Genital Edema in a Patient on Continuous Ambulatory Peritoneal Dialysis

Abstract

Infographic

Case Description

A 68-year-old man with an underlying ESKD presented to our department with painless scrotal and penile swelling 1 day after prolonged crouch position. He was on continuous ambulatory peritoneal dialysis (CAPD) using a fill volume of 1.8 L for 10 months. He had a break-in period since peritoneal catheter placement to initiate peritoneal dialysis of 3 weeks. He had undergone herniorrhaphy to repair a right abdominal wall hernia 10 years ago. His BP was 156/77 mm Hg, and his body mass index was 22.27 kg/m². He had localized scrotal and penile edema without evidence of inflammation (Figure 1A). No ascites, abdominal wall swelling, or leg swelling were found. Laboratory investigation revealed a BUN of 62 mg/dl, creatinine of 7.93 mg/dl, and intact parathyroid hormone of 567.5 pg/ml. Previous dialysis adequacy was a Kt/V of 2.45 weekly and creatinine clearance of 82.9 L weekly. Computed tomographic peritoneography showed a leakage of the contrast-hydrolysate mixture in the right inguinal canal through the right patent processus vaginalis, right scrotum, and penis (Figure 1, B and C). The patient was diagnosed with abdominal wall leakage in ESKD on CAPD. His mode of dialysis was temporarily shifted from CAPD to hemodialysis (HD), and subsequently, his condition was resolved a week after HD.

Figure 1.: The clinical characteristic and computed tomographic (CT) peritoneography of the patient. (A) Physical examination revealed localized scrotal and penile edema. (B) Coronal plane of the CT peritoneography shows right patent processus vaginalis with leakage of the contrast-hydrolysate mixture via the right inguinal canal (asterisk) into the right scrotum and penis. (C) Axial plane of the CT peritoneography shows leakage of the contrast-hydrolysate mixture in the right scrotum (arrowhead) and penis (asterisk).

Discussion

Abdominal wall leakage is a late dialysate leak in peritoneal dialysis that usually occurs within a month to 2 years after CAPD initiation (¹). Risk factors include abdominal wall weakness, increased age, and high body mass index (¹,²). Genital or groin edema, weight gain, and ultrafiltration failure are significant clinical manifestations for this condition (¹). Scrotal edema with concomitant penile edema is more common than labial edema. Differential diagnosis are abdominal wall hernia, hydrocele, and volume overload with inadequate dialysis. Computed tomographic peritoneography or intraperitoneal infusion of radioisotope followed by peritoneal scintigraphy are gold standard tests for diagnosis (¹). Management of abdominal wall leakage consists of a variety of techniques, including rest from PD for 1–3 weeks, temporary shift of dialysis mode to HD or automating PD with low daytime fill volume aimed to decrease intra-abdominal pressure, and surgical repair of the abdominal wall defect (¹,²). Recurrence of this complication ranges from 0% to 60%, depending on the choice of treatment (¹).

Teaching Points

• Abdominal wall leakage is a late dialysate leak in PD, with abdominal wall weakness as a major risk factor.
• Previous abdominal wall surgery is not an absolute contraindication for CAPD initiation.
• Management of abdominal wall leakage, such as temporary shift to HD and low fill volume automated PD, are used to decrease intra-abdominal pressure. In addition, surgical repair of the abdominal wall defect is required in some cases.

Disclosures

All authors have nothing to disclose.

Funding

None.