45 ISSN East Cent. Afr. J. surg

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1 45 ISSN Eat Cent. Afr. J. urg Biochemical Analyi of Hydrocele fluid in Male with hydrocele in a Filariai endemic Community: An experience at urgical camp in Tanga Mchembe M.D, Mwanga A, Ramadhan H Department of Surgery- MUHAS, Dar e Salaam - Tanzania Correpondence to: Mabula Mchembe, mchembem@gmail.com Background: Adult hydrocele i a very common urological dieae in mot of the ub- Saharan African countrie; the reported incidence of adult hydrocele i up to 20 28% in ome lymphatic filariai endemic communitie. The aociated economic burden involved with the treatment of hydrocele can be ignificant in thee motly poor reource economie. There i hortage of publihed data regarding biochemical analyi of hydrocele fluid in Tanzania and the tudy area in particular. Thi tudy wa conducted in our local etting in an endemic filariai affected area to decribe and highlight the biochemical component of adult male hydrocele fluid, the clinical appearance of the hydrocele fluid and tunica vaginali at operation. Method: Thi wa cro-ectional decriptive tudy, done at Pangani to all patient een at the camp in the year 2011 and found to have hydrocele in one or both ide. Demographic data were entered, neceary invetigation were taken and patient were cheduled for operation. Statitical data analyi wa performed uing SPSS verion Reult: A total of 81 patient were tudied, all being Male. The commonet age of patient at diagnoi wa 60 year (39%) followed by the age range between year (34%). Majority of patient had their dieae duration of < 5year (41 patient) followed by patient with the dieae > 10 year (22 patient). In term of location of the hydrocele, mot of the patient had their dieae located on the left ide (24 patient) followed by thoe with bilateral dieae (22 patient). The clinical hydrocele fluid appearance at operation wa found to be traw coloured in the majority of cae (48 patient), followed by the clear yellow fluid (19 patient). For the tunica vaginali characteritic at operation, 34 patient (the majority) had thin and oft tunica vaginali. Mot of the electrolyte teted in hydrocele fluid (Na +, K +, Ca 2+ and Cl - ) were found to be within normal range with the known erum normal level. Concluion: Biochemical electrolyte compoition of adult male hydrocele fluid in filariai endemic area community i almot imilar to normal erum major electrolyte. Key word: Adult male hydrocele fluid, biochemical analyi in an endemic filariai community, urgical camp, Tanzania. Introduction A hydrocoele i an abnormal accumulation of fluid mot commonly occurring in the crotum in men, or the labia majora in women. Hydrocele can be claified a either primary (congenital) or econdary (acquired) baed on the time at onet, and alo can be claified a communicating (if proceu vaginali i communicating with the peritoneal cavity) and non-communicating (if limited to the crotum and no communication with the peritoneal cavity 1,2,3. Non- communicating type of hydrocele i caued by an imbalance between ecretion, aborption and drainage of fluid in the crotal ac. Increaed crotal fluid ecretion may be caued by local inflammation of the teti and epididymi from bacteria or virue, while poor aborption commonly reult from men and thickening of the ac or lymphatic malfunction 4,5. Noncommunicating hydrocele are the mot common 5,6,7,8,9 type of hydrocoele globally, affecting more than 30 million boy (WHO 2013). Adult hydrocoele i a very common urological dieae in mot of the ub-saharan African countrie; the reported incidence of adult hydrocoele i up to 20 28% in ome lymphatic COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

2 46 ISSN Eat Cent. Afr. J. urg filariai endemic communitie. The aociated economic burden involved with the treatment of hydrocoele can be ignificant in thee motly poor reource economie 2,3,4. Hydrocoele i the commonet manifetation of bancroftian filariai among male and filarial hydrocoele and chylocele account for up to 80% of hydrocoele in endemic area. Hydrocoele fluid i imilar to other tiue fluid in the body, uch a peritoneal fluid. It i a olution of motly water, electrolyte, and protein. A 1994 tudy revealed that hydrocoele fluid had higher level of calcium, albumin, total protein and creatine-kinae, and lower level of potaium, apartate tranaminae, and alkaline phophatae than blood erum. The hydrocoele fluid itelf i amber in colour and the ediment how a characteritic predominance of vacuolated meothelial cell, fibrin, old blood clot, choleterol cleft, and calcium dut 10,11,12,13 ]. Clinico-Pathologically filarial infection related hydrocoele it i characterized by a ditended, generally thickened tunica, vaginali with hyalinization and fibroi of the uberoal layer, diorganization of the mucle layer, lymphoid and foreign-body giant cell infiltration, and, in extreme cae, calcification 5,6,7,8,9. Pathogenei of econdary hydrocoele follow obtruction of the teticular venou or lymphatic veel i aociated with acute hydrocoele development. Venou or lymphatic obtruction can be caued by torion of the teticle, lymphoma, or the death of paraitic filarial worm. In the temperate climate of Europe, North and South America, and China, mot primary hydrocele of adult male are idiopathic. In tropical region, mainly in LMIC, lymphatic filariai (LF) i the mot ignificant rik factor for the development of noncommunicating hydrocoele. LF i caued by infection with the moquito-borne worm, Wuchereria bancrofti (Michael, Bundy, and Grenfell 1996; WHO 2005). LF i a complex dieae affecting everal part of male genital anatomy. The biological predilection of the adult filarial worm to live and reproduce in the lymphatic channel of the crotum mean that greater than 50 percent of infected men will, with age, develop chronic hydrocele (Addi and other 1995; Eigege and other 2002; Mathieu and other 2008). Hydrocele caued by LF are ometime called filaricele. In tropical or ubtropical zone, the Culex, Aede, and Anophele moquitoe carry the filarial paraite. The cycle of infection require that moquitoe depoit larvae on the hot kin, and thee migrate through the puncture ite to the venou ytem and lymphatic, where they mature into adult. Net of the male and female adult are mot commonly identified in the male crotal lymphatic, where they produce the firt-tage larvae (microfilariae) that are ubequently conumed by moquitoe 5,6,7. Cytic welling of the crotum are invariably painle and can attain very large ize without cauing much dicomfort to the patient. However, thee are a common urgical problem which affect the phyical wellbeing of the patient, it i rather a mental agony for him. Thee welling are eaily acceible for clinical examination Indication for treatment include pain, dicomfort and the cometic appearance of the crotum or the patient wih 6,7,8,9. The pectrum conit of hydrocoele, epididymal cyt, permatocele, hematocele, pyocele, chylocele, paraitic cyt and ebaceou cyt. There i lack of information regarding biochemical electrolyte component of hydrocoele fluid in Tanzania and the tudy area in particular. Thi i partly due to a lack of publihed local data regarding thee fluid. Thi tudy wa deigned to decribe the electrolyte component in hydrocoele fluid and the clinicopathological appearance of fluid and tunica vaginali in a filarial endemic community. The main objective of thi tudy wa to analyze the electrolyte component of hydrocoele fluid and clinico-pathological appearance of the fluid and tunica vaginali in an endemic filarial community. The pecific objective were to determine the age and duration of hydrocoele among operated patient in an endemic filarial community. COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

3 The tudy wa further aimed at: 47 ISSN Eat Cent. Afr. J. urg 1. Determining the characteritic of hydrocoele fluid and tunica vaginali in an endemic filarial community 2. Etablihing the common ite and duration of hydrocoele in an endemic filarial community 3. Determining the level of common electrolyte in hydrocoele fluid in an endemic filarial community Patient and Method Thi wa a propective decriptive cro-ectional tudy of conecutive erie of 81 male adult patient with hydrocoele een and operated at the five day urgical camp conducted in Pangani-Tanga in September All male adult patient een at the camp and found to have hydrocoele in one or both ide of the crotum were included. Patient with hydrocoele econdary to acite, congetive heart failure, of acute onet, and thoe of pediatric age le than 18 year were excluded from thi erie. It i aumed that mot of the cae were of filarial origin baed on hitory and phyical examination and on the fact that the hopital catchment area of thi tudy i motly in the coat area and i conidered an endemic region for lymphatic filariai. Preoperative evaluation included detailed hitory of the dieae and included quetion on onet of illne, duration, preence of pain and other relevant medical hitory. All the patient had preoperative phyical examination of the crotum, lower extremitie and inguinal region, hemoglobin level, erum blood ugar and urinalyi wa ordered a routine tet. The patient were couneled and went ahead to have hydrocelectomy uing the partial exciion technique. The main indication for urgery wa the patient' deire motly due to the large ize of the hydrocoele. At operation, Aeptic technique wa ued to prepare the operative area and Local anetheia wa ued (lignocaine +/- edation), lateral or Midline raphe longitudinal inciion wa made and hydrocele wa identified and dierted out with intact tunica vaginali. Sterile Syringe 10ml and needle ued wa ued to draw fluid from the tunica Vaginali. About 10 ml hydrocoele fluid wa drawn, put in Vacuntainer terile bottle and tored in Refrigerator at 8 0 c and ample were ent for biochemical analyi. Appearance of fluid and tatu of the tunica vaginali wa recorded. Statitical data analyi wa performed uing tatitical package for ocial cience (SPSS) verion 17.0 for Window (SPSS, Chicago IL, U.S.A). The median + (IQR) and range were calculated for continuou variable wherea proportion and frequency table were ued to ummarize categorical variable. Chi-quare (χ2) tet were ued to tet for the ignificance of aociation between the independent (predictor) and dependent (outcome) variable in the categorical variable. The level of ignificance wa conidered a P < Multivariate logitic regreion analyi wa ued to determine predictor variable that predict the outcome. Reult In reference to table above, there wa no ignificant aociation between patient age group with duration of their dieae a it i hown by X 2 = 2.8 and p-value= Table 2, how the relationhip between duration dieae and ite (location) of the hydrocele and it wa revealed that there wa an aociation a evidenced by X 2 = 12.4 and p-value = Table 3, how there wa no aociation between duration of dieae and fluid type whether traw or yellow a revealed byx 2 = 2.7 and p-value = 0.6. COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

4 48 ISSN Eat Cent. Afr. J. urg Table1. Age Group in Relation to Duration of Illne in Year Age 5 yr 5-10 yr 10 yr Total (34.2%) 6 (33.3%) 7(31.8%) 27 (33.3%) (26.8%) 8 (44.4%) 9 (40.9%) 28 (34.8%) 60 16(39%) 4 (22.3%) 6 (27.3%) 26 (32.1%) Total 41 (100%) 18 (100%) 22 (100%) 81 (100%) Table 2. Duration of Dieae in Relation to Location of Hydrocele Duration Right Left Bilateral Total 5 8 (53.3%) 17 (70.8%) 16 (38.1%) 41 (50.6%) (26.7%) 8 (25%) 9 (19%) 18 (22.2%) 10 3 (20%) 4 (4.2%) 6 (42.9%) 22 (27.2%) Total 15 (100%) 24 (100%) 22 (100%) 81(100%) Table 3. Duration of Illne in Relation to Fluid Type of Hydrocele Duration Straw Clear yellow Thick yellow Total 5 22(45.8%) 12 (63.2%) 7(50%) 41 (50.6%) (25%) 4(21.1%) 2 (14.3%) 18 (22.2%) 10 14(29.2%) 3(15.7%) 5 (35.7%) 22 (27.2%) Total 48 (100%) 19 (100%) 14 (100%) 81 (100%) Table 4. Duration of Dieae in Relation to Tunica Characteritic Duratio Soft & thin Thick & hard Calcified Total 5 20(58.8%) 14 (51.9%) 4 (20%) 18 (22.2%) (17.7%) 8(29.6%) 7(35%) 41 (50.6%) 10 8(23.5%) 5(18.5%) 9 (45%) 22 (27.2%) Total 34 (100%) 27 (100%) 20 (100%) 81 (100% Figure 1: Sodium level COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

5 49 ISSN Eat Cent. Afr. J. urg Table 4 how that there wa no ignificant aociation between duration of dieae and tunica characteritic of the hydrocele a hown by X 2 = 5.7 and p-value= 0.2. Electrolyte level found on hydrocele A hown from the figure above, equal and above 146 mmol/l wa a commonet odium level found to patient with hydrocele followed by mmol. From figure 2, it i hown that mmol/l wa the highet level of potaium found to majority of patient with hydrocele The highet chloride level found in the majority of patient with hydrocele wa 108 mmol/l and above a it i revealed by the figure above. A hown from figure 4, equal and above 2.65 mmol/l wa a highet calcium level found to mot of patient with hydrocele. Figure 2: Potaium level Figure 3. Chloride level COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

6 50 ISSN Eat Cent. Afr. J. urg Figure 4. Calcium level Dicuion In thi tudy, 81 patient were operated for crotal hydrocele. None of thee patient on preoperative evaluation or on urgical exploration wa diagnoed with a more eriou underlying pathology. The importance of detailed hitory of illne and good phyical examination cannot be underetimated. In thi tudy, only hitory and phyical examination wa ued to diagnoe hydrocele and plan urgery for the diagnoed patient. Thi i different from other tudy 4 whereby tranillumination tet and crotal ultraound i inited to be done before urgery. Tranillumination tet are not very ueful in dark kin individual and ultraound i alo expenive to conduct in low ocial income ocietie. Therefore clinical acumen i highly needed for the diagnoi and final deciion on the treatment of thee patient. The commonet age of patient at diagnoi wa 60 year (39%) followed by the age range between year (34%). Majority of patient had their dieae duration of < 5year (41 patient) followed by patient with the dieae > 10 year (22 patient). Age group in relation to the duration of the dieae, in thi tudy howed no any aociation. Hence, it eem that longtanding hydrocele are motly benign in nature poibly in contrat to hydrocele of acute onet. Duration of the dieae with repect to location of the hydrocele, finding on thi tudy how that many patient had left ided hydrocele followed by bilateral hydrocele at the duration of le or equal to five year. Thi can poibly be explained that thoe who had their dieae at that duration and location of hydrocele turned up well for the urgical camp than other. Clinical appearance of the hydrocoele fluid at operation in thi tudy howed that majority of patient had traw coloured and clear yellow fluid; thi i the ame finding a reported by Nazim and Devrie et al. The tunica vaginali wa found to be oft and thin among the majority of the patient operated in thi tudy. Thi could be due to the hort duration of the illne among thee patient a mot of them had their dieae in le than five year. However, imilar finding have been reported by other tudie 5, 6, 7, 8, 9, 10. Baed on the pathophyiology of hydrocele dieae in filarial affected communitie, thi tudy expected to find high level of the invetigated electrolyte (Sodium, potaium, chloride and calcium), but to the contrary all the teted electrolyte were found to be normal compared to the known erum level. Thi tell that, depite the obtructive effect of filarial worm, yet the electrolyte balance mechanim in the tunica vaginali of filarial affected crotum till function normally. Similar finding have alo reported by other tudie 13,14,15. Very few cae had their COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

7 51 ISSN Eat Cent. Afr. J. urg electrolyte below the normal erum level. However, tudy by Mandlala et al 13, reported high level of calcium, albumin and creatine-kinae in hydrocoele fluid and low level of potaium, alanine tranaminae and apartate tranaminae 14. Concluion Hydrocoele fluid in filarial affected communitie do contain the ame electrolyte level a erum and only few cae contain low level a compared to known erum level. The tunica vaginali of filarial related hydrocoele are oft and thin in mot cae epecially thoe with hort duration of the dieae and majority of the hydrocoele fluid i traw or clear yellow in colour. Study limitation Few cae were obtained at the urgical camp. Due to limitation of reagent, only common electrolyte were teted Acknowledgement We are grateful to our reident in the department of Surgery for their upport in participating in the urgical camp and data collection. We alo like to thank all member of National intitute of medical reearch Tanzania and all the urgical and medical taff at pangani hopital. Reference 1. Chritopher Fowler. The teti and crotum. chapter 79.in;bailey and love hort practice of urgery, Ruel R.C.G.et.al.(ed).24 th edition,london; Arnold publiher2004; Marc Goldtin.urgical management of male infertility and other crotal diorder.vol.1.in;campbell urology,patrickc.walh, Alan B Retik, Vaughan(ed).8 th edition. Edinburgh:WBaunder company 2002; Margaret. Surgery of the groin and External genitalia. In: Farquharon Text book of operative general urgery, Farquaron M, Morgan B Hodder (ed). 9 th edition. Edinburgh: Arnold Publiher 2004; Hohino H, Nakajima N, Hihara T, Hayakawa M, Kawamura N. What are the content of a hydrocele teti?tokai J ExpClin Med Mar;9(1): devrie, CR The Role of the Urologit in the Treatment and Elimination of Lymphatic Filariai Worldwide. BJU International 89 (uppl 1) Simonen PE, Meyrowitch DW, Makunde WH, Magnunen P. Bancroftianfilariai: The pattern of microfilaraemia and clinical manifetation in three endemic communitie of northeatern Tanzania. Acta Trop. 1995;60: Thoma G, Richard FO, Jr, Eigege A, Dakum NK, Azzuwut MP, Sarki J, et al. A pilot program of ma urgery week for treatment of hydrocele due to lymphatic filariai in central Nigeria. Am J Trop Med Hyg. 2009;80: Chukwudi O, Okorie CO, Loui L, Piter LL, Ping Liu. Long tanding hydrocele in adult Black African: I Preoperative crotal ultraound jutified? NigerMed J2011; 52: Jat N, Bano F, Memon IA, Memon MS, Azmi MA. Primary vaginal hydro- cele; different urgical procedure: a comparative tudy. Profeional Med J 2014;21(5): Gooding G A,Leonhardt W C, Marhall G, Seltzer MA, Preti J C. CholeterolCrytal in hydrocele:onograhpic detection and poible ignificance. AJR am J Reontgenol 1997;169(2): Norõe, J., D. Addi, A. Cedenho, J. Figueredo-Silva, G. Lima, and other Pathogenei of Filarial Hydrocele: Rik Aociated with Intracrotal Nodule Caued by Death of Adult Wuchereriabancrofti. Tranaction of the Royal Society of Tropical Medicine and Hygiene 97: COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)

8 52 ISSN Eat Cent. Afr. J. urg 12. Rodriguez, W.C., D.D. Rodriguez, R.F. Fortuño The Operative Treatment of Hydrocele: A Comparion of 4 Baic Technique. Journal of Urology 125: Madlala TS, Rencken RK, Bornman MS, Reif S, Joubert HF, Van der Merwe CA. Biochemical analyi of tunica vaginali fluid in patient with or without idiopathic hydrocele. Br J Urol Oct; 74(4): Sivam NS 1, Jayanthi S, Ananthakrihnan N, Elango A, Yuvaraj J, Hoti SL, Pani SP. Tropical vaginal hydrocele: are they all filarial in origin. Southeat Aian J Trop Med Public Health Dec;26(4): Ku JH. The Exciion, Plication and Internal drainage technique- a Comparion of the reult for idiopathic Hydrocoele. Britih Journal of Urology International 2001; 87: COSECSA/ASEA Publication -Eat & Central African Journal of Surgery. Nov/Dec 2014 Vol. 19 (3)