Simulated testicular torsion in a neonate: complication of ventriculoperitoneal shunt

Treatment Options for Scrotal Migration of Ventriculoperitoneal Shunts: Case Illustration and Systematic Review of 48 Cases

BACKGROUND

Scrotal migration of intact or disconnected tubing is a rare complication of ventriculoperitoneal shunts. While some illustrative case reports can be found in the literature, a systematic review on treatment options is lacking.

OBJECTIVE

To propose the first literature-based treatment algorithm on scrotal shunt migration.

METHODS

We conducted a literature search using the keywords: "VP," "ventriculoperitoneal," "shunt," and "scrotum." We identified 36 publications with 48 cases reported including our index case.

RESULTS

Median age at presentation was 13.5 mo (3 d to 65 yr) which was 4 mo (3 d to 72 mo) after last shunt-related surgery. All patients had scrotal swelling, 39 (81%) patients presented without other symptoms, 4 (8%) had additionally local pain, and 4 (8%) patients presented with symptoms of shunt dysfunction. Treatment was surgically in all but one case where spontaneous resolution without repeat migration occurred. In 3 of 4 patients who had either subcutaneous shortening or abdominal repositioning of the shunt without hernia repair, scrotal shunt migration recurred within the following month. Whereas the surgical treatment with reposition of the migrated catheter back into the peritoneal cavity via a groin incision plus hernia repair yielded a definite treatment in all 26 performed cases, the revision rate was significantly higher in the shunt revision without hernia repair cohort (P = .0009).

CONCLUSION

Scrotal shunt migration is a rare shunt complication with good recovery when treated surgically. We recommend hernia repair in addition to either manual or surgical repositioning of migrated tubing.

Rare complication of ventriculoperitoneal shunt. Early onset of distal catheter migration into scrotum in an adult male: Case report and literature review

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Cases of scrotal migration of distal catheter in adults are rare.

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There have been no reports for scrotal migration in adults at an early onset.

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Early detection of migration of distal catheter prevents shunt malfunction.

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Prompt surgical management of catheter repositioning is recommended.

Introduction

The role of shunt placement is to divert cerebrospinal fluid from within the ventricles to an alternative location in the setting of hydrocephalus. One of the rare shunt complications is distal catheter migration, and various body sites have been reported, including the scrotum. Although cases of scrotal migration of distal catheter have been reported in pediatric patients, cases in adult patients are rare due to obliterated processus vaginalis. Furthermore, there has not been a case reported for scrotal migration in an adult at an early onset.

Presentation of case

65-year-old male underwent shunt placement for normal-pressure hydrocephalus-like symptoms. On post-operative day seven patient developed right testicular edema, for which ultrasound was performed, revealing hydrocele along with the presence of distal catheter in the scrotum. On post-operative day nine patient underwent distal catheter trimming via laparoscopic approach with general surgery, with post-operative imaging showing satisfactory location of distal catheter in the peritoneal cavity.

Discussion/Conclusion

Early onset of distal catheter migration into scrotum in an adult male is a unique case, as most cases are reported in pediatric patients, and it is the first case reported in the English literature to have occurrence at an early onset during the peri-operative period. As our case demonstrates, early occurrence and detection of scrotal migration of the distal catheter prevent shunt malfunction. Prompt surgical management of catheter repositioning is therefore recommended to avoid the risk of further complications.

Shunt in scrotum: unusual complication in operated cases of hydrocephalus

Shunt surgeries in patients with hydrocephalus are associated with morbidity and mortality. The most common problems are shunt obstruction and malfunction. We described a case of shunt migration into the scrotal sac masquerading as scrotal swelling. Shunt repositioning along with posterior wall repair and herniotomy was performed.

Pyocele of the scrotum in the pediatric patient

Pyocele of the scrotum has been reported but is not well described in the pediatric population. The majority of published cases have been treated definitively with surgical drainage, and the severity of some cases has led to orchiectomy. We report a cases series of four boys with idiopathic pyocele, two of whom were managed successfully without operative intervention. Of these, one case was likely due to hematogenous spread of infection, and one case was secondary to spread of abdominal contamination via a patent processus vaginalis. To our knowledge, this is the first case series reporting non-surgical management of infant pyocele. Although rare, this clinical entity should be considered in the differential diagnosis of acute scrotum in the pediatric patient.

Case report: neonatal adrenal haemorrhage presenting as an acute right scrotal swelling (haematoma)--value of ultrasound

Acute scrotal swelling resulting from remote intra-abdominal pathology is a well recognized but rare entity. The present report relates to such a case in a neonate who presented with an acute right scrotal haematoma, adrenal haemorrhage not being suspected clinically, but detected ultrasonographically. In the imaging of neonatal scrotal swellings, abdominal ultrasound is important in excluding a primary intra-abdominal event.

Emergency department management of ventriculoperitoneal cerebrospinal fluid shunts

Emergency physicians must be familiar with VP shunts in order to recognize critical complications associated with these devices. Knowledge of the major types of shunt devices commonly used and the mechanics of those devices allows emergency physicians to evaluate patients with shunts in an orderly manner.

Idiopathic infant pyoceles

Three infants presented with acute scrotal swelling, erythema, and a tender irreducible firm mass within the scrotum. All patients were operated upon with the preoperative diagnosis of testicular torsion. At operation, grossly purulent fluid was found in a hydrocele sac. In all the cases, the testes were normal and no source of the scrotal infection was identified. A variety of bacterial organisms were cultured and responded readily to antibiotics. Follow-up has documented survival of the testes without apparent atrophy. "Idiopathic" infant pyocele is rarely described and consequently, not included in the differential diagnosis of patients with acute surgical conditions of the inguinoscrotal region.

Acute scrotal lesion secondary to barium peritonitis in an infant

We report on an acute scrotal lesion occurring secondary to barium peritonitis in an infant with a patent processus vaginalis. To our knowledge, this has not been described previously. Treatment of the peritonitis may be sufficient for the scrotal lesion.

Scrotal swelling as the presenting symptom of acute perforated appendicitis in an infant

A ten-week-old patient with a known communicating hydrocele suddenly developed a tense, tender swelling of the scrotal half containing the hydrocele. Operated upon with the presumptive diagnosis of testicular torsion, pus was found in the hydrocele exuding from the abdominal cavity. At laparotomy a perforated appendix was discovered .

Migration of a dissected peritoneal shunt catheter into the scrotum

Migration of a dissected peritoneal piece of the shunting material into the scrotum was encountered in a 1-year-old boy who had received a V-P shunt. Removal of the migrated shunt tube by inguinal exploration and herniorrhaphy were performed, and another V-P shunt was installed simultaneously. This case was considered worthy of reporting as a rare complication of a V-P shunt, and the causal mechanism is discussed with a review of the literature.

Ventriculoperitoneal (VP) shunt migration causing an acute scrotum: a case report of Doppler evaluation

The diagnosis and management of a scrotal complication of a ventriculoperitoneal shunt simulating testicular torsion in a neonate is outlined. Radiologic evaluation determined the location of the shunt tube and adequate blood flow to the testicle was confirmed by use of the Doppler stethoscope, allowing for definitive therapy by extraperitoneal shortening of the shunt catheter. Surgery to the scrotum was, thus, avoided.

Abdominal and genitourinary complications following ventriculoperitoneal shunts

Three patients with complications secondary to ventriculoperitoneal shunts for the management of hydrocephalus are described. Abdominal and genitourinary complications that may occur after the shunting procedure usually are owing to abnormal accumulation of cerebrospinal fluid or perforation by the shunting catheter tip.