Localized Genital Edema in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

0022-534 7/85/1345-0880$02.00/0 Vol. 134, November

THE JOURNAL OF UROLOGY

Copyright © 1985 by The Williams & Wilkins Co.

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LOCALIZED GENITAL EDEMA IN PATIENTS UNDERGOING CONTINUOUS AMBULATORY PERITONEAL DIALYSIS RICHARDT. KOPECKY, MARK M. FUNK AND PHILIP R. KREITZER From the Departments of Medicine and Urology, State University of New York, Upstate Medical Center, Syracuse, New York

ABSTRACT

Localized genital edema occurred in 8 of 81 patients (10 per cent) undergoing continuous ambulatory peritoneal dialysis. Underlying causes included defects in the inguinal canal and noninguinal peritoneal leaks that were localized with clinical, radiographic and scintigraphic techniques. Management included temporary cessation of continuous ambulatory peritoneal dialysis exchanges in half of the patients, particularly those with recently inserted catheters. Surgical repair was recommended in all cases when inguinal defects were identified. Edema resolved permanently in 6 patients and all patients were able to remain on continuous ambulatory peritoneal dialysis. Localized edema of the external genitalia may develop in patients with end stage renal disease undergoing continuous ambulatory peritoneal dialysis. 1 - 6 This complication may present immediately at the onset of therapy or after many months of dialysis that had been free of trouble. Edema results from escape of dialysate from the peritoneal space and movement into the genitals along 2 possible routes (fig. 1). Fluid that leaks from the peritoneal insertion site of the dialysis catheter, a ventral or umbilical hernia, or a peritoneo-fascial defect remaining from previous abdominal surgery may track through the soft tissues of the abdominal wall into dependent genital tissues. Alternatively, fluid may pass directly into the scrotum or labia via an inguinal hernia or a patent processus vaginalis. Prevention of this condition by detection and repair of hernias before initiation of continuous ambulatory peritoneal dialysis obviously is important. However, genital edema can occur in the absence of detectable hernias. Appropriate management of this condition is based upon accurate identification of the underlying structural defect, adequacy of peritoneal catheter function and rapidity with which it develops after the initiation of continuous ambulatory peritoneal dialysis. We report 8 cases of genital swelling complicating continuous ambulatory peritoneal dialysis therapy, and discuss the diagnostic and therapeutic approach to this problem. Pertinent features of all 8 patients are shown in the table. Case histories of 3 patients are presented in detail.

processus vaginalis that did not contain bowel and a left inguinal hernia repair was performed. A week postoperatively continuous ambulatory peritoneal dialysis exchanges were resumed, and dialysate volume was increased gradually to 2,000 ml. per exchange. The patient continued to do well on continuous ambulatory peritoneal dialysis without recurrence of scrotal edema and received a successful renal transplant in August. Case 2. A 34-year-old man with end stage renal disease secondary to hypertensive nephrosclerosis had a silicone dual cuff catheter placed surgically in July 1983. He achieved excel-

Dialysis catheter

CASE HISTORIES

Case 1. A 29-year-old man with end stage renal disease secondary to medullary cystic disease began chronic hemodialysis in March 1982 and had a silicone dual cuff catheter implanted surgically in February 1984 for initiation of continuous ambulatory peritoneal dialysis. Catheter patency was maintained with 500 ml. flushes twice weekly for 3 weeks, after which dialysis training was started with 1,500 ml. exchanges. The dialysis catheter functioned normally. On training day 2 painless left scrotal swelling was noted, which rapidly increased when the patient stood. Examination revealed unilateral left scrotal swelling approximately 8 cm. in diameter. The testes and epididymis were normal. The scrotal fluid collection transmitted light and was reduced easily with manual compression. Palpation of the inguinal canal revealed no discernible fascial defect or hernia impulse. There was no peripheral edema. Continuous ambulatory peritoneal dialysis training was discontinued and the patient returned to hemodialysis. On March 19 exploration of the left groin revealed a patent Accepted for publication July 12, 1985.

FIG. 1. Possible routes of fluid movement from peritoneal space into external genitalia in patients undergoing continuous ambulatory peritoneal dialysis. A, direct movement through inguinal canal via inguinal hernia (contents not shown) or patent processus vaginalis. B, leakage of fluid into abdominal wall through peritoneo-fascial defect with or without associated hernia. C, leakage at peritoneal dialysis catheter insertion site. Fluid entering abdominal wall beneath Scarpa's fascia (B and C) may track caudally into genitals without being clinically apparent at site of leakage.

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LOCALIZED GENITAL EDEMA DURING CONTINUOUS AMBULATORY PERITONEAL DIALYS:iS

Clinical features of patients with localized genital edema while wulergoing continuous ambulatory peritoneal dialysis

Pt. No.-Sex-Age

Diagnosis

Previous Hernia Repair (date)

Date of Catheter Time From Placement for Catheter Continuous Placement to Ambulatory Development of Peritoneal Genital Edema Dialysis

1-M-29

Medullary cystic disease

Feb. 1984

3 wks.

2-M-34

Hypertensive nephrosclerosis

July 1983

7 mos.

3-F-22

Congenital obstruc- Abdominal incisional hernia, tive uropathy (Aug. 1983)

Apr. 1984*

2 days

4-M-45

Intravenous drug abuse nephropathy

June 1983

8 mos.

5-M-71

Hypertensive neph- Ventral hernia rosclerosis, is(Mar. 1983) chemic heart disease

Feb. 1983

5 mos.

6-M-64

Hypertensive neph- Undescended lt. rosclerosis, istestes chemic heart disease

Dec. 1982

6 mos.

7-M-67

Hypertensive neph- Rt. inguinal hernia repair rosclerosis in childhood, lt. hydrocele

Feb. 1985

1 wk.

8-F-28

Chronic glomerulonephritis

Sept. 1982

19 mos.

Presentation

Diagnostic Study

Treatment

Outcome (mos. of followup on continuous ambulatory peritoneal dialysis)

Reducible lt. scrotal swelling on training day 2

Stop dialysis Dialysis refor 3 wks., sumed, no ligation of recurrence It. patent (5)t processus vaginalis Decreased dialysate Peritoneal leak Stop dialysis Dialysis rereturn, massive demonstrated for 1 wk., sumed, no bilat. scrotal and by contrast bed rest, recurrence material rapenile edema for scrotal el(6)t 12 hrs., nonrediography evation ducible Lt. labial and thigh Peritoneal leak Stop dialysis Dialysis reswelling while on at catheter for 10 sumed, no 500 ml. postoperinsertion site days, bed recurrence ative exchanges by contrast rest (3)t material radiography Bilat. scrotal and Contrast mate- Refused sur- Resolved in 1 penile edema inirial radiogragery for wk., contially, 2 days phy neg. presumed tinued dilater only reducipatent alysis, ocble rt. scrotal processus casional swelling revaginalis, mild recurmained continued rence redialysis duced by with rept. (5):j: duced volumes, bed rest, scrota! elevation Bilat. scrotal Continued Resolved in 3 edema after 3 dialysis days, condays of continuwith retinued dious 4.25% diduced volalysis with alysis exchanges, umes of reduced exnonreducible 1.5% dichange volalysate, umes, no bed rest, recurrence scrotal el(18) evation Fluctuating bilat. Continued Resolved in l scrotal and pendialysis day, conile edema graduwith retinued dially increased duced volalysis, ocduring 2 wks., umes, bed casional nonreducible rest, scromild deta! elevapendent tion scrotal swelling (2):j:

Decreased dialysate Lt. inguinal Stopped direturn, massive herniademalysis for nonreducible bionstrated by 21 days, lat. scrotal and -Tc scintigbed rest, penile edema, It. raphy scrotal elinguinal hernia evation clinically evident after resolution of edema Bilat. labial swellReduced exing (It. greater change than rt.) 1 wk. volume to after increasing 11., bed exchange volume rest to 1.5 1.§

Resolved in 1 wk., dialysis resumed at reduced volumes, no recurrence (1) II Resolved in 4 days, continued dialysis, no recurrence (8)11

* Second peritoneal catheter. t Continuous ambulatory peritoneal dialysis discontinued following renal transplantation. :j: Died of unrelated causes.

§ Patient has been using 1.0 1. exchanges since starting continuous ambulatory peritoneal dialysis in September 1982. II Died of unrelated causes pending left inguinal herniorrhaphy. 11 Transferred to hemodialysis for unrelated reasons.

lent control of blood pressure and fluid balance on continuous ambulatory peritoneal dialysis with 4, 2,000 ml. exchanges daily. On January 22, 1984 he noticed a decrease in dialysate

drainage for several consecutive exchanges. That evening mild peripheral edema developed and the next day massive painless scrotal swelling occurred.

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KOPECKY, FUNK AND KREITZER

On examination the scrotum was indurated, nontender and symmetrically enlarged to a diameter of 15 cm. It did not transmit light and the swelling was not reducible with manual compression. There was moderate penile and lower extremity edema but no edema in the abdominal wall. The catheter exit site was well healed without dialysate leakage or infection. A trial dialysis exchange caused immediate further scrotal enlargement and continuous ambulatory peritoneal dialysis was discontinued. Radiographic contrast material (50 ml. diatrizoate meglumine) injected through the dialysis catheter escaped from the peritoneal space and moved along tissue planes into the scrotum (fig. 2). No evidence of a patent processus vaginalis or inguinal hernia was seen in this study. The patient was placed at bed rest with scrotal elevation, and was maintained with intermittent hemodialysis using femoral venous access. Scrotal swelling resolved entirely in 1 week, although a right groin hematoma occurred as a complication of femoral vein cannulation. Re-examination revealed no fascial defects or inguinal hernia thrust. Continuous ambulatory peritoneal dialysis was resumed with 1,000 ml. exchanges with the patient at bed rest. Gradual return to normal activities and progression to 2,000 ml. exchanges were accomplished during a 3-week period without recurrence of scrotal swelling. The patient remained free of complications on continuous ambulatory peritoneal dialysis through August when he underwent renal transplantation. Case 3. A 22-year-old woman, with end stage renal disease owing to congenital obstructive uropathy, began continuous ambulatory peritoneal dialysis in May 1981. In August 1983 an abdominal incisional hernia was repaired without incident. Recurrent episodes of peritonitis secondary to a tunnel infection necessitated removal of the peritoneal catheter and a

FIG. 3. Case 3. Radiographic contrast material flows freely through peritoneal catheter into peritoneal space. Leakage into abdominal soft tissues has occurred at catheter insertion site.

temporary period of hemodialysis was started in February 1984. On April 19 a flanged peritoneal catheter was placed for reinstitution of continuous ambulatory peritoneal dialysis, and catheter patency was maintained with 500 ml. exchanges. The catheter functioned well but 2 days postoperatively severe left labial and thigh edema developed. The edema decreased when exchanges were discontinued for 24 hours but it recurred immediately upon their continuation. Examination revealed moderate induration and tenderness of the left thigh and inguinal region, and severe left labial edema. No inguinal or abdominal hernia impulse was palpable. There was no external fluid leakage at the catheter exit site and no abdominal wall edema. Radiographic contrast material injected through the catheter on April 24 demonstrated leakage of fluid into the subcutaneous tissues surrounding the peritoneal insertion site (fig. 3). Continuous ambulatory peritoneal dialysis was discontinued and the patient was maintained on hemodialysis for 10 days with complete resolution of the edema. On May 7 continuous ambulatory peritoneal dialysis exchanges were resumed and gradually increased to full volumes without recurrence of edema. Dialysis was continued until August when the patient underwent renal transplantation. DISCUSSION

FIG. 2. Case 2. Radiographic contrast material infused through peritoneal catheter has escaped from peritoneal space and moved into massively enlarged scrotum. No evidence of patent processus vaginalis or inguinal hernia was seen in this study. Silicone dialysis catheter can be seen faintly crossing iliac crest just below contrast material filled external tubing in left upper corner of illustration.

Localized genital edema is now a recognized complication of continuous ambulatory peritoneal dialysis. In previous reports of a sizable patient population the incidence of this disorder has not been defined. 1- 6 From December 1981 to February 1985 continuous ambulatory peritoneal dialysis was initiated at our center in 51 male and 30 female patients who, subsequently, underwent a total of 1,043 months of dialysis treatment. During that period 6 men and 2 women experienced a significant episode of localized genital swelling (see table). Affected patients had a mean age of 45 years (range 22 to 71 years). Three patients had undergone earlier herniorrhaphies. An undescended testicle and a small hydrocele were present in 1 patient each before beginning continuous ambulatory peritoneal dialysis. None of the 8 patients had clinical evidence of an abdominal or inguinal fascial defect or hernia impulse before the development of genital swelling. None had diabetes mellitus or was receiving steroid medication. In 3 patients genital edema occurred within 3 weeks following surgical implantation of the

LOCALIZED GENITAL EDEMA DU.RING CONTKNUOUS AMBULATORY PERITONEAL rnAL YSIS

dialysis catheter. The remaining patients had been on continuous ambulatory peritoneal dialysis for 5 or more months. Specific defects identified as the cause of genital swelling included a patent processus vaginalis in 2 patients, an inguinal hernia in 1 and a peritoneal leak into the abdominal soft tissue in 2. In 3 patients a specific defect was not localized. Of these patients 2 had genital swelling in temporal relation to an increase in exchange volume or tonicity and 1 had known cryptorchidism. Four patients required temporary suspension of continuous ambulatory peritoneal dialysis exchanges for 1 to 3 weeks. In no instance was it necessary to stop dialysis permanently. Surgical repair of a patent processus vaginalis was performed in 1 patient with excellent results. Another patient died of unrelated causes while awaiting repair of an inguinal hernia. A patient who refused surgery for a patent processus vaginalis remained on continuous ambulatory peritoneal dialysis at reduced exchange volumes and continued to experience intermittent mild scrotal swelling. Only 1 of 5 patients managed conservatively had a subsequent recurrence of genital edema, which was mild. Movement of peritoneal dialysate into the external genital tissues may occur by the inguinal canal or the extraperitoneal abdominal soft tissues (fig. 1). The development of inguinal hernias in patients on continuous ambulatory peritoneal dialysis is not unexpected 7 ' 8 owing to the sustained increase in intra-abdominal pressure. These hernias may present as painless genital edema without a demonstrable fascial defect or cough impulse. 1 Occasionally, a newly developed hernia may only become apparent after resolution of local edema (patient 7), A completely or partially patent processus vaginalis (patients 1 and 4), which is present in 15 to 37 per cent of men, 9 also may allow fluid movement into the genitals via the inguinal canal without an evident hernia. 2- 4 Dialysis fluid that escapes into the abdominal soft tissues may track along tissue planes and present as genital edema without bringing direct attention to the actual site of leakage (patients 2 and 3). Small peritoneal defects with or without an associated abdominal wall hernia may present in this way. 5 •6 Leakage of fluid at the peritoneal insertion site of the dialysis catheter immediately following implantation, once a frequent complication, 10 can be minimized by using small volume exchanges to allow time for catheter sealing, Even with this precaution leakage still occurs in some patients. Accurate localization of the underlying structural abnormality is of obvious importance when genital edema occurs in a patient on continuous ambulatory peritoneal dialysis. The surgical history should be reviewed carefully for possible sources of incisional leakage or herniation. Cryptorchidism raises the suspicion of an associated patent processus vaginalis. Unilat-

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era! or asymmetric genital swelling suggests a defect in the ipsilateral inguinal canal, especially when partial reduction is possible with manual compression. However, noninguinal leaks may present asymmetrically (patient 3) and fluid reaching the scrotum through a single inguinal canal may distribute bilaterally in the loose scrotal tissues if swelling is severe (patient 4). Adequate examination of the inguinal canals is difficult in the presence of massive edema, and careful re-examination upon resolution of the swelling is mandatory. Catheter function may be normal or compromised (usually failure to drain adequately) with any form of leak and in our experience it is not a helpful diagnostic clue, Several imaging techniques have been used to localize leaks whose site was not apparent on physical examination. In 2 patients plain radiographs after instillation of iodinated contrast material into the peritoneal catheter demonstrated noninguinal escape of fluid from the peritoneum (figs, 1 and 2). No adverse effect occurred from this procedure. However, a similar study performed in patient 4 failed to demonstrate a patent processus vaginalis, which was clearly believed to be present on clinical grounds alone. Computerized tomographic scanning of the abdominal wall following the administration of contrast material may be diagnostic when standard radiographs are unrevealing. 5 Intraperitoneal instillation of 3 to 5 mCi. 99 mtechnetium (Tc) followed by scintigraphic scanning has successfully demonstrated inguinal and abdominal dialysate leaks in patients on continuous ambulatory peritoneal dialysis with genital edema. 2 ' 4 ' 6 We used this procedure to visualize an inguinal hernia that could not be identified clinically owing to massive scrotal swelling (fig. 4). In our opinion, the ability of peritoneal scintigraphy to localize either type of leak makes it the diagnostic procedure of choice. The management of genital swelling complicating continuous ambulatory peritoneal dialysis depends on several factors, including the adequacy of catheter function, duration of time since catheter implantation and nature of the underlying defect. Initially, the clinician must determine if continuous ambulatory peritoneal dialysis exchanges should be suspended and dialysis continued by an alternate method, Obviously, if catheter drainage is impaired significantly and genital swelling is massive, exchanges must be discontinued to prevent progressive volume overload. In our experience when edema occurs soon after catheter implantation (less than 1 month), especially in a patient still receiving small exchange volumes, resolution will not occur unless dialysis is stopped temporarily. Patients who have genital swelling after months of uncomplicated dialysis with full volume exchanges often will improve dramatically with bed rest, scrotal elevation, more frequent exchanges of reduced volume and avoidance of the more hypertonic (2,5

FIG, 4, Scintigraphic scans obtained 10 minutes (A) and 210 minutes (B) after instillation of 1 I, L5 per cent dialysate containing 99 mTc minicolloid (5 mCi.) into peritoneum of patient 7, Movement of fluid down left inguinal canal into scrotum is clearly demonstrated. Marker in part A and upper marker in part B are located at base of penis, Lower marker in part B is located at left lower margin of scrotum,

884

KOPECKY, FUNK AND KREITZER

and 4.25 per cent) dialysis solutions. When genital swelling has been precipitated by a sudden increase in intraperitoneal pressure, such as frequent use of 4.25 per cent dialysate (patient 5) or a recent increase in exchange volumes (patient 8), conservative treatment along with removal of the inciting factor often corrects the problem without the need for further evaluation or surgery. When a patent processus vaginalis or a hernia (abdominal or inguinal) is confirmed to be the cause of genital swelling it should be repaired surgically, since bowel incarceration remains possible even when the edema can be managed conservatively.7 Leakage around a newly inserted catheter or through a peritoneal defect unassociated with a hernia may respond to conservative measures. In patients 2 and 3 a 1 to 2-week suspension of dialysis followed by a gradual return to normal exchange volumes allowed the leak to seal and prevented a surgical procedure. Dr. Edward T. Schroeder provided helpful comments for the preparation of this paper. REFERENCES 1. Cooper, J. C., Nicholls, A. J., Simms, J. M., Platts, M. M., Brown, C. B. and Johnson, A. G.: Genital oedema in patients treated by continuous ambulatory peritoneal dialysis: an unusual presentation of inguinal hernia. Brit. Med. J., 286: 1923, 1983. 2. Schurgers, M. L. C., Boelaert, J. R. 0., Daneels, R. F. S., Robbens, E. J. and Vandelanotte, M. M. J.: Open processus vaginalis. Perit. Dial. Bull., 3: 30, 1983.

3. Sherlock, D. J. and Smith, S.: Complications resulting from a patent processus vaginalis in two patients on continuous ambulatory peritoneal dialysis. Brit. J. Surg., 71: 477, 1984. 4. Ducassou, D., Vuillemin, L., Wone, C., Ragnaud, J.M. and Brendel, A. J.: Intraperitoneal injection of technetium-99m sulfur colloid in visualization of a peritoneo-vaginalis connection. J. Nucl. Med., 25: 68, 1984. 5. Schultz, S. G., Harmon, T. M. and Nachtnebel, K. L.: Computerized tomographic scanning with intraperitoneal contrast enhancement in a CAPD patient with localized edema. Perit. Dial. Bull., 4: 253, 1984. 6. Orfei, R., Seybold, K. and Blumberg, A.: Genital edema in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Perit. Dial. Bull., 4: 251, 1984. 7. Rubin, J., Raju, S., Teal, N., Hellems, E. and Bower, J. D.: Abdominal hernia in patients undergoing continuous ambulatory peritoneal dialysis. Arch. Intern. Med., 142: 1453, 1982. 8. Chan, M. K., Baillod, R. A., Tanner, A., Raftery, M.,' Sweny, P., Fernando, 0. N. and Moorhead, J. F.: Abdominal hernias in patients receiving continuous ambulatory peritoneal dialysis. Brit. Med. J., 283: 826, 1981. 9. Snyder, W. H., Jr. and Greaney, E. M., Jr.: Inguinal hernias. In: __ Pediatric Surgery, 2nd ed. Edited by W. T. Mustard, M. M. Ravitch, W. H. Snyder, Jr., K. J. Welch and C. D. Benson. Chicago: Year Book Medical Publishers, Inc., vol. 1, part IV, sect. 1, chapt. 46, pp. 692-707, 1972. 10. Rubin, J., Adair, C., Raju, S. and Bower, J.: Complications of the Tenckhoff catheter (T). In: Abstracts, American Society for Artificial Internal Organs 27th Annual Meeting. Chicago, Illinois, vol. 11, p. 63, April 14-16, 1982.