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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 507-510
Conservative treatment of processus vaginalis hernia in two peritoneal dialysis patients


Peritoneal Dialysis Unit, King Fahad University Hospital, Al-Khobar, Kingdom of Saudi Arabia

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Date of Web Publication26-Apr-2010
 

   Abstract 

Dialysate leakage represents one of the major noninfectious complications of peri­toneal dialysis (PD). In some instances, dialysate leakage may lead to discontinuation of the technique. Despite its importance, the incidence, risk factors, management, and outcome of dia­lysate leakage are poorly characterized in the literature. Here, we report two PD patients who pre­sented with painless scrotal swelling. Computerized peritoneography confirmed the diagnosis of processus vaginalis hernia that was treated conservatively.

How to cite this article:
Al-Wadani H, Alqahtani AA, Al-Dossari N, Alsawad A, Al-Atiqu M, Saad I, Al-Hwiesh AK. Conservative treatment of processus vaginalis hernia in two peritoneal dialysis patients. Saudi J Kidney Dis Transpl 2010;21:507-10

How to cite this URL:
Al-Wadani H, Alqahtani AA, Al-Dossari N, Alsawad A, Al-Atiqu M, Saad I, Al-Hwiesh AK. Conservative treatment of processus vaginalis hernia in two peritoneal dialysis patients. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Oct 30];21:507-10. Available from: https://www.sjkdt.org/text.asp?2010/21/3/507/62690

   Introduction Top


Abdominal hernias are significant problem in patients treated with continuous peritoneal dia­lysis (PD). [1] In the early 1980s, the incidence of abdominal hernia was approximately 10 to 15% per year. The most common location was the inguinal area (23%), followed by exit site (19%), umbilical (19%), and other incisional site hernias (10%); [1] the incidence was lower with intermittent than with continuous ambula­tory PD, with the former having an annual rate of less than 5%. A subsequent advance, the utilization of a paramedian approach to PD ca­theter insertion, has significantly reduced the incidence of exit site and incision hernias.

Hernia rates are currently reported at a rate of 0.06 to 0.08 per patient per year. [2],[3] The most common location for hernias is now the um­bilical area [2],[3] with leaks most commonly loca­ted in the pericatheter area. [2],[3],[4]

Here, we discribe two peritoneal dialysis pa­tients with processus vaginalis hernia, which was treated without surgical intervention. To our knowledge, this conservative management of processus vaginalis hernia in PD has been reported in a few cases in the literature.


   Case Reports Top


Case 1

A 37-year-old saudi man was admitted to the hospital on July 2005 with uremic symptoms including nausea, vomiting, and generalized weakness. His end-stage renal failure was con­tributed to focal segmental glomerular sclerosis.

The physical examination revealed a soft non­tender abdomen with no organomegaly detec­ted, The inguinal orifices were intact, but the lower limbs had +3 edema. The intra-abdomi­nal pressure measured by foley's catheter was 24 mmHg.

The patient was started on continuous ambu­latory peritoneal dialysis (CAPD) solution 2 L, 4 times a day. The peritoneal equilibration test (PET) was high average. After two moths, the patient presented with ultrafiltratin failure and right scrotal swelling. Abdominal x-ray was within nornal limit, but the CT peritoneogra­phy showed bilateral processus vaginalis he­nias [Figure 1]. Therefore, the patient was shif­ted to automated PD (APD) with a gradully in­creased 15 L fill volume and dry day time in addition to scrotal support. One year later, the day dwell was increased gradually to 2 liters without complications and the spontanous her­nia healed.

Case 2

A 43-year-old saudi man presened with end­stage renal failure secondary to focal segmen­tal glomerulosclerosis. He was started on CAPD, and 2 weeks later he developed ultrafiltration failure and scrotal swelling. CT (peritoneo­graphy revealed a processus vaginalis hernia [Figure 2]. Therefore, the patient was shifted to APD nine hours during the night and dry day time with scrotal support. After one year, the day dwell was gradully increased without com­plications and the spontaneous hernia healed.


   Discussion Top


A weak abdominal wall (due to multiple sur­geries, multiple pregnancies, obesity, previous use of steroids, hypothyroidism, polycystic kid­ney disease, chronic lung disease) under in­creased tension (from higher intra-abdominal pressure and volume) may lead to the develo­pment of hernias and related leaks. [5] Our both patients had intra-abdominal pressure of 23 and 22, which was significantly elevated.

Leaks, particularly late ones, may present in a much more subtle fashion. Their clinical mani­festations may include pericatheter drainage, but more often present with subcutaneous swelling and edema (pale discoloration/peau d'orange), weight gain, peripheral or genital edema, and apparent ultrafiltration failure with reduced dia­lysate outflow volumes. This reduced dialysate drainage may easily be mistaken for ultrafil­tration failure at the peritoneal membrane le­vel. Abdominal wall edema is easily overlooked, particularly in obese patients. Reduced drain volumes occur because a substantial portion of the dialysate (probably several hundred milli­liters per exchange) leaks into the abdominal wall, and once a steady-state is achieved, is ab­sorbed at a rate equal to the leakage rate. [3] A normal PET is useful in suggesting the diagno­sis of leakage.

Groin or genital edema caused by leaks are usually related to underlying hernias (which are often palpable), with a patent processes va­ginalis, or a peritoneal membrane defect along the catheter tract. Scrotal edema is much more common than labial edema; it is generally bila­teral and penile edema can be observed conco­mitantly. [6] Abdominal hernias may develop in nearly 10% of patients on CAPD, [7] and even more often with polycystic kidney disease. A significant proportion of hernias is incisional and may occur through the surgical incision for catheter placement or at the catheter site where an abdominal defect has been created. In addition, hernias may develop through sites of previous abdominal surgeries, or at um­bilical and inguinal sites. The frequency with which hernias are complicated by dialysate leakage is unknown. Most late leaks tend to develop during the first year of CAPD, a few during the second year, and rarely beyond the third year. [3]

If the diagnosis is uncertain or if there is a clinical need to demonstrate the anatomy of the leak, an imaging approach becomes desi­rable. Available methods include intraperito­neal infusion of contrast material through the catheter with plain abdominal radiography, com­puted tomography (CT). [8],[9],[10]

Several treatment modalities for dialysate leaks have been advocated, including surgical repair, temporary transfer to hemodialysis (HD), lower dialysate volumes, and PD with a cycler. [10],[11]

PD should be interrupted when early subcuta­neous leaks develop, since they may seal off during a prolonged (dry) rest period. Recent recommendations [11] propose a standard approach to the treatment of early and late dialysate leaks: one to two weeks of rest from CAPD, and surgery in case of recurrence. Surgical re­pair has been strongly suggested for leakage causing genital swelling. [12],[13] However, in our patients the processus vaginalis hernia was treated conservatively and the hernia completely resolved.


   Acknowledgment Top


The author would like to thank all the staff in peritoneal dialysis Unit at King Fahad Univer­sity hospital for their valuable help and coope­ration.

 
   References Top

1.Rocco MV, Stone WJ. Abdominal hernias in chro-nic peritoneal dialysis patients: A review. Perit Dial Bull 1985;5:171.  Back to cited text no. 1      
2.Wankowicz Z, Pietrzak B, Przedlacki J. Colloid peritoneoscintigraphy in complications of CAPD. Adv Perit Dial 1988;4:138-43.  Back to cited text no. 2      
3.Bernardini J. Peritoneal dialysis catheter com­plications. Perit Dial Int 1996;16(suppl 1): S468-71.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Tzamaloukas AH, Gibel LJ, Eisenberg B, et al. Early and late peritoneal dialysate leaks in patients on CAPD. Adv Perit Dial 1990;6:64-­70.  Back to cited text no. 4  [PUBMED]    
5.Charytan C, Spinowitz BS. Dialysate leaks. In: Dialysis Therapy, in Nissenson AR, Fine RN (eds). Hanley and Belfus, 1993:188-9.  Back to cited text no. 5      
6.Gokal R, Alexander S, Ash S, et al. Peritoneal catheters and exit-site practices toward opti­mum peritoneal access: 1998 update. Perit Dial Int 1998;18:33.  Back to cited text no. 6      
7.Bargman JM. Complications of peritoneal dialysis related to increased intra-abdominal pressure. Kidney Int 1993;43(suppl 40):S75-­80.  Back to cited text no. 7      
8.Nomoto Y, Suga T, Nakajima K, et al. Acute hydrothorax in continuous ambulatory peri­toneal dialysis: a collaborative study in 161 centers. Am J Nephrol 1989;9:363-7.  Back to cited text no. 8  [PUBMED]    
9.Schultz SG, Harmon TM, Nachtnebel KL. Computerized tomographic scanning with intra­peritoneal contrast enhancement in a CAPD patient with localized edema. Perit Dial Bull 1984;4:253-4.  Back to cited text no. 9      
10.Twardowski ZJ, Tully RJ, Ersoy FF, Dedhia NM. Computerized tomography with and with­out intraperitoneal contrast for determination of intra-abdominal fluid distribution and diag­nosis of complications in peritoneal dialysis patients. ASAIO Trans 1990;36:95-103,  Back to cited text no. 10      
11.Litherland J, Gibson M, Sambrook P, Lupton E, Beaman M, Ackrill P. Investigation and treatment of poor drains of dialysate fluid associated with anterior Abdominal wall leaks in patients on chronic ambulatory peritoneal dialysis. Nephrol Dial Transplant 1992;7:1030-­4.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Abraham G, Blake PG, Mathews RE, Bargman JM, Izatt S, Oreopoulos DG. Genital swelling as a surgical complication of continuous ambu­latory peritoneal dialysis. Surg Gynecol Obstet 1990;170:306-8.  Back to cited text no. 12  [PUBMED]    
13.Singal K, Segel DP, Bruns FJ, Fraley DS, Adler S, Julian TB. Genital edema in patients on continuous ambulatory peritoneal dialysis. Am J Nephrol 1986;6:471-5.  Back to cited text no. 13  [PUBMED]    

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Correspondence Address:
Abdullah K Al-Hwiesh
Consultant Nephrologist, Assistant Profesor, Chief of Peritoneal Dialysis Unit, King Fahad University Hospital, Al-Khobar, Kingdom of Saudi Arabia

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    Abstract
    Introduction
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