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| Year : 2009 | Volume
: 6
| Issue : 2 | Page : 116-117 |
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| Patent processus vaginalis: A window to the abdomen |
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N Rahman, K Lakhoo
Department of Paediatric Surgery, Children's Hospital Oxford, University of Oxford, United Kingdom
Click here for correspondence address and email
| Date of Web Publication | 29-Jul-2009 |
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 Abstract | | |
A patent processus vaginalis (PPV) allows a communication between the peritoneum and scrotum. Hydrocoele is the usual presentation of a PPV in children. However, with intraabdominal pathology the patent PPV may provide the first clue to the mischief within the abdomen. We present here two unusual cases associated with a PPV and migration of intraabdominal contents from the abdomen to the scrotum. Keywords: Appendicitis, patent processus vaginalis, ventriculoperitoneal shunt
How to cite this article:
Rahman N, Lakhoo K. Patent processus vaginalis: A window to the abdomen. Afr J Paediatr Surg 2009;6:116-7 |
| Introduction | |  |
A patent processus vaginalis (PPV) has been estimated to be present in 80-95% of all male newborns, declining to 60% at one year of age, 40% at two years, and 15- 37% thereafter. [1] It represents a natural communication between the peritoneum and scrotum through which bowel or peritoneal fluid may descend. We present two unusual cases associated with a PPV and migration of intraperitoneal contents from the abdomen to the scrotum.
| Case Reports | | |
Case 1
A four-year-old boy with hydrocephalus secondary to a pilocytic astrocytoma underwent insertion of a ventriculoperitoneal (VP) shunt along with tumour debulking and chemotherapy. One month later, he presented with a right reducible inguinal hernia and an intermittent hydrocele. Both testes were palpable within the scrotum. He underwent elective ligation of his right PPV. During examination under anaesthesia coils of the VP shunt were palpable within the scrotum. This was confirmed by plain abdominal radiography [Figure 1]. Intraoperatively, the VP shunt was found to have migrated via a PPV into the scrotum. The tip of the shunt was excised prior to repositioning it back into the peritoneum and the PPV ligated proximally. He received a course of oral antibiotics.
Case 2
A seven-year-old boy underwent appendicectomy confirming the presence of a perforated appendix with purulent fluid in the abdominal cavity. Cultures were taken and peritoneal irrigation performed. He received perioperative antibiotics which were continued postoperatively. On the fourth postoperative day, he developed an acute left hemiscrotum. He underwent urgent exploration of the hemiscrotum and was found to have pus within the tunica extending proximally into a PPV. This was managed successfully with drainage. Cultures from the scrotal abscess matched the intraabdominal cultures and grew E. coli and Streptococcus milleri . The patient recovered uneventfully.
| Discussion | | |
Although present in the majority of newborn male infants, the incidence of a PPV declines to 60% at the age of one year and 15% to 37% at adulthood. It allows the passage of intraperitoneal contents between the abdomen and scrotum, and 20% of those in whom the PPV remains patent will present clinically with an inguinal hernia or hydrocele during their lifetime. [2] This route will also allow the passage of other intraperitoneal fluid including blood, as seen occasionally following splenic rupture, [3] and peritoneal dialysis fluid in renal patients. [4]
Increased intraabdominal pressure may be related to the development of inguinal hernia and there is increased incidence of hernia and hydrocele in children who have had VP shunt placement; [5] who are also more likely to develop contralateral hernia.
In addition to the more frequent complications seen with VP shunts, such as blockage and infection, migration of the catheter has been described into the stomach, gallbladder, bladder, vagina, liver, chest, [6] and even transorally. [7] In our first case, the VP shunt had migrated from the abdomen into the scrotum via a PPV. Although rare, a clinician should consider VP shunt migration in any patient who has a shunt in place and presents with an inguinal mass, scrotal swelling, or an acute scrotum. Management includes administration of an antibiotic with gram-positive coverage capable of penetrating the blood-brain barrier along with reduction of the herniated shunt and closure of the PPV.
Our second case represents a rare complication of perforated appendicitis. Intraperitoneal abscess formation following perforated appendicitis is a common occurring in 8% to 14% of the patients. [8] However, the passage of pus through a PPV into the scrotum is rare. In a patient presenting with an acute scrotum following a suppurative appendicitis, scrotal abscess secondary to a PPV must be considered. Patients known to have an inguinal hernia preoperatively, or those in whom a PPV is found intraoperatively, should be carefully monitored in the postoperative period and explored early if scrotal pain develops. Repair of the hernia at time of appendicectomy is not recommended, as this may lead to isolation of infected fluid in the scrotum. [9] If a scrotal abscess is formed, early diagnosis and surgical intervention is essential to avoid complications including testicular gangrene. [10]
Our two cases highlight that a PPV represents a window to the abdomen and may be the cause for unusual scrotal pathology.
| References | | |
| 1. | Watson DS, Sharp KW, Vasquez JM, Richards WO. Incidence of inguinal hernia diagnosed during laparoscopy. South Med J 1994;87:23-5.  [PUBMED] [FULLTEXT] |
| 2. | Rowe MI, Copelson LW, Clatworthy HW. The patent processus vaginalis and the inguinal hernia. J Pediatr Surgery1969;4:102-7. |
| 3. | Skoog SJ, Belman AB. The communicating hydrocele: An usual presentation for blunt splenic trauma. J Urol 1986;136:1092-3. [PUBMED] |
| 4. | Abraham G, Blake PG, Mathews RE. Genital swelling as a surgical complication of continuous ambulatory peritoneal dialysis. Surg Gynecol Obstet 1990;170:306-8. |
| 5. | Grosfeld JL, Cooney DR. Inguinal hernia after ventriculoperitoneal shunt for hydrocephalus J Pediatr Surg 1974;9:311-5. |
| 6. | Borkar SA, Satyarthee GD, Khan RN, Sharma BS, Mahaptra AK. Spontaneous extrusion of migrated ventriculoperitoneal shunt catheter through chest wall: A case report. Turkish Neurosurgery 2008;18:95-8. |
| 7. | Berhouma M, Messerer M, Houissa S, Khaldi M. Transoral protrusion of a peritoneal catheter: A rare complication of ventriculoperitoneal shunt. Pediatr Neurosurg 2008;44:169-71. [PUBMED] [FULLTEXT] |
| 8. | Schmit PJ, Hiyama DT, Swisher SG, Bennion RS, Thompson JE. Analysis of risk factors of postappendectomy intraabdominal abscess. J Am Coll Surg 1994;179:721-6. |
| 9. | Thakur A, Buchmiller T, Hiyama D, Shaw A, Atkinson J. Scrotal abscess following appendendectomy. Pediatr Surg Int 2001;17:569-71. [PUBMED] [FULLTEXT] |
| 10. | Robertson FM, Olsen SB, Jackson MR, Rochon RB. Inguinal-scrotal suppuration following treatment of perforated appendicitis. J Pediatr Surg 1993;28:267-8. [PUBMED] [FULLTEXT] |
Correspondence Address:
K Lakhoo
Children's Hospital Oxford, Headley Way, Oxford OX3 9DU
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0189-6725.54778
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