District NTD Training module

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1 Revision Date: 13 May 2015 District NTD Training module Learner s Guide Module 6: Morbidity Management and Disability Prevention (MMDP) Part I: Introduction Session purpose: Session 3: Hydrocele Surgery This session is designed to give an overview of hydrocele diagnosis and surgery for district-level health and public health staff. The focus is on case finding and clinical care. Prerequisite modules/sessions: Module 1, Session on Lymphatic Filariasis? Session 1. Planning MMDP Activities at District Level Learning objectives: By the end of this session, participants will understand: How to diagnose and treat hydrocele How to assess burden and find cases of hydrocele How to monitor and evaluate hydrocele surgery activities Abbreviations and acronyms: GPELF: Global Programme to Eliminate Lymphatic Filariasis LF: lymphatic filariasis M&E: monitoring and evaluation MDA: mass drug administration MMDP: morbidity management and disability prevention Definitions:

Part 2: Key concepts Hydrocele What is hydrocele? Hydrocele is characterized by fluid accumulation in the sac covering the testes. Swelling increases over time and the scrotum can become enormous.

Note: There are other genital conditions related to LF, but they will not be covered in this session, including: Lymphoedema of the genital organs, which requires more specialized care.

2 Part 2: Key concepts Hydrocele What is hydrocele? Hydrocele is characterized by fluid accumulation in the sac covering the testes. Swelling increases over time and the scrotum can become enormous. There is no diagnostic test to confirm if hydrocele is caused by LF, but surgery for hydrocele is the same regardless of the cause. Note: There are other genital conditions related to LF, but they will not be covered in this session, including: Lymphoedema of the genital organs, which requires more specialized care. Epididymitis, funiculitis (inflammatory swelling of the spermatic cord) characterized by severe pain, tenderness and swelling of scrotum with fever and rigor. What are the consequences of hydrocele? People with chronic manifestations are often unable to complete basic daily activities. They can be unable to move. They can be in constant pain. They sometimes cannot work. Liability to trauma whilst working or cycling Interference with urination (penis buried in the scrotal sac) This contributes to reduced productivity in the community, but can be improved by appropriate care of patients.

3 People with chronic manifestations often feel stigmatized and therefore hide their condition. They can be depressed. They can be isolated in their houses. They can have trouble finding marriage prospects. While mass drug administration (MDA) is used to interrupt transmission of LF, patients with chronic manifestations need to be cared for through the health system. MDA is usually implemented by the public health disease control district staff, but it is usually nurses and doctors who care for patients with lymphoedema. Hydrocele activities Look for cases of scrotal swelling in the community Diagnose cases Surgery Monitor and report Evaluate See Powerpoint slide for more information. Diagnosis LF s effect on lymphatic system The lymphatic system has 2 functions: 1. transport waste and excess fluid produced in the body, and 2. fight infections as part of the body s defense system Worms cause dilation of lymph vessels, which causes stasis of lymph liquid and an accumulation of liquid around the tissues. Diagnosis of scrotal swelling Presence of fluid in the scrotal sac, which can cause swelling Not linked with presence of parasite Patients might not have microfilaremia, antigen or antibodies to LF Hydrocele can resemble hernia LF MMDP activities should include surgery for hernia cases as well, as it is difficult to distinguish during case finding Various stages based on size - have been proposed for classification of hydrocele, but none has been universally adopted Burden assessment The following table shows the positives and negatives of different methods to assess the number of cases of hydrocele that exist in a district. These methods can be used if the information already known in the district is not enough to make decisions about platforms of care to use or supplies needed.

4 Due to stigma, hydrocele is often underreported. Some programmes have found it useful to use a trained male nurse to go door-to-door to look for hydrocele cases. Physical examination is the best way to determine if someone has lymphedema. Survey questionnaires, with photos, can also be used, but often underestimate the number of patients. Method Pros Cons Census by community health workers/pre- MDA registration Post-MDA coverage survey or TAS - Most comprehensive method if done well, can get line listing of cases - Provides prevalence estimate - Easier to include in communitybased TAS than school-based TAS - Patients need to be followed up by trained nurses or doctors to confirm diagnosis - Data often do not make it past the health center level to higher levels - Self-reported patients need to be followed up by health staff to confirm Populationbased national surveys - Provides prevalence estimate - Can add a few questions about LF morbidity to another survey, such as the WHO disability model survey - Still need to find all the cases - Has to be coordinated at a national level - Timing depends on health programme implementing the survey Key informant interviews - Flexible, low cost - Large variations in accuracy - Possibility of underreporting of cases Active case finding Districts might need to use active methods to find all hydrocele cases. The district should use the local terms for hydrocele. What is the main message during active case finding? Individuals with swollen scrotum to report to nearest health center How is this message disseminated? Village chiefs Town criers Radio broadcasts Community health workers/volunteers going door-to-door Posters at health centers, posts and dispensaries How are patients registered? Suspected patients confirmed by trained nurse

5 Hydrocele surgery Recorded in LF consultation register What should happen during a pre-surgical visit? Confirm whether hydrocele or hernia or both Confirm that patient is qualified for surgery Do not operate if patient has uncontrolled diabetes Do not operate if patient is jaundiced Refer if patient has complicated hydrocele Get informed consent from patient Pre-surgery actions Good bath day before and morning of surgery Close cutting or shaving of scrotal hair Antibiotics day before and morning of surgery Hydrocele surgery Useful to involve surgeons and nurses in practical training workshops to ensure quality surgeries Surgery is curative if properly conducted. Quality pre- and post-operative care are important components that help make this surgery successful.

Before After Antibiotic coverage should continue for 5 days post-surgery and analgesia should continue for 5-7 days. Sterile bandage changes should be done on days 3, 5, and 7.

Surgical outcomes are better in patients who are followed up for bandage changes by trained wound care nurses. Patients should ideally stay in the hospital for 7 days post-surgery.

6 Before After Antibiotic coverage should continue for 5 days post-surgery and analgesia should continue for 5-7 days. Sterile bandage changes should be done on days 3, 5, and 7. If there is a sign of local infection on Day 3, bandages should be changed daily until the incision heals nicely. Surgical outcomes are better in patients who are followed up for bandage changes by trained wound care nurses. Patients should ideally stay in the hospital for 7 days post-surgery. On day 7, they can be released if the wound is nicely closed and dry or they live close enough to return for further bandage changes. It is important to carefully document the state of the surgical wound at each postoperative examination. This should include any complications, such as haemorrhage, haematoma, infection or recurrence. After day 7, intermittent follow up should be done by trained local nurses to ensure no future complications and to look for recurrence. The follow up on Day 14 should examine the scrotum. Follow up should also occur at 1 month, 2 months, 6 months and 1 year. Patient counselling Psychological counselling can be necessary for all hydrocele patients, especially those with severe disease Patients can suffer from sexual dysfunction, shame, isolation, and intense chronic pain and suffering If psychological counselling is available, health center staff should know how to refer patients to these services Before and after surgery, patients need to be told what the risks are and what to expect Nurses and doctors need to assure patients understand the recovery time from the surgery and the care needed during this time

Free drugs (antiseptics for local care, analgesics and antibiotics) given free to the patients 7 days hospital stay Post-operative care in

7 Health care system Service delivery platforms Surgical camps Mass surgery weeks Routine surgery in regular hospital setting Example of a hydrocele surgery camp 25 patients could be operated on per day by a team of 4 surgeons corresponding to 125 patients during a week period camp Free drugs (antiseptics for local care, analgesics and antibiotics) given free to the patients 7 days hospital stay Post-operative care in health centres Costs vary by region. But, in general, 150 USD / person (in the camp or as outpatient) or 250 USD/person (inpatient, 7 days) is a good estimate.

8 Role of health care workers 1. Find potential cases a. Can be done as community screening (CHWs, nurses) 2. Confirm cases (district hospital doctor or surgeon) 3. Pre- and post-surgery counselling 4. Perform the hydrocele surgery a. Uncomplicated hydroceles (district hospital doctor or surgeon) b. Complicated hydroceles (provincial or regional referral hospital surgeon or urologist) 5. Follow up patient s condition post-surgery a. Important to ensure they are appropriately caring for themselves and have not developed infections or other complications Role of the District NTD Management Team This role will vary by country, but usually includes the following responsibilities: 1. Oversee district MMDP data. a. Liaise with regional/central levels to ensure district data is accurate/updated based on surveys, MMDP implementation activities, etc. 2. Coordinate planning and implementation of situation analysis at district level (see module 6.1). 3. Plan and implement surveys and data collection activities. a. Often coordinated with the national programme, this could include burden assessments and/or line listing of cases. 4. Plan and implement training on hydrocele management for health care workers and patients. a. If a national training-of-trainers has taken place, this would involve planning with trainers from the regional level to lead the district-level training. The training of health workers could take place at regional level, combined with other districts. b. This could be done in combination with lymphoedema management training. 5. Plan and implement training on hydrocele surgery for surgeons and surgical nurses. a. It is useful to coordinate with the national programme to determine if there are certified trainers for hydrocele surgery available to visit the district hospital. 6. Work with district hospital to determine a platform and plan to provide surgery to hydrocele patients. 7. Supervise activities to ensure quality/promote monitoring and evaluation. 8. Report to regional NTD focal point.

9 Monitoring and Evaluating The following information should be gathered in each patient s chart. Patient information Diagnosis Duration of scrotal swelling Surgery data Complications Name Age Address Telephone Hydrocele Hydrocele+Hernia Hernia Date Technique Antibiotics Analgesia Duration of wound healing Haematoma Infection Anaemia Death Recurrence Psychosocial wellbeing Occupation Family life Satisfaction with procedure Health centers should report to districts every 6 months (or every year): Number of hydrocele patients in health center Number of hydrocelectomies in previous 6 months Districts should report to national level every 6 months (or every year): The indicators above, aggregated by health center Measuring availability of care should be done within 2 years of submitting dossier: Percentage of district reference hospitals providing hydrocele surgery Measuring quality of care can be done through a special survey that collects data on: Percentage of patients who died within 5 days of surgery Percentage of patients with infection within 5 days of surgery Percentage of patients with haematoma with 5 days of surgery Percentage of patients who had a recurrence of hydrocele after surgery

10 The national LF programme might visit some districts to implement a direct inspection of the direct reference hospital to see how care for hydrocele is being provided. Coordination and integration Hydrocele surgery can be integrated with: Hernia surgery Obstetric fistula District-level surgical strengthening initiatives E.g., training for surgical nurses on infection control could include information specific to hydrocele surgery Part 3: Session activities Activities: Activity 1: Discuss the following: Which methods of active case finding do you think would work best to find all hydrocele cases in your district? Once cases of hydrocele have been found and diagnosed, which type of service delivery platform would you recommend be used in your district for hydrocele surgeries? Why? Activity 2: If additional time is available, complete the Excel Planning Template for hydrocele MMDP activities in your district.

11 Part 4: Summary job aide Key words Assess burden Find suspected cases Diagnose cases Determine service delivery platform Conduct hydrocele surgeries Monitor and report Evaluate Key action points for district level personnel Select a method above to assess the number of cases of hydrocele that exist in your district Actively find hydrocele cases by disseminating the message that those with swollen scrotums should report to the nearest health center to be registered and treated Use the images and list of symptoms above to confirm suspected cases of hydrocele Identify the best service delivery platform surgical camps, mass surgery weeks or routine surgery through which to conduct hydrocele surgeries in your district Plan for pre-surgical visits and post-operative care and use the method identified above to have surgeries conducted in your district Health centers should report to districts, and districts should report to the national level every 6 months (up to a year) District management teams, in coordination with the national programme, can do special surveys or direct inspection visits to evaluate quality of care. Part 5: References and additional resources References: Lymphatic Filariasis: Managing Morbidity and Preventing Disability: An Aide-Memoire for National Programme Managers (WHO 2013) West African Lymphatic Filariasis Morbidity Project Surgical Handbook: An Aid to District Hospital Surgeons (Mante and Seim 2007): Organizing a Lymphoedema Management Program at the Health District Level (CDC 2010) Annexes and additional resources: N/A

Session 3: Hydrocele Surgery

Module 6 Morbidity Management and Disability Prevention (MMDP) Session 3: Hydrocele Surgery Meeting NTD STAG, 29-30 April 2013, Geneva, Switzerland 1 Purpose and objectives Purpose: To give an overview