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An Unusual Cause of Hydrocele: Malpositioned Ventriculoperitoneal Shunt in the Scrotum

Devrim Karaosmanoglu, MD, Yavuz Metin, MD, Deniz Akata, MD and Mithat Halilolu, MD

Department of Radiology, Hacettepe University School of Medicine Ankara, Turkey

To the Editor: Ventriculoperitoneal (VP) shunts are commonly used surgical materials used for treatment of cerebrospinal fluid circulation disorders. Although it is widely used and a relatively safe procedure, shunt placement may also give rise to several potential complications. Migrations of VP shunts to several body compartments, including the mediastinum, chest, abdominal wall, gastrointestinal tract, and scrotum, have been reported.¹ Here we present the sonographic findings of a patient with scrotal migration of a VP shunt. We think that sonography should be the imaging modality of choice for patients when clinical suspicion of scrotal shunt migration exists.

A 14-month-old boy was admitted to the emergency department with a high-grade fever and confusion. His mother stated that he was in good health until the day before the admission, and in the last 24 hours, the patient gradually deteriorated both mentally and physically, and the high-grade fever developed. The patient’s medical history was remarkable for myelomeningocele and VP shunt placement. On physical examination, the patient was found to be obtunded with questionable nuchal rigidity. The patient was immediately given antibiotic treatment, and a lumbar puncture was performed to detect the possible pathogenic agent. On the following days of his admission, abdominal pain developed, and his high-grade fever persisted (albeit not as high as on the day of admission). On physical examination, the house officer of the floor detected mild abdominal distension and swelling of the left hemiscrotum. Abdominal sonographic examination of the patient was not optimal because of prominent distension of the bowel segments and lack of patient cooperation. A subsequent scrotal sonographic examination showed the VP shunt catheter ends in the right hemiscrotum with a resultant hydrocele. The shunt catheter was also clearly seen throughout the inguinal canal with surrounding fluid (Figure 1). Abdominal computed tomography (CT) was then performed to rule out any potential intra-abdominal collection that may have been missed on sonography. The CT examination revealed no intra-abdominal abscess. However, the course of the VP shunt was unusual, moving down to the right inguinal canal (Figure 2). On the basis of these results, the shunt catheter was removed, and the patient’s medical treatment was continued.

View larger version (284K): [in this window] [in a new window]   Figure 1. Sonograms of the inguinal canal and scrotum. A, Sagittal gray scale sonogram showing the VP shunt during its course in the inguinal canal (arrows) surrounded by hypoechoic fluid. B, Ventriculoperitoneal shunt (arrowhead) coursing anterior to the right testis (arrows). Also note the hydrocele in the right hemiscrotum.

View larger version (163K): [in this window] [in a new window]   Figure 2. Computed tomograms from the patient. A, Scout CT image showing the abnormally low VP shunt tip in the right hemiscrotum (arrow). Radiopaque round lesions correspond to calcified mesenteric lymph nodes detected in the upper sections of the CT study (arrowheads). B, Axial postcontrast CT image shows the tip of the shunt in the right hemiscrotum (arrow).

References

1. Oktem IS, Akdemir H, Koç K, et al. Migration of abdominal catheter of ventriculoperitoneal shunt into the scrotum. Acta Neurochir (Wien) 1998; 2:167–170.
2. Rowe M, Copelson LW, Clatworthy HW. The patent processus vaginalis and inguinal hernia. J Pediatr Surg 1969; 4:102–107.[Medline]
3. de Aquino HB, Carelli EF, Borges Neto AB, Pereira CU. Nonfunctional abdominal complications of the distal catheter on the treatment of hydrocephalus: an inflammatory hypothesis? Experience with six cases. Childs Nerv Syst 2006; 10:1225–1230.
4. Patel CD, Matloub H. Vaginal perforation as a complication of ventriculoperitoneal shunt. J Neurosurg 1973; 38:761–762.[Medline]

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