depression is believed to account for more than 5 million disability-adjusted life years.[59]

By causing physical disability, reducing productivity, and limiting job opportunities, filarial hydroceles place an enormous economic burden on the patient, their family, and their caregivers.[13][20][60][61][62] The socioeconomic impact on patients, families, medical and nursing resources, and entire communities is multiplied, and healthcare spending for affected individuals is markedly increased.[13][20][60][61][62]

A comprehensive examination, including a thorough assessment of the lower extremities, is crucial to identify other manifestations of lymphatic filariasis that may also be present. The majority of patients with lymphatic filariasis infections (up to 70%) are asymptomatic with no physical signs. However, even asymptomatic infections can cause damage to the kidneys, lymphatic system, and immune system.

Filarial hydroceles are generally painless and bilateral. The scrotal skin typically appears thickened from lymphedema and may be oozing lymphatic fluid. Superimposed bacterial infections are uncommon. However, patients with elephantiasis and scrotal edema often develop superinfections.

Although most lymphatic filariasis infections are asymptomatic, several manifestations other than filarial hydroceles may occur.[7][8]

Acute adenolymphangitis: Sudden fever with painful lymphadenopathy, often associated with lymphangitis (inflammation of the lymphatic vessels).[63]
- Symptoms often resolve in 7 days but may recur.
- Skin exfoliation of the affected area is often observed when the episode resolves.[63]
- This is a common presentation of acute lymphatic filariasis.[8]

Filarial fever: Body aches, chills, headaches, high-grade fever, and rigors associated with acute filariasis. This condition is typically not associated with lymphadenopathy but is sometimes misdiagnosed as malaria.[64]
Genital swelling [65]
Inguinal lymphadenopathy [7][8]
Lower leg or genital swelling/lymphedema: Multiple inflammatory episodes lead to leg lymphedema, lymphatic damage, chronic swelling, hydrocele formation, and elephantiasis of the lower extremities.[66]
Scrotal skin exfoliation, thickening, or hardening
Testicular or inguinal pain
Tropical pulmonary eosinophilia: A lung disorder caused by a hyperactive immune response to filarial parasites. Characterized by breathlessness, dry paroxysmal nocturnal cough, wheezing, malaise, weight loss, elevated blood eosinophil counts, and lung infiltrates on chest x-ray.[67] Physical findings include scattered wheezes and crackles in both lungs.[67]

Filarial hydroceles may present as either acute or chronic conditions.

Acute Filarial Hydroceles

Acute filarial hydroceles present with painful nodules in the scrotal region, with or without palpable enlargement of the scrotal sac due to fluid. These hydroceles are believed to be caused by the death of adult worms and may or may not be related to treatment.[22] The nodules are caused by an inflammatory response to the disintegrating parasite, leading to lymphangitis.

Chronic Filarial Hydroceles

Chronic filarial hydroceles typically present as a painless swelling of the scrotal sac. The size of the hydrocele can vary from barely detectable to extremely large. Patients may report discomfort due to the weight of the swollen scrotum. A detailed history may reveal prior filariasis infection and episodes of painful nodules in the scrotal area that resolved within a week.[68] Most patients with hydroceles may report up to 2 episodes of inflammation each year, varying in severity, which can lead to scrotal nodules.[30][47]

Pain may be present if inflammatory lymphangitis is severe. On examination, the genitals may reveal variably sized hydroceles, some of which may be quite large and disfiguring at diagnosis. Patients may have thickened spermatic cords and numerous firm nodules in the epididymis or cord. In long-standing hydroceles, calcification can develop in the tunica, which may be detected by palpation or imaging studies. A history of residence in or travel to an endemic region supports the diagnosis.

Chyluria occurs when lymphatic fluid leaks into the urine due to damaged lymphatic channels. This condition can result in a significant loss of protein and fat. Chyluria is rare, typically intermittent, and may resolve spontaneously.

Evaluation

Differentiating filarial hydroceles from non-infectious hydroceles can be challenging, particularly in endemic regions.

The evaluation of filarial hydrocele includes laboratory investigations, such as a complete blood count to assess for eosinophilia (active filariasis), and a thick peripheral blood examination to detect microfilariae. A urinalysis should be performed to identify chyluria, proteinuria, or hematuria. Microfilariae are only rarely detected in urine samples.

The peak time of W bancrofti microfilariae in the bloodstream is at night between 10 PM and 2 AM (nocturnal periodicity), which corresponds to peak mosquito activity in tropical regions.[69] Blood smears may be stained with Giemsa, Wright-Giemsa, hematoxylin and eosin, Delafield's hematoxylin, Ziehl-Neelsen carbol fuchsin, or Leishman stain.[69][70] Specimen concentration techniques, such as the Knott method—which is preferred—and membrane filtration, can be useful in diagnosing filariasis.[69] The Centers for Disease Control and Prevention recommends examining at least 2 thin and 2 thick film peripheral blood smears, or using a concentration technique, such as the Knott method, when filariasis is suspected in endemic areas.[69]

Microscopically, W bancrofti microfilariae are sheathed with a short head space and gently curved with anucleate tails tapering to a point. These microfilariae contain a nuclear column of loosely packed cells. Active infection is probably not present by the time a chronic filarial hydrocele develops. Microfilariae are relatively large microorganisms, measuring 240 to 300 µm; therefore, low-power magnification is suggested initially.[69]

Lymphatic filariasis is best and most sensitively diagnosed by detecting circulating filarial antigens of W bancrofti DNA in the blood. Circulating filarial antigens can also be detected by enzyme-linked immunosorbent assay or other rapid diagnostic tests suitable for field use.[71][72][73] The presence of filarial antigens in the blood confirms a nematode (roundworm) infection.[71] Additionally, this test can be used to monitor the effectiveness of treatment.[71] The Food and Drug Administration (FDA) has not approved serum antigen assays for W bancrofti for use in the United States.

Biopsies are generally not recommended except for obviously cutaneous lesions, as they may further impede lymphatic drainage. Fine needle aspiration cytology may detect microfilariae or even adult worms in lymphatic fluid.[74] W bancrofti parasites and microfilariae are rarely found in hydrocele fluid.

Other serological investigations may be performed to assess elevated levels of immunoglobulins and interleukins. Polymerase chain reaction–based serum assay tests for W bancrofti are quite sensitive but not approved for use in the United States and are not widely available elsewhere.[75][76][77] In recent years, several recombinant antigens, such as WbSXP-1, have been developed for use in filarial immunoassays. These antigens detect circulating filarial antibodies, specifically IgG1 and IgG4, to W bancrofti antigens. Unlike testing for the presence of microfilariae, immunoassay blood samples can be drawn during the daytime.[78]

As some patients may have an asymptomatic infection, testing can help identify infected individuals in endemic areas.[26][79][80][79] Patients with active infections generally have elevated serum IgG4 levels. Patients with treated or burned-out infections may not demonstrate microfilariae or circulating W bancrofti antigens but still test positive for filarial antibodies.

Ultrasonography is the primary imaging modality used to evaluate filarial hydroceles. This method can help detect even non-palpable fluid collections in the tunica vaginalis and visualize lymphatic obstructions. During the ultrasound examination, various structures are assessed, including the scrotal lymph vessels, the size and morphology of testes, epididymis for nodules, spermatic cord for nodularity, and layers of the tunica vaginalis for any fluid.[79] Ultrasound imaging can also identify the characteristic movement of adult worms in lymphatic vessels (filarial dance sign) in approximately 80% of cases. Additionally, it is useful for monitoring the effectiveness of treatment.[68][80][81][82]

Radionuclide lymphoscintigraphy can reliably identify lymphatic abnormalities in patients with filarial hydroceles; however, because it does not help differentiate filarial from nonfilarial etiologies, its use remains limited.[23]

Treatment / Management

According to the WHO, over 657 million individuals in 39 countries are at risk of lymphatic filariasis for whom preventive therapy is recommended. In 2000, the WHO launched a Global Program to Eliminate Lymphatic Filariasis (GPELF) to eradicate the widespread regional parasitic infections. A combination of albendazole and diethylcarbamazine was distributed in endemic areas through mass drug administration programs. These programs have been highly successful in reducing global filarial infections from nearly 200 million in 2000 to approximately 40 million today.[6]

Mass drug administration programs involve administering an annual dose of medications to the entire at-risk population. These regimens have effectively controlled the transmission cycle of filaria when the entire at-risk population is treated annually for at least 4 to 6 years. Although the medications have a limited effect on adult parasites, they significantly reduce the number and density of microfilariae in the bloodstream, preventing the spread of the parasites to the mosquitoes and breaking the cycle.

Doxycycline

Doxycycline administered at 200 mg daily for 6 weeks demonstrates significant antifilarial activity against both adult and larval filaria through its activity against the essential intracellular endosymbiotic Wolbachia bacteria.[50][83][84][85][86][87][88][89][90][89] Lymphedema and hydroceles improve with 6 weeks of doxycycline therapy.[83] The antibiotic is particularly effective in reducing filarial hydroceles when used in the early stages of the infection.[41] (A1)

Doxycycline can also inhibit embryogenesis in adult female W bancrofti nematodes for weeks.[17] Doxycycline is most effective when used in the early phase of hydrocele development.[17] However, it cannot be used during pregnancy or in children, and a 6-week course of treatment is not a realistic option for many patients in the developing world.

Although drug treatment is effective for lymphatic filariasis, it is best suited for patients with early infection and to decrease general disease transmission. However, medical therapy—especially following mass drug administration—has been reported to sometimes precipitate the development of acute conditions such as lymphedema or hydroceles.[37][38][39][40]

Patients with large, symptomatic filarial hydroceles typically require surgical intervention, as medical therapy alone is often insufficient for effective management.

World Health Organization–Recommended Preventive Therapy

Albendazole: Albendazole causes selective degeneration of cytoplasmic microtubules in parasites and their larvae by binding to the B-tubulin microtubular subunit, thereby blocking microtubule growth and polymerization.[91][92][93] Albendazole inhibits the parasite's glucose metabolism and reduces its glycogen storage reserves.[93] At higher concentrations, it can also halt the Krebs cycle by inhibiting key enzymes such as malate dehydrogenase.[91][92][93] This inhibition drastically reduces ATP production, resulting in reduced energy, immobilization, and the death of the parasite.[91][92][93] Albendazole is effective against both adult nematodes and microfilariae; however, its effects are gradual, so adverse effects from the rapid killing of parasites are not typically observed.(A1)

Due to poor solubility and low gastrointestinal absorption, albendazole should be given with a high-fat meal, which improves its bioavailability.[91][94]
Albendazole is metabolized through the cytochrome P450 pathway; therefore, it should not be administered with other cytochrome P450 pathway–stimulating medications, such as carbamazepine, phenobarbital, phenytoin, and rifampin, as they can reduce effective concentrations by up to 50%.[91][92] Cytochrome inhibitors, such as cimetidine and grapefruit juice, can increase albendazole concentrations by as much as 50%.[91][95]
Albendazole may have synergistic effects when combined with ivermectin (European Medicines Agency).[96]
The recommended dosage of albendazole for an active infection is 400 mg twice daily for 21 days.[91]
Common adverse effects include headaches, elevated liver enzymes, abdominal pain, nausea, vomiting, and fever.[91][97][98]

(A1)

Diethylcarbamazine Citrate: Diethylcarbamazine citrate is a derivative of piperazine and a first-line treatment for filariasis. Diethylcarbamazine citrate inhibits arachidonic acid metabolism in the parasite, temporarily immobilizes the worm's muscles by opening TRP channels, and alters its skin membranes, making it more antigenic and thereby susceptible to the body's natural immune system.[99][100][101] This process is accomplished by increasing antigen exposure on the organism's surface, thus triggering antibody-mediated phagocytosis of the nematode.[99][100][101]

Diethylcarbamazine has good oral absorption and a half-life of 12 to 14 hours. Approximately half of the drug is metabolized by the liver, with the remainder excreted by the kidneys.
Large amounts of antigens from dying parasites may be released 2 hours after dosing, potentially causing an allergic reaction.
- Symptoms may include fever, headache, nausea, muscle pain, arthralgia, itching, and postural hypotension.

Diethylcarbamazine should not be used in patients who have onchocerciasis (African river blindness) caused by the Onchocerca volvulus parasite, as it can accelerate the onset of blindness and cause a potentially lethal allergic response.[102][103]
- This hypersensitivity, known as the Mazzotti reaction, causes symptoms including tachycardia, hypotension, fever, rashes, and itching.[103]
- This response is so common that it forms the basis of the diethylcarbamazine skin patch test to confirm the diagnosis of onchocerciasis.[104][105]

The dosage of diethylcarbamazine for an active W bancrofti infection is 2 mg/kg orally 3 times a day for 1 day. This treatment is continued for 2 to 3 weeks if tropical pulmonary eosinophilia, a severe lung response to trapped microfilariae, is present.[67]
Diethylcarbamazine is no longer approved by the FDA due to the rarity of lymphatic filariasis in the United States. However, it can still be obtained with positive lab results for filariasis.

Ivermectin: Ivermectin is used in combination with other medications to treat filariasis.[106] This medication is effective against a wide range of parasites. Ivermectin is particularly effective in clearing microfilariae larvae from the bloodstream and reducing their production, but it does not generally kill the adult nematodes.[107][108][109][110] A single dose of ivermectin decreases microfilaremia by approximately 90% even 1 year after the drug is administered.[108][109](A1)

Ivermectin works by targeting glutamate-gated chloride channels, which are primarily found in insects and nematodes.[111][112]
The drug's effect is to increase the flow of chloride ions, which polarizes the parasite's nerves and muscle cells.[111][112]
- Humans also have glutamate-gated chloride channels, but they are protected in the brain and spinal cord, as ivermectin does not cross the blood-brain barrier.[111][112]

Ivermectin also affects GABA and other neurotransmitter receptors in the parasite.[111][112]
These combined effects result in paralyzing the nematode, ultimately leading to its death.[111][112]
Evidence suggests that ivermectin can reduce the production of defensive secretions that otherwise diminish the host's immune response.[111][112]
A good host immune response is necessary for optimal efficacy.[111]
The use of ivermectin is synergistic when combined with albendazole (European Medicines Agency).[96]
- Ivermectin works by causing paralysis of the parasite by targeting its nerves and muscles, whereas albendazole inhibits its metabolism and energy production (European Medicines Agency).

Oral absorption of ivermectin is incomplete but improves 2.5 times when taken after a high-fat meal.[111] Ivermectin is metabolized by the cytochrome P450 liver pathway and is excreted in the feces.[111]
Adverse effects typically include fever, headache, lightheadedness, postural hypotension, myalgias, sore throat, or cough, which occur 18 to 36 hours after administration.[108]
- These adverse reactions are typically considered mild, self-limiting, and generally well-tolerated by patients.[108]

(A1)

The standard dose for active infection is a single oral dose of 150 to 400 mcg/kg.
Drug resistance is a concern and has been reported in animals and a few humans, most likely due to its widespread use.[108][111]
Ivermectin is contraindicated in patients with loiasis due to the development of possible encephalopathy.[113]

(A1)

The WHO-recommended mass drug administration regimen varies depending on the presence of lymphatic filariasis, with other parasitic infections as follows:

Albendazole (400 mg) alone twice per year for regions with endemic loiasis.
Albendazole (400 mg) and ivermectin (200 mcg/kg) in regions with endemic onchocerciasis.
Albendazole (400 mg) and diethylcarbamazine citrate (6 mg/kg) in regions without endemic onchocerciasis.
Albendazole (400 mg), diethylcarbamazine citrate (6 mg/kg), and ivermectin (200 mcg/kg) in regions without endemic onchocerciasis and where other specified parameters are met.[114]
- The 3-drug regimen is the most effective and preferred option in regions where it can be safely administered.[114][115][116][117][118][119]

(A1)

Surgical Therapy for Filarial Hydroceles

Surgical excision is the mainstay of treatment for significant, symptomatic filarial hydroceles. However, the surgical management is not standardized, and the procedure may be technically challenging due to the lesion's size, anatomical distortion, structural changes, fibrosis, deformity, and scarring.[30] Furthermore, there are no standardized guidelines or protocols available regarding the use of preoperative antibiotics, specific optimal surgical techniques, postoperative dressings, and perioperative management.(B3)

The primary objective of surgery is to completely excise the hydrocele, relieve symptoms, and prevent recurrence. This objective is accomplished by permanently exposing the secretory portion of the tunica vaginalis to the internal absorbing surface of the scrotal wall.[1][30][120](B3)

Access to surgery is critically important in patients with filarial hydroceles. Some patients who are not given this option may decide to have their hydroceles drained in an unsterile manner. This practice increases the likelihood of infection and damage to the testes over time.[121] Successful hydrocele repair has enabled patients to return to healthier lives, improve their sexual functioning, enhance their mental health, increase their mobility, and access better employment opportunities. Studies have shown that the overall economic benefits of surgery are much greater than the costs of the procedures over time.[4][122](B3)

Patients undergoing filarial hydrocele surgery should also receive appropriate medical antiparasitic therapy as part of their comprehensive treatment plan to address the underlying W bancrofti infection.

Several surgical techniques are used in filarial hydrocele repair, with no clear evidence published that any one specific procedure is superior. Fundamental factors influencing the specific procedure chosen include complications, cost-effectiveness, efficacy, hydrocele size, recurrence rate, safety, scrotal wall factors, expected surgical time, surgeon's personal preference, and technical simplicity.[30][120][123][124] Although surgical techniques vary widely across regions, the best outcomes are achieved when standard surgical principles are followed, as outlined below.[1][20][30][125][126][127][128](B2)

Suggested Consensus on Surgical Procedure and Good Hydrocelectomy Practice Guidelines

Preoperative and postoperative antibiotics are recommended to reduce the incidence of infection.[125] (WHO 2002 Guidelines)
- One published protocol includes amoxicillin 500 mg and metronidazole 500 mg on the night before surgery (preoperative) and then again 3 times daily for 1 week postoperatively.[125]

(B3)

After extensive and careful cleaning and preparation of the scrotum, a midline incision is made.[20][125][129]
- Filarial hydroceles are typically bilateral, so a midline incision is the most useful surgical approach.

(B3)

A simple hydrocelectomy can often be performed on smaller hydroceles.[1]
The hydrocele should be carefully freed from the internal scrotal wall, which is easily done by simple blunt finger dissection.[1][20][125]
Deliver the hydrocele out of the scrotum.[20][125]
If the hydrocele is very large, it can be partially aspirated first to facilitate its removal from the scrotum without the need for making a longer incision.
After removal from the scrotum, the hydrocele is aspirated and then opened and drained.
Care should be taken not to injure the spermatic cord or testicle when opening the hydrocele sac.
If necessary, the location of the testicle can be identified by dimming the surgical lights and transilluminating the hydrocele sac.[1]
To minimize complications and improve outcomes, complete resection of the hydrocele sac is recommended, as it consistently yields lower recurrence rates, fewer postoperative infections, and fewer complications.[20][30][42][121][125]
- However, the eversion technique is simpler to perform and still gives acceptable results.[30][121]

(B3)

In a partial resection, the hydrocele sac is opened, everted with or without partial resection of the sac, and the edges sutured behind the testis, leaving the proximal end widely open.[30]
Meticulous hemostasis is a key to achieving a good outcome by minimizing leakage, hemorrhage, and hematoma formation.[20][125]
Electrocautery is recommended for excising the hydrocele sac, as it produces better hemostasis, particularly when the hydrocele sac is abnormally thickened, scarred, or fibrotic.
After resection, the remaining edges of the hydrocele sac should be cauterized if not performed earlier, and closed with a continuous, preferably interlocking, absorbable suture, such as 3-0 Vicryl.[125]
Damaged, leaking, or dilated lymph vessels should be meticulously removed, cauterized, or ligated.[30][125][130][131][132][133]
- Lymphatic fluid from ruptured, dilated lymphatic vessels is an essential component of chronic filarial hydrocele fluid and likely leads to a recurrence if not well controlled at surgery.[30]

(A1)

Complete excision of the sac, along with meticulous resection, cauterization, or ligation of any lymph fistulas, lymphatic leakages, or dilated lymphatic vessels, produces better outcomes.[30]
Care should be taken during surgery to avoid any injury to the epididymides, testes, vas deferens, or testicular vasculature.[20][121]
If a testis is necrotic or irreparably damaged, it should be removed.[20][121]
Any additional or associated pathologies, such as an inguinal hernia, should be repaired.[1] Prophylactic removal of the appendix testis and epididymis is also recommended.[1]
Resection and reconstructive surgery may be needed when the scrotal skin is particularly thickened or oozing lymphatic fluid—a condition known as scrotal lymphedema or superficial scrotal lymphangiomatosis (lymph scrotum).[134][135][136][137][138][139]
- Scrotal reconstruction may require skin grafting.[134]
- If the penis is involved, penile reconstruction may be required.[134]

(A1)

When possible, lymphovenous anastomoses (bypass shunts) should be considered to improve lymphatic drainage.[7][140][141][142]
- Microsurgical lymphovenous bypass shunts are more commonly performed for severe lower extremity lymphedema and elephantiasis.[134][142][143][144][145][146][147]

(A1)

After complete, meticulous hemostasis and lymphatic leakage control, the testes are replaced into the scrotum without fixation.
The wound is then closed with at least 2 layers of absorbable suture (such as 3-0 Vicryl) without drains.
The scrotum is dressed with multiple sterile dressings and an expandable (elastic) scrotal support that provides gentle compression.[1] A supportive dressing using adhesive tape may also be used.[125]
In some regions, postoperative inpatient hospitalization may be needed to ensure proper care and improve outcomes.[125]

(B3)

Potential postoperative surgical complications include hematomas, infections, poor wound healing, and recurrence of the hydrocele.[125](B3)

Overall, patient satisfaction after hydrocele surgery is very high, and surgical treatment of large, symptomatic filarial hydroceles is recognized by the WHO as an essential surgical procedure.[20][134][148] (A1)

Surgery for filarial hydroceles is not being performed at the scale necessary to fully alleviate the unnecessary human suffering caused by this treatable condition.[20] Barriers to more widespead available of hydrocelectomy surgery due to filariasis include cost and economic factors; lack of surgical capacity and healthcare infrastructure; insufficient numbers of trained surgeons; logistical challenges, such as lack of transportation and geographic isolation; inadequate funding of public health initiatives and mosquito eradication programs; civil disturbances; ignorance of the availability and benefits of surgery; and fear of procedural intervention.[5][20][30][134][149][150](A1)

Differential Diagnosis

All causes of scrotal enlargement or mass must be excluded. A detailed history, a thorough physical examination, and ultrasonography are essential diagnostic tools. The differential diagnosis of filarial hydrocele includes the following:[79][151]

Angioedema
Common non-infectious hydrocele (nematode-free)
Dependent edema
Elephantiasis (nonfilarial)
Epididymal cysts
Epididymitis or orchitis
Gonorrhea
Idiopathic scrotal edema
Inguinal hernia
Bacterial or fungal lymphadenitis
Congenital or hereditary lymphedema (such as primary congenital lymphedema, also known as Milroy syndrome)
Lymphoma
Lymphosarcoma
Meige disease (a lymphatic system disorder, also referred to as familial lymphedema praecox, which causes lymphedema of the lower extremities and scrotum) [152]
Sporotrichosis
Testicular torsion
Testicular tumor
Traumatic testicular hematocele
Tuberculosis
Urogenital schistosomiasis haematobium
Varicocele

Prognosis

Filarial hydroceles can take a devastating toll on an individual's psychosocial well-being, often leading to social isolation, depression, poverty, unemployment, sexual dysfunction, disability, and disfigurement. Although filariasis is not a lethal disease, the prognosis is generally poor if the disease is untreated, as filariasis affects multiple aspects of a patient's life, leading to considerable morbidity. If a chronic hydrocele develops and no therapeutic intervention occurs, the patient can be physically, socially, psychologically, and economically impacted.[16]

If left untreated, hydroceles can lead to an infection risk as scrotal skin breaks down and ulcerations occur. Urogenital manifestations such as lymph scrotum—characterized by scrotal lymphedema with superficial oozing lymphatic fluid and multiple surface lymphatic vesicles that easily rupture—result in leakage of lymphatic fluid and a wet scrotal discharge that leads to frequent infections and ulcerations.[153] The condition can progress to scrotal elephantiasis and chronic inflammation of the inguinal glands.[17]

Complications

Complications of untreated filarial hydrocele may include infertility, infection risk, scrotal skin break down and ulcerative lesions, physical disability, decreased mobility, greater reliance on others for self-care, increased poverty due to loss of work annd employment opportunities, social stigma, and mental health issues, such as depression and a sense of helplessness.[16]

Filarial hydrocele can also lead to various urogenital conditions, including inflammation of the penis, scrotum, inguinal lymph nodes, and scrotal elephantiasis.[17]

Lower extremity lymphedema is a complication of filarial infections and can be observed in individuals with filarial hydroceles.[134]

Surgical complication rates for filarial hydrocele repair in competent facilities are reported as 5% to 7%.[125] These primarily include delayed wound healing, hematoma formation, or infection. Recurrence rates are reported as 3% to 5%.[125]

Other complications include the following:[16][17][134]

Decreased mobility
Depression and mental health issues
Elephantiasis
Increased dependency on caregivers
Increased risk of infection
Infertility
Inflammation of the genitalia
Inguinal lymphadenopathy
Isolation
Lymphedema of the lower extremities
Loss of employment opportunities and loss of work
Physical disability
Scrotal lymphedema
Scrotal skin ulcers
Sexual dysfunction
Social stigma

Postoperative and Rehabilitation Care

Postoperative care is necessary for optimal results and outcomes.
Dressings should be changed daily or at least every other day for 7 to 10 days or until healed.
An elastic external scrotal dressing with mild compression is recommended, although supportive adhesive tape may also be used.
Any complications such as wound dehiscence, infection, bleeding, swelling, or fever should be addressed promptly.
Follow-up examinations are essential for good outcomes.
Patients should be on appropriate medical therapy for filariasis after surgery.

Deterrence and Patient Education

Mosquito control programs and implementing plans, such as WASH (water, sanitation, and hygiene), have been effective in certain endemic areas.[154] Mass drug administration programs overseen by the WHO have successfully been conducted in efforts to reduce transmission and eliminate filarial infections.[17][106] For example, the WHO has sponsored the GPELF and mass drug administration programs in endemic regions.

Public health education strategies that inform residents about the transmission of infections and proper hygiene practices have also demonstrated improved outcomes in endemic regions.[155] Patient and community education to destigmatize the disorder can help reduce the morbidity caused by filarial hydrocele.

Better access to surgical care centers and improved training of local practitioners to perform surgical interventions have proven helpful.[125]

Increased awareness and understanding of filarial disease among the population can lead to earlier treatment-seeking behavior, reducing the overall health burden of filarial hydroceles. In endemic areas, better knowledge about the disease empowers individuals to seek care sooner, thereby minimizing its health and economic consequences.

Obstacles to the surgical treatment for symptomatic filarial hydroceles include patient preferences for home remedies, fear of surgery, embarrassment, financial concerns (despite free surgery in many endemic regions), logistical issues such as the need for travel, and ignorance that highly successful surgery is available.[156]

Facilitating factors include enhanced public education, local financial support, flexible guidelines for performing surgery, and decentralization of healthcare services, such as the creation of free hydrocele surgery centers or camps in districts with particularly high incidences of filariasis.[156]

Reasons for mass drug administration program failures include poor patient compliance, particularly during the later years of the program. Poor compliance is due to misconceptions that patients with clinical filariasis are not being adequately treated, individuals moving and no longer living at home, and the perception that the absence of symptoms, such as leg swelling, elephantiasis, and hydroceles, indicates successful completion, particularly after several years of drug administration.[157] These issues must be addressed through education.

Pearls and Other Issues

A hydrocele surgical facility assessment tool has been developed to evaluate the readiness of surgical services, specifically before the implementation of hydrocelectomy surgical training and public information campaigns.[158]

The tool assesses key factors such as availability of critical medications, background information, emergency patient transfer services, essential amenities available, existing filarial hydrocele practices, infection prevention protocols, laboratory capabilities, permanent (non-disposable) equipment, and the level of surgical training among clinicians and staff.[158]

This surgical facility assessment tool can identify critical areas required for quality improvement in local healthcare centers before launching local and regional hydrocele surgery campaigns in endemic areas with limited resources.[158]

Enhancing Healthcare Team Outcomes

Many healthcare professionals are involved in the care of patients with filarial hydroceles. Local healthcare workers, nurses, and clinicians are often the first to evaluate patients presenting with symptoms, whereas surgeons and trained local practitioners are involved in the surgical treatment of hydroceles. Public health officials and epidemiologists play key roles in monitoring and analyzing infection patterns at local, regional, and global scales.

Nurses assist with preoperative and postoperative care, patient education, wound care management, hygiene instruction, and dressing changes as necessary. There is strong evidence supporting the use of hygienic measures to manage filarial lymphedema in endemic areas.[159]

Public health outcomes can be significantly improved by the training of local practitioners and staff to perform hydrocelectomy procedures in areas where healthcare and surgical capacity are otherwise limited.[125]

Preventive health educators and workers in these affected regions assist in providing public education, dispensing medications through mass drug administration programs, and setting up mobile clinics. A large network of healthcare team members, both on-site and off-site, contributes to enhancing clinical outcomes in filarial hydrocele management worldwide. Local educational and clinical outreach is critical, as professionals specializing in the lymphatic system and infectious diseases often do not work near affected communities.

Mosquito control programs, such as WASH and similar public health initiatives, have been effective in various regions. These programs are typically supervised by global health organizations, such as the WHO. The primary objectives of these programs are to reduce the spread of mosquito-borne diseases and eliminate infections caused by filaria, a parasite transmitted exclusively by mosquitoes. Significant progress has been made toward achieving these goals.

Other WHO-sponsored initiatives, such as the GPELF and mass drug administration programs, have been quite successful in reducing the incidence of global filariasis and filarial hydroceles. According to the WHO, 51 million people were infected with lymphatic filariasis in 2018, representing a 74% decline since the launch of GPELF in 2000. As a result, more than 870 million people no longer require preventive treatment.

The combination of large-scale public health programs led by the WHO, surgical training in endemic regions, medication delivery, and mobile clinics and surgical units contributes to the improvement in overall care and treatment of patients with filarial hydrocele.[160] Several local barriers that hinder access to treatment and impede the implementation of prevention and eradication strategies should be addressed.[161] A systems-based approach that considers all stakeholders may be better for global filarial prevention and eradication strategies.[162][163]

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