Hydrocele scrotal elephantiasis

　　The morphologies of the adult worms of Brugia malayi and Brugia timori are similar, and their internal structures are almost completely identical, but Brugia malayi is shorter and smaller than Brugia timori. In the human body, the embryonic larvae in the uterus of the female adult worm develop into active filarial microfilariae. When mosquitoes suck the blood of filariasis patients, the microfilariae are吸入 into the mosquito body and develop into infective larvae. During the mosquito's blood-sucking, infective larvae enter the human body; after the infective larvae enter the human body, some die, and some larvae enter the lymphatic vessels or lymph nodes to develop into adults. The lifespan of adults in the human body can reach more than 10 years, and the lifespan of microfilariae in the human body is about 2 to 3 months, and they can survive for 6 weeks at 4℃ in the external environment. The Brugia malayi and Brugia timori microfilariae prevalent in China have a marked nocturnal periodicity, that is, they are mostly concentrated in the pulmonary capillaries during the day and appear in peripheral blood at night. The peak time for the Brugia malayi microfilariae is from 8:00 PM to 4:00 AM the next morning, and for the Brugia timori microfilariae, it is from 10:00 PM to 2:00 AM the next morning.

　　The onset and lesions of filariasis are mainly caused by adult worms, and the infective larvae also play a certain role, but have little to do with the microfilariae in the blood. From the time the larvae penetrate the human skin to the stage of development into adults, the metabolic products produced by the larvae and adults, as well as the excretory products in the uterus of the worms, can cause systemic allergic reactions and tissue reactions in the local lymphatic system. The clinical features are manifested in the early stage as periodic发作 lymphangitis, lymphadenitis, and filarial fever, etc.; and in the late stage, it is due to the pathological changes of the lymphatic tissue and secondary bacterial infection.

　　Hydrocele scrotal elephantiasis often occurs in areas with filariasis, and in the early stage, it is often recurrent diffuse lymphangitis of the scrotum. In the later stage, due to the long-term chronic stimulation of the skin and subcutaneous tissue by recurrent lymphangitis and lymph fluid exudation, the skin and subcutaneous connective tissue become thickened and hardened, dry, and the skin appearance presents with orange peel-like, granular, and warty hyperplasia. The scrotal skin loses elasticity and contraction. Due to the hyperplasia of connective tissue and the accumulation of lymph fluid, the scrotum becomes spherical. Under the influence of gravity and weight, the swollen scrotum can hang down to the knee level, weighing several kilograms, with the largest reaching 102kg, affecting the patient's movement and normal life. At this time, the hanging scrotum, the lower skin damage becomes more severe, while the skin and the transition area of the healthy skin above the pubic symphysis, perineum, and thigh gradually become thinner. The penis often retracts into the swollen scrotum. When the skin of the penis also has elephantiasis, it protrudes like a bent ram's horn. The cavernous body of the penis retracts into the foreskin and even into the scrotum, forming a cave-like tunnel reaching the glans penis and the external urethral orifice. During urination, urine leaks out of the cave mouth, wetting the clothes and socks. The testicles are buried in the swollen scrotal skin, and sometimes can be complicated with hydrocele of the tunica vaginalis.

　　Severe cases of penoscrotal elephantiasis may be complicated by epididymitis, and occasionally orchitis. During the acute phase, it can also be recurrent lymphangitis, lymphadenitis, and fever; during the chronic phase, it is lymphedema and elephantiasis, and severe cases may present with myocarditis, lower limb or scrotal edema, mental symptoms, and even exhaustion. Therefore, once the infection of filariasis is diagnosed, active anti-infection treatment should be carried out to reduce complications, such as using diethylcarbamazine 200mg, 3 times a day, for 7 days, with a total dose of 4.2g (for adults).

　　Patients with a history of residence in filariasis-endemic areas or a history of filarial infection, with a history of recurrent cellulitis or lymphangitis in the scrotum. Most patients have symptoms such as chills, high fever, and scrotal pain during the acute phase, often accompanied by swelling and tenderness of the inguinal lymph nodes; the inflammation may subside after several days, but there may be several days of recurrence every year, and over time, the scrotum gradually increases in size. Early physical examination may show enlargement of the scrotum, rough and thickened skin, soft texture, and edema that can extend to the penis. In the late stage, the scrotum further swells, sometimes as large as a child's head, even reaching tens of kilograms, becoming a massive畸形物. The scrotal skin thickens and hardens to several centimeters, showing a dry leather-like appearance, losing elasticity and contraction. The skin of the penis can also thicken simultaneously, and it is prone to cracking and secondary infection; it seriously affects the patient's activities and local appearance. Due to the large volume of scrotal elephantiasis, it often causes the penis and prepuce to contract and sink, even completely buried within the scrotal elephantiasis.

　　The only effective treatment for penoscrotal elephantiasis is plastic surgery, which should widely or even completely excise the diseased skin, plant normal skin, and the prognosis is good. However, it should be performed after complete cure of filariasis; otherwise, there is a possibility of recurrence. So, how to prevent penoscrotal elephantiasis? The following experts introduce the preventive measures for penoscrotal elephantiasis:

　　1. Actively and effectively treat filariasis patients to cut off the source of infection.

　　2. Eliminate mosquitoes and their breeding grounds to cut off the transmission media.

　　3. In areas with high prevalence, the general population should take 0.3% diethylcarbamazine citrate (Hydroxyguanidine salt) for 6 months, with a small dose and few side effects, which is easy for the masses to accept.

　　入睡后静脉抽血检查可发现微丝蚴，将有助于诊断，血嗜酸性粒细胞增高达5％以上，鞘膜积液，鞘膜乳糜肿或尿液内也可找到微丝蚴。

　　病理切片检查可发现丝虫虫体及嗜酸性粒细胞大量浸润，并有嗜酸性粒细胞肉芽肿形成。

　　在丝虫病流行区采用海群生食盐疗法，每公斤食盐中掺入海群生3g，平均每人每日16.7g食盐，内含海群生50mg，连用半年，可降低人群中微丝蚴阳性率。阴茎阴囊象皮肿病人应以高蛋白、高维生素、高纤维素、高热量、低脂肪的饮食为主，尤其要注意忌口。阴茎阴囊象皮肿病人禁食烟、酒及辛辣刺激食物如葱、蒜、韭菜、姜、花椒、辣椒、桂皮等。

　　阴茎阴囊象皮肿治疗首先是抗丝虫的药物治疗，然后施行阴茎阴囊的象皮肿切除和成形术。手术切除全部肥厚坚硬的阴茎阴囊皮肤与皮下肥厚的结缔组织。切除或翻转睾丸鞘膜、妥善保护睾丸附睾与精索，然后修剪并应用阴囊根部较正常的皮肤重建阴囊与阴茎皮肤。阴茎的象皮肿皮肤切除后可利用健康的阴茎包皮内板翻转与阴囊皮肤缝合；亦可切取股内侧无毛区中厚层皮瓣做阴茎阴囊的游离植皮术，伤口以无菌敷料加压包扎，定期更换敷料以保持干净与创口一期愈合。对巨大的阴茎阴囊象皮肿，因为手术范围大，创伤重，渗液与失血较多，手术困难，常常需行植皮术等，所以手术者应做好术前的准备如手术方式的设计、麻醉、输血与输液等等，手术效果良好，病人于手术后可迅速恢复正常生活与劳动。但有少数又有术后远期象皮肿复发者，亦可再次施行手术治疗。