Scrotal Mass: A Rare Complication of Ventriculoperitoneal Shunt

Abstract

IntroductionVentriculoperitoneal (VP) shunt is a common procedure in managing hydrocephalus. Complications associated with VP shunt are numerous and can be disastrous. Among the complications that can occur are migration of the catheter into the abdominal wall, gastrointestinal tract, bladder, vagina, scrotum, mediastinum and infections like peritonitis, ventriculitis, and meningitis (24-47 %) (5, 7). One of the rare complications associated with ventriculoperitoneal shunt is herniation of the peritoneal catheter into the scrotum. Here we describe the migration of a fractured VP shunt catheter into the left scrotum. Case reportA 14-year-old boy with congenital hydrocephalus on VP shunt, presented with a history of left scrotal swelling for three days associated with pain and fever. There was no previous history of epididymitis or orchitis. Examination of the scrotum revealed a 4x3 cm mass, separate from the testis, in the scrotum. Cough impulse and transillumination test was negative. Full blood count and urine test was normal. Ultrasound done showed a foreign body in the scrotum with mild hydrocoele.On further questioning, his mother admitted that his previous VP shunt catheter had fractured a year ago and was replaced with a new one. The shunt had then migrated into the abdominal cavity but since it was not causing any problem, his parents were not keen for any abdominal surgery. An abdominal pelvic x-ray was done and it confirmed the migration of the previously fractured VP shunt into the left scrotum (Fig. 1).Removal of the catheter was attempted via an inguinal incision but failed. A scrotal incision had to be made to remove the catheter (Fig. 2). The hernia sac was then ligated and divided via the inguinal wound. Post operatively, he recovered well and was discharged the next day. Clinic followup at one, three and six months showed that there was no recurrence or complications. Summary: Ventriculoperitoneal shunts are associated with multiple complications. Among them are disconnection and migration of the tubing into the peritoneal cavity. Here we describe a case of a fractured ventriculoperitoneal shunt which migrated and coiled in the scrotum, masquerading as a scrotal swelling. Removal of the shunt via a scrotal incision was performed concomitantly with repair of the hernia sac.

Shunt in scrotum: unusual complication in operated cases of hydrocephalus

“…Rowe et al 12 have explained the aetiology of peritoneal catheter migration, which has been universally accepted over the years by various authors 13. Peritoneal cavity distension due to draining CSF also prevents the obliteration of the processus vaginalis as reported by Ho et al 14 and Ozveren et al 15…”

Scrotal migration of a ventriculoperitoneal shunt

“…We recommend close follow up and regular scrotal examinations for all male paediatric patients up to 12 months of age. Should a hydrocele be discovered, timely surgical closure of the PPV should be considered to avoid complications, such as pain, hydrocele progression or the development of an indirect inguinal hernia with its ensuing potential complications, such as bowel incarceration or strangulation …”

Migration of the peritoneal catheter of a ventriculoperitoneal shunt into the scrotum

“…2,5,[7][8][9][10][11][12][13] It has been emphasised that the development of scrotal swelling or hydrocoele in a child with a VP shunt should raise the possibility of a shunt complication. 14 An explanation of the migration of the peritoneal catheter is difficult but migration of the peritoneal catheter into the scrotum tends to occur in younger children because of the higher incidence of an unobliterated processus vaginalis and smaller volume of the peritoneal cavity in these patients.…”

“…10 Prompt surgical repair of the hernia and repositioning of the peritoneal catheter is recommended as there is increased risk of incarceration in infancy. 5,7,18,19 Although contralateral groin exploration is advised in in fants with VP shunt because of the likelihood of patent processus vaginalis in infancy, and the high bilaterality rate (75 -80%), 7 in older children it may not be appropriate as by this time is has been obliterated.…”