Eastvold Pearl #23: Swollen Scrotum

Hey guys,

  I have been absent for a while, and hope to send more of these out.  This one was provoked by the conference notes sent (great idea btw).  I ran across a patient with a non-infectious complication from peritoneal dialysis...the massively swollen scrotum.  

65 yo M with h/o ESRD on CAPD presented to ED with [1] massively swollen scrotum (his concern), and honestly [2] facial droop (wife's concern) for 5 days, which turned out to be a Bells palsy or peripheral CN VII palsy.  You gotta love a guy like this.

We have all seen massive scrotal edema in the setting of anasarca, with the work-up really having nothing to do with GU but merely a work-up for anasarca.  

What was different with this guy was that he had no lower extremity or abdominal wall edema, it was all isolated to his scrotum and penis.  No hernia on exam or bedside US.

Quick google search at work, popping out the attached article, then pretending I knew this beforehand as I talked to the nephrologist on-call really changed the work-up and treatment for this patient. 

It turns out that patient with continuous ambulatory peritoneal dialysis (CAPD) have about a 5% risk of dialysate leakage, representing a non-infectious complication of CAPD that we should know.  Why is this important, these patients will need to stop PD and switch to hemodialysis as part of the treatment.  Thus, they will need to be admitted as most do not have HD capabilities.  Why to have to stop PD?  See below and read attached article if time.

PD dialysate leaks are classified as early (1st 30 days of catheter placement) or late (>30 days).  The above complication is a late complication, which is what I'll cover.  Late leaks most often "related to mechanical or surgical tear in the peritoneal membrane, presenting as internal leakage (e.g., pleural cavity, abdominal wall, external genitalia).  Enhanced stress on the supporting abdominal wall structure may lead to" leakage and/or hernia.  The leakage can be considered a mechanical intra-abdominal pressure-related complication due to micro-tears (which may seal up with cessation of PD) or larger tears or hernias (which require surgery).

Diagnosis: Known in the nephrology field as "skinny legs, big scrotum."  May need US to rule out hernia, or CT with PD catheter-instilled contrast to evaluate for leakage based on extravasation of contrast outside peritoneal cavity.

Treatment: [1] Stop CAPD for 1-3 weeks, again this will require most to be admitted. [2] Switch to temporary hemodialysis, which is thought to allow these micro-tears to seal up. [3] Surgery if recurrence after re-initiating CAPD.  Other indications for surgery are concurrent hernia, and some advocate that genital edema is an indication for surgery as these patients fail the PD rest period.

Reference:  Dialysate Leaks in Peritoneal Dialysis. Semin Dial. 2001 Jan-Feb;14(1):50-4. Leblanc M, Ouimet D, Pichette V. Nephrology Division, Maisonneuve-Rosemont Hospital, University of Montreal, Quebec, Canada.
Dialysate leakage represents a major noninfectious complication of peritoneal dialysis (PD). An exit-site leak refers to the appearance of any moisture around the PD catheter identified as dialysate; however, the spectrum of dialysate leaks also includes any dialysate loss from the peritoneal cavity other than via the lumen of the catheter. The incidence of dialysate leakage is somewhat more than 5% in continuous ambulatory peritoneal dialysis (CAPD) patients, but this percentage probably underestimates the number of early leaks. The incidence of hydrothorax or pleural leak as a complication of PD remains unclear. Factors identified as potentially related to dialysate leakage are those related to the technique of PD catheter insertion, the way PD is initiated, and weakness of the abdominal wall. The pediatric literature tends to favor Tenckhoff catheters over other catheters as being superior with respect to dialysate leakage, but no consensus on catheter choice exists for adults in this regard. An association has been found between early leaks (< or =30 days) and immediate CAPD initiation and perhaps median catheter insertion. Risk factors contributing to abdominal weakness appear to predispose mostly to late leaks; one or more of them can generally be identified in the majority of patients. Early leakage most often manifests as a pericatheter leak. Late leaks may present more subtly with subcutaneous swelling and edema, weight gain, peripheral or genital edema, and apparent ultrafiltration failure. Dyspnea is the first clinical clue to the diagnosis of a pleural leak. Late leaks tend to develop during the first year of CAPD. The most widely used approach to determine the exact site of the leakage is with computed tomography after infusion of 2 L of dialysis fluid containing radiocontrast material. Treatments for dialysate leaks include surgical repair, temporary transfer to hemodialysis, lower dialysate volumes, and PD with a cycler. Recent recommendation propose a standard approach to the treatment of early and late dialysate leaks: 1-2 weeks of rest from CAPD, and surgery if recurrence. Surgical repair has been strongly suggested for leakage causing genital swelling. Delaying CAPD for 14 days after catheter insertion may prevent early leakage. Initiating CAPD with low dialysate volume has also been recommended as a good practice measure. Although peritonitis and exit-site infections are the most frequent causes of technical failure in peritoneal dialysis (PD), dialysate leaks represent one of the major noninfectious complications of PD. In some instances, dialysate leakage may lead to discontinuation of the technique (1). Despite its importance, the incidence, risk factors, management, and outcome of dialysate leakage are poorly characterized in the literature. We will review the limited available information on this topic in the next few sections. PMID: 11208040 [PubMed - indexed for MEDLINE]