In men, vaginal hydrocele is the most common morbidity due to Wuchereria bancrofti . Diagnosis is straightforward most of the time but when the swelling is not transilluminant, patients in whom the diagnosis is in doubt, children with hydroceles and those with co-morbid conditions should have ultrasonography to differentiate these swellings. Studies on the effect of medical treatment with diethylcarbamazine on the size of hydroceles are inconclusive. The only effective treatment for hydrocele is surgery as the minimally invasive therapy like aspiration and sclerotherapy are known to have high recurrence rates. Several surgical options are available for managing hydrocele but the recommended operation is hydrocelectomy, i.e. a subtotal excision of the parietal layer of the tunica vaginalis leaving a rim of approximately one-centimeter width around the testis and epididymis.

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Lymphatic filariasis (LF) is currently endemic in as many as 80 countries round the globe, particularly in the tropics and sub-tropics. Wuchereria bancrofti as a causative organism accounts for over 90% of the global burden. India contributes about 40% of the total global burden and accounts for about 50% of the people at the risk of infection. In India, states like Andhra Pradesh, Bihar, Gujarat, Kerala, Maharastra, Orissa, Tamil Nadu, Utter Pradesh and West Bengal contribute to about 95% of total burden. W. bancrofti is the predominant species accounting for about 98% of the national burden, widely distributed in 17 states and six union territories. Diethylcarbamazine (DEC) is an effective drug acting on the parasite (without report of resistance in past five decades) and mass annual single dose community drug administration with selective vector control could result in effective elimination of infection by interruption of transmission. The WHO has called for targeting filariasis elimination by 2020. India is the largest LF endemic country and has targeted the elimination of LF by 2015.

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The medical treatment of filariasis and chyluria is based on dietary modification, i.e. a diet excluding fat, supplemented by medium chain triglycerides (MCT) and high protein content. Drug therapy include administration of antifilarial drugs like diethylcarbamizine (DEC), ivermectin and albendazole. Annual mass drug administration of DEC combined with albendazole is recommended by the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in endemic areas. DEC-medicated salt has been effectively used in various filarial endemic countries and as well as in certain parts of India. Vector control is a useful means in addition to chemotherapy in control of lymphatic filariasis.

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Chyluria, the passage of intestinal lymph in urine is common in the rural and economically weaker population of our country. Etiologically it has been classified as parasitic and nonparasitic (rare). By far the most important and most common cause effect relationship of chyluria is with Wuchereria bancrofti. The issues in diagnosis making of chyluria include: confirmation of chyluria, localization of site of leakage in urinary tract, identifying the cause of chyluria and assessing as to how bad is the disease? A number of biochemical and radiological diagnostic tests are available for the same. Since this is 'a disease of the poor', there is a need to modify the approach of diagnostic evaluation and therapeutic protocols in order to curtail the overall cost of treatment.

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Filarial disease, transmitted from person-to-person by mosquitoes, principally affects people in tropical and sub-tropical areas. One hundred and twenty million people in at least 80 nations of the world have lymphatic filariasis. One billion people are at risk of getting infected. Ninety percent of these infections are caused by Wuchereria bancrofti , and most of the remainder by Brugia malayi. For W. bancrofti , humans are the exclusive host. The major vectors for W. bancrofti are culicine mosquitoes in most urban and semiurban areas, anophelines in the more rural areas. Larvae in the blood of human hosts are ingested when the insect vectors feed. Within the vector, the microfilarias migrate to specific sites and develop from first-stage larvae into infective third-stage larvae. The vector transmits the infective larvae into a human host when feeding. Mosquitoes deposit the larvae on the host skin adjacent to the puncture site and the third stage larval (L3) parasites migrate through the venous system and lungs to eventually take up residence in the lymphatics. There they form nests occupied by male and female worms, and produce the first stage larvae or microfilariae by viviparous reproduction These larvae migrate from the lymphatics to the peripheral blood where mosquitoes ingest them. The filarial disease has protean manifestaions in the form of chronic, acute and 'asymptomatic' presentations as well as a number of syndromes associated with these infections that may or may or not be caused by the parasites.

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Lymphatic filariasis is a leading cause of chronic disability worldwide; an estimated 120 million persons are infected with the filarial parasites that cause the disease and an estimated 40 million persons suffer from chronic clinical manifestations, primarily lymphedema and hydrocele. Following a flurry of scientific advances during the late 1980s and early 1990s, the World Health Organization announced a Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 1998. Unlike most other disease eradication or elimination programmes, the goals of the GPELF are twofold: to interrupt transmission of the filarial parasite and to alleviate the suffering of those with filariasis-related disease. Embracing the challenge of morbidity control or disability alleviation has both challenged and enriched the GPELF. The paper reviews the scientific developments and decisions that led to the creation of the GPELF, highlights progress towards achieving programme goals and discusses the remaining challenges.

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Genital lymphedema secondary to filariasis is a common problem in most of the filarial endemic regions of the world. Repeated filarial attacks lead to obstruction of lymph flow resulting in various types of genital manifestations in both males and females. Currently there is no cure for lymphedema. As yet no operative procedure has restored normal lymphatic function, and significant swelling recurs after all of the currently available approaches. Progress has been made by micro-lymphatic operations combined with conservative measures to relieve many of these patients of much of their swelling without resort to lifetime use of conservative measures.

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Purpose:0 We analyzed various modes of presentation of chyluria in our patients. Various treatment options available and associated complications were also studied. Materials and methods:0 Retrospective review of records of patients of chyluria treated at our institute between January1987 to June 2005 was done. Chyluria was diagnosed by urine examination. Treatment was tailored according to severity of chyluria, which included dietary modification, antifilarial drugs and sclerotherapy. Those not responding to two sessions of sclerotherapy were taken up for chylolymphatic disconnection. Results:0 A total of 600 patients were treated between January 1987 and June 2005. Before 1999 we routinely used 1% silver nitrate. Between January 1999 and June 2003, povidone iodine (0.2%) and dextrose (50%) were also used besides silver nitrate (1%). Instillation of dextrose was used in 21 patients only and its use was discontinued because of high immediate failure (57%) and recurrence rate (38%). Instillation of povidone iodine was as effective as silver nitrate. 91% of the patients in the silver nitrate and 98% in the povidone group showed immediate clearance. The chyluria recurred in 21 and 22% in two groups, respectively. The cumulative success rate after two courses of sclerotherapy was 82% in the silver nitrate and 83% in the povidone group. Side effects were much less with povidone iodine. Those who did not responded to two courses of sclerotherapy did well after chylolymphatic disconnection. Conclusion:0 Presenting symptoms of chyluria vary according to severity of the disease. Most patients respond to dietary modifications, antifilarial drugs and sclerotherapy. Those not responding to sclerotherapy do well after chylolymphatic disconnection.

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The management of Chyluria is challenging. Various treatment options are available. Among them sclerotherapy has reasonable success but the problem is the recurrence. Surgery is an option in such refractory cases. This article looks at various surgical options and their success.

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Chyluria is a debilitating illness seen in 1-2% of patients of filariasis after 10-20 years of initial infection. The obstructed retroperitoneal lymphatics rupture into pelvicalyceal system and leads to patient passing milky white chylous urine with haematuria and chylous clots. Sclerotherapy as a minimally invasive treatment modality has been used for last 35 years. Hypertonic saline, hypertonic glucose, contrast (15-25% Na iodide and Na diatrizoate), silver nitrate (0.1, 0.5, 1, 3, and 5%) and povidone-iodine (0.2%) have all been used as sclerosants with varying results. The various complications and lessons learned due to the most widely used sclerosant, silver nitrate, have been discussed in detail. The prerequisites and precautions, both preoperative and intraoperative, especially when using 1% silver nitrate instillations for sclerotherapy have been outlined to make it a safe, effective and minimally invasive treatment for chyluria.

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Chronic filarial disease with lymphedema is affecting about 15 million individuals worldwide, India alone accounts for 38% of the total disease. The disease causes physical disability, psychological despair, social isolation, and loss of economic productivity to the tune of about 1.5 billion dollars annually in India alone. The global elimination of lymphatic filariasis (LF) programme has been launched in many countries. It was felt that LF, though not usually deadly, is a prime disabler both of people and of progress. Yet it is a disease that is curable with the right resources and political will. Thus under the leadership of the World Health Organization (WHO) emerged the global alliance in the year 2000 for the elimination of lymphatic filariasis (GAELF). The goal of the alliance was set to eliminate LF as a public health menace by 2020. Their strategy is, the entire population at risk in the endemic areas is to be treated with annual single dose of filaricidal drug combination of albendazole and DEC for 4-5 years to cover the life span of the adult filarial worms.

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Chyluria is a chronic debilitating condition characterized by formation of pyelo-lymphatic connections. Renal pelvic instillation sclerotherapy (RPIS) is a minimally invasive treatment modality in treatment of chyluria. It involves placement of ureteric catheter under cystoscopic guidance into the pelvis of the offending renal unit and the renal pelvic capacity is measured after contrast instillation in a radiologist suite. Sclerosants acts by inducing an inflammatory reaction in the lymphatic vessels and blockade of the communicating lymphatics by fibrosis. Silver nitrate and povidone iodine are the most commonly used sclerosants in RPIS. Various protocols have been described in literature but we follow 8 h instillations (nine doses) for 3 days. Silver nitrate (0.1-1%) is effective in 60-84% of cases and povidone iodine has shown similar efficacy as silver nitrate. Patients with early recurrence after RPIS do not fare better with second-course of RPIS in comparison to the patients with delayed recurrence. Overall sclerotherapy has shown effectiveness of ~85% in curing chyluria.

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Objective:0 To evaluate the relationship between dietary fat intake and degree of lipid excretion in the urine of patients with chyluria. Patients and methods:0 This study was performed in two phases. In phase I, 20 patients with chyluria were included in the study, where the relationship between quantity of the dietary fat consumed and degree of loss of lipid in urine was studied. In phase II of the study, 20 patients with chyluria were studied to see the relationship between the quality of dietary fat and degree of lipid loss in urine. Results:0 Fat restriction can significantly diminish lipiduria and massive lipiduria may occur following consumption of even 25 g/day dietary fat. With increment in the dietary fat intake, there were paradoxical changes. Lipiduria is minimum with 50 g/day fat consumption. Lipiduria is affected by the quality of fat consumption. Ghee is the major culprit inducing maximum lipiduria as compared to mustard oil. Conclusion:0 In the patients of chyluria, lipid loss in urine is influenced by quantity as well as quality of daily fat intake.

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Purpose: We present our experience with retroperitoneoscopic lymphatic disconnection for the treatment of patients with intractable chyluria. Materials and Methods: From November 1996 to March 2003, 12 patients (three females and nine males), with intractable chyluria were treated at our department with the retroperitoneoscopic technique. Diagnosis was based on urine examination for the presence of chyle and fat globules, cystoscopy, excretory urogram and retrograde ureteropyelography. The technique of retroperitoneoscopic management of chyluria consisted of nephrolympholysis, ureterolympholysis, hilar vessel stripping, fasciectomy and nephropexy. The first three procedures were done in all cases, whereas fasciectomy was only done in four cases and nephropexy in three as required. Results: Chyluria disappeared in all ipsilateral renal units of the patients who underwent retroperitoneoscopic management but it recurred in two patients at 1 and 9 months of follow up from the contralateral side. Both the cases have since been successfully treated with contralateral retroperitoneoscopic management. Complications included lymphatic leak through the drain, which persisted for 5 days in one case and an inadvertent clipping of a branch of the posterior segmental artery of the kidney in one. The latter patient did not have pain or hypertension and the renal scan did not reveal any focal deficit at follow up. All patients were followed periodically from 6 to54 months (mean of 31 months). Conclusion: Retroperitoneoscopic chylolymphatic disconnection is a safe and effective management of intractable chyluria. The reroperitoneoscopic approach provides direct access to the kidney without transgressing the peritoneum.

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