Surgical Treatment of Genital Manifestations of Lymphatic Filariasis: A Systematic Review

Filarial Epididymitis: A Diagnostic Challenge in Pediatric Acute Scrotum

Genital lymphatic filariasis (LF) is a condition that can present both acutely and chronically, complicating its diagnosis due to nonspecific symptoms. This case report describes an 11-year-old boy who presented with symptoms of acute scrotum. Initial Doppler ultrasound suggested acute epididymo-orchitis; however, despite conservative management, the symptoms persisted, prompting surgical exploration. The surgery revealed an edematous epididymis with a cystic lesion, leading to a diagnosis of filarial epididymitis. This case highlights the diagnostic challenges associated with genital filariasis and underscores the importance of considering it in the differential diagnosis of scrotal swelling, especially in endemic regions. Surgical intervention not only confirms the diagnosis but also alleviates symptoms and helps prevent future complications such as infertility.

Conservative and integrated management of genital lymphoedema: case reports for men

Genital oedema of primary and secondary aetiology is gaining increased recognition; it occurs in people of all ages, although accurate prevalence remains unknown. While reports of surgical intervention are quite common, clear description of conservative management is rare, and, overall, diagnosis and management remain largely delayed. Conservative management of genital oedema requires imaginative use of compression bandages and support garments, adapted manual lymphatic drainage, enablement of exercise and activities required for school/employment and diligent skin care to avoid cellulitis. The aim of this article is to present case reports from two European countries discussing five males of differing ages and with genital oedema of different aetiology as examples of conservative management of male genital oedema. The case reports include an adolescent boy with genital oedema since age 1 year, a 49-year-old man treated for penile cancer, a 60-year-old man treated for primary rectal lymphoma, a 48-year-old man with morbid obesity and a 49-year-old with obesity and recurrent infections. The latter two cases integrate surgery and conservative care. Case reports can be a useful means of addressing education needs related to rarer conditions and sharing practice where diagnostic criteria and specific protocols of care are lacking.

Genital Lymphedema and How to Deal with It: Pearls and Pitfalls from over 38 Years of Experience with Unusual Lymphatic System Impairment

Background and Objectives: Conservative treatment represents an essential pillar of lymphedema management, along with debulking and physiologic surgeries. Despite the consistent number of treatment options, there is currently no agreement on their indications and possible combinations. When dealing with unusual lymphedema presentation as in the genitalia (Genital Lymphedema—GL), treatment choice becomes even more difficult. The authors aimed to present their targeted algorithm of single and combined treatment modalities for rare GL in order to face this paucity of information. Materials and Methods: Data were collected from a prospectively maintained database since January 1983, and cases of GL that were managed in the authors’ department were selected. Only patients that were treated in the authors’ institution and presented a minimum follow-up of 3 months were admitted to the current study. Results: From January 1983 to July 2021, 19 patients with GL were recruited. All the patients were male, and their ages ranged from 21 to 73 years old (average: 52). Ten cases (52.6%) presented with ISL (International Society of Lymphology) stage I, five (26.3%) were stage II and four (21.1%) were stage III. GL was managed with conservative treatment (12 cases), LVA (LymphaticoVenous Anastomosis) (3) or surgical excision (4). In a mean follow-up of 7.5 years (range: 3 months—11 years), no major complications occurred, and all cases reached improvements in functional and quality of life terms. Conclusions: Contrary to the predominant thought of the necessity to avoid surgery in unusual lymphedema presentations such as GL, they can be managed using targeted multimodal approaches or by adapting well-known procedures in unusual ways to achieve control of disease progression and improve patients’ quality of life.

The implementation and impact of a pilot hydrocele surgery camp for LF-endemic communities in Ethiopia

BACKGROUND

Ethiopia aims to eliminate lymphatic filariasis by 2020, through a dual approach of mass drug administration to interrupt transmission and morbidity control which includes making hydrocele surgery available in all endemic areas. Locating patients requiring surgery, providing high quality surgeries, and following up patients are all formidable challenges for many resource-challenged or difficult-to-reach communities. To date, hydrocele surgery in Ethiopia has only occurred when a patient has the knowledge, time and resources to travel to regional hospitals. Ethiopia tested the novel approach of using a surgical camp, defined as mobilizing, transporting, providing surgery at a static site, and following up of a large cohort of hydrocele patients within a hospital's catchment area, to address delays in seeking and receiving care.

METHODOLOGY AND RESULTS

Health extension workers mobilized 252 patients with scrotal swelling from a list of 385 suspected hydrocele cases from seven endemic districts in the region of Beneshangul-Gumuz. Clinical health workers and surgeons confirmed 119 as eligible for surgery. Of 70 additional patients who self-referred, 56 were eligible for surgery. Over a two-week period at a regional hospital, 175 hydrocele excision surgeries were conducted. After discharge three days after surgery, trained clinical health workers followed up with the patients on Day 5, Day 8, Day 14 and 1st-month benchmarks with a randomized follow-up of a selection of patients conducted at 9-12 months. There were no post-operative complications upon discharge at Day 3 and 22, while minor complications occurred (12.6%) between Day 3 and one month. The 9-12 month follow-up found patients self-reported an improvement in quality of life, health and economic status.

CONCLUSION

A hydrocele surgery camp was effective at providing a large number of quality surgeries in a short time. Using peripheral health workers to mobilize and follow up patients helped address delays in seeking and receiving quality care. Mainstreaming patient mobilization and follow-up into a community health system could be effective in other countries. The camp's results also influenced two regions in Ethiopia to change their policies in order to offer free hydrocele surgery (including patient transport, consultation, surgery, diagnostic tests and necessary medications).

An unusual case of genital filariasis of the testicular tunics in an Italian patient

At least 27 million men present with urogenital manifestations of genital filariasis (GF). Although there is a large burden of GF in residents in endemic regions, infection in short-term travellers and in non-endemic areas is rare. We report the case of a 75-year-old Italian man referred to our institution for a testicular discomfort. Clinical examination and ultrasound detected a mass of 40×18 mm in the scrotum without signs of varicocele, hydrocele and testicular or epididymal abnormalities. After ineffective medical treatment, the patient underwent surgical excision. Histology demonstrated filarial granuloma with thick cuticles pathognomonic of an adult worm in the testicular tunics. Surgery has a fundamental role in localized cases of GF to remove nematodes from the fibrotic nodules. The present manuscript describes a singular case of GF observed in Italy in a non-immigrant patient with evidence of remnants of an adult worm in the testicular tunics. SIMILAR CASES PUBLISHED: 11.

Significant improvement in quality of life following surgery for hydrocoele caused by lymphatic filariasis in Malawi: A prospective cohort study

Background

Lymphatic filariasis (LF) is a mosquito-borne parasitic infection that causes significant disabling and disfiguring clinical manifestations. Hydrocoele (scrotal swelling) is the most common clinical condition, which affects an estimated 25 million men globally. The recommended strategy is surgical intervention, yet little is known about the impact of hydrocoele on men’s lives, and how it may change if they have access to surgery.

Methodology/Principal findings

We prospectively recruited and followed-up men who underwent surgery for hydrocoele at six hospitals in an LF endemic area of Malawi in December 2015. Men were interviewed at hospitals pre-surgery and followed-up at 3-months and 6-months post-surgery. Data on demographic characteristics, clinical condition, barriers to surgery, post-surgery symptoms/complications and quality of life indicators were collected and analysed pre- and post-surgery, by age group and stage of disease (mild/moderate vs. severe), using chi-square tests and student’s t test (paired).

201 men were interviewed pre-surgery, 152 at 3-months and 137 at 6-months post-surgery. Most men had unilateral hydrocoeles (65.2%), mild/moderate stages (57.7%) with an average duration of 11.4 years. The most reported cause of hydrocoele was it being sexually transmitted (22.4%), and the main barrier to surgery was the cost (36.3%). Pre-surgery, a significant difference in the scrotum side affected was found by age group (X² = 5.978, p = 0.05), and men with severe stage hydrocoele reported more problems with their quality of life than those with mild/moderate stage (t = 2.793; p = 0.0006). Post-surgery, around half of the men reported some pain/discomfort (55.9%), swelling (8.6%), bleeding (3.3%) and infection (5.9%), most of which had resolved at 3-months when the most significant improvements in their quality of life were found (t = 21.3902; p = 0.000). Post-surgery at 6 months all men reported no physical, social, psychological problems and took no time off work.

Conclusion/Significance

Surgery had a significant positive impact on many aspects of a patient’s life, and the expansion of this treatment to all those affected in LF endemic areas would greatly improve the quality of men’s and their families’ lives, and greatly contribute to the global goal of providing universal health care.

Lymphatic filariasis is a mosquito-borne infection that causes significant disabling and disfiguring clinical conditions. Hydrocoele (scrotal swelling) is the most common condition affecting an estimated 25 million men worldwide. Surgery is the main intervention, however, there is limited information on its impact. This study assessed men before and after surgery in an endemic region of Malawi, to identify potential barriers and determine how surgery may change the quality of their life. Before surgery, 201 men reported to have moderate to severe problems with many aspects of their life including pain, mobility, usual activities, self-care, social issues, psychological health and ability to work. The main barrier to hydrocoele surgery was the cost, including associated transport and accommodation costs. After surgery, follow-up surveys at 3-months and 6- months found that men reported minimal or no physical, social, psychological problems and took no time off work. Surgery had a significant positive and lasting impact on men’s lives. National programmes need to advocate for resources to increase funding to support men and the uptake and demand for quality surgical services.

Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

Burden of hydrocoele assessed from medical and surgical records in a lymphatic filariasis endemic country, Samoa

Background

Samoa is a Pacific Island country that has long been known to have a high burden of lymphatic filariasis. Little has been documented about the burden of disability due to the chronic complications of the disease. We examined the rates of hydrocoele amongst the Samoan male population to better understand the situation.

Methods

Information on numbers of suspected hydrocoele cases in men aged 18 years and older from 2006 to 2013 was sought using ICD-10 codes and/or keywords from three sources: the hospital patient information system plus the surgical clinic and operating theater records in Tupua Tamasese Meaole and Malietoa Tanumafili II hospitals in Samoa. Chart review of suspected hydrocoele cases was used to confirm the diagnosis of hydrocoele amongst suspected cases. The following data items were extracted from patient records where available: date of diagnosis, age, village, hydrocoele characteristics (duration, size, and volume), history and cause of injuries, whether lymphatic filariasis was a differential diagnosis, whether ultrasound scan was used to verify diagnosis, and details of any surgery performed. Population data were obtained from the Samoa Bureau of Statistics.

Results

There were 535 suspected cases identified from the 3 sources between 2006 and 2013, of which 328 were diagnosed as hydrocoele; charts for 56 suspected cases (10.5%) could not be located. The mean age of men with hydrocoele was 49.2 years. The proportion of men aged ≥ 18 years diagnosed with hydrocoele over the study period was 0.62% (328/52,944). North West Upolu had the highest proportion amongst the four regions of Samoa (p < 0.001). The proportion of men presenting with hydrocoele increased with age (p < 0.001). 14.3% of patients had an injury that could have contributed to the hydrocoele. Only 4.0% of all patient records had lymphatic filariasis recorded as a differential diagnosis. 60.7% of all patients with hydrocoele had some form of surgery, with no difference between regions (p = 0.276). The majority of surgeries were hydrocoelectomies, where the tunica vaginalis is everted. The mean age of patients that had surgery was 48.2 years. It was difficult to estimate hydrocoele size and duration due to non-standardized way of reporting.

Conclusions

This study used multiple sources to document the number of hydrocoele cases that presented annually to medical facilities in Samoa. This represents a minimum estimate of the burden since some cases may have not presented for treatment. The numbers presenting have fluctuated over the years (2006 to 2013), and improvements in the reporting system are needed. The health system needs to consider ways to address a large number of patients that still require surgery, as well as conducting follow-up of those that did receive surgery. Additionally, clinicians should consider lymphatic filariasis as a differential diagnosis for hydrocoeles.

Global surgery and the sustainable development goals

Background

The field of global surgery has gained significant recent momentum, catalysed by the 2015 publication of the Lancet Commission on Global Surgery, Disease Control Priorities 3 and World Health Assembly resolution 68.15. These reports characterized the global burden of disease amenable to surgical care, called for global investment in surgical systems, and recognized surgery and anaesthesia as essential components of universal health coverage.

Methods

A strategy proposed to strengthen surgical care is the development of national surgical, obstetric and anaesthesia plans (NSOAPs). This review examined how NSOAPs could contribute to the achievement of sustainable development goals (SDGs) 1, 3, 5, 8, 9, 10, 16 and 17 by 2030, focusing on their potential impact on the healthcare systems in Ethiopia, Tanzania and Zambia.

Results

Due to the cross-cutting nature of surgery, obstetrics and anaesthesia, investing in these services will escalate progress to achieve gender equality, economic growth and infrastructure development. Universal health coverage will not be achieved without addressing the financial ramifications to the poor of seeking and receiving surgical care. NSOAPs provide a strategic framework and a data collection platform for evidence-based policy-making, accountability and implementation guidance.

Conclusion

The development and implementation of data-driven NSOAPs should be recognized as a powerful road map to accelerate achievement of the SDGs by 2030.

Evaluation and management of adult acquired buried penis

Adult acquired buried penis represents the clinical manifestation of a wide spectrum of pathology due to a variety of etiologies. It can be related to obesity, a laxity in connective tissue, lichen sclerosis (LS), complications from penile/scrotal enlargement surgery, scrotal lymphedema, or hidradenitis suppurativa (HS). Buried penis can be associated with poor cosmesis and hygiene, voiding dysfunction, and sexual dysfunction. Evaluation and management of buried penis largely depends on etiology and degree of affected tissue. It is an increasingly common problem seen by reconstructive urologists and here we present several frequently seen scenarios of buried penis and management options.

The History of Bancroftian Lymphatic Filariasis in Australasia and Oceania: Is There a Threat of Re-Occurrence in Mainland Australia?

Lymphatic filariasis (LF) infects an estimated 120 million people worldwide, with a further 856 million considered at risk of infection and requiring preventative chemotherapy. The majority of LF infections are caused by Wuchereria bancrofti, named in honour of the Australian physician Joseph Bancroft, with the remainder due to Brugia malayi and B. timori. Infection with LF through the bite of an infected mosquito, can lead to the development of the condition known as elephantiasis, where swelling due to oedema leads to loss of function in the affected area and thickening of the skin, 'like an elephant'. LF has previously been endemic in Australia, although currently, no autochthonous cases occur there. Human immigration to Australia from LF-endemic countries, including those close to Australia, and the presence of susceptible mosquitoes that can act as suitable vectors, heighten the possibility of the reintroduction of LF into this country. In this review, we examine the history of LF in Australia and Oceania and weigh up the potential risk of its re-occurrence on mainland Australia.

Surgical Reconstruction of Giant Penoscrotal Lymphedema in Sub-Saharan Africa

OBJECTIVE

To present management challenges, surgical technique, and outcome associated with penoscrotal reconstruction in patients with giant scrotal lymphedema in sub-Saharan Africa.

METHODS

A prospective study of all patients who had penoscrotal reconstruction for giant scrotal lymphedema at our university teaching hospital between January 2003 and December 2012 was carried out. Patients' preoperative clinical evaluation findings, operative technique, and postoperative course were reviewed after obtaining ethical approval and informed consent from the patients.

RESULTS

Nineteen patients with giant scrotal lymphedema presented to us during the period of study; out of which, 11 had surgical excision and were studied. Their mean age and median duration of symptoms were 48.5 years and 11.5 years respectively. They all had surgical reconstruction using modified Charles procedure by the same combined team of urologists and plastic surgeons. Scrotal hematoma (27.3%) and superficial surgical site infection (18.2%) were complications encountered postoperatively. One patient (9.1%) had recurrence within 24 months, requiring repeat excision.

CONCLUSION

Giant scrotal lymphedema poses severe physical challenge to the sufferer. Surgery remains the only hope to reduce penoscrotal size. Combined effort of urologic and plastic surgeons is essential for reconstruction.