| 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 Nov 24];21:507-10. Available from: https://www.sjkdt.org/text.asp?2010/21/3/507/62690
| Introduction|| |
Abdominal hernias are significant problem in patients treated with continuous peritoneal dialysis (PD).  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%);  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. , The most common location for hernias is now the umbilical area , with leaks most commonly located in the pericatheter area. ,,
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|| |
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.
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|| |
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.  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.  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.  Abdominal hernias may develop in nearly 10% of patients on CAPD,  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. 
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). ,,
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. ,
PD should be interrupted when early subcutaneous leaks develop, since they may seal off during a prolonged (dry) rest period. Recent recommendations  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. , However, in our patients the processus vaginalis hernia was treated conservatively and the hernia completely resolved.
| Acknowledgment|| |
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|| |
|1.||Rocco MV, Stone WJ. Abdominal hernias in chro-nic peritoneal dialysis patients: A review. Perit Dial Bull 1985;5:171. |
|2.||Wankowicz Z, Pietrzak B, Przedlacki J. Colloid peritoneoscintigraphy in complications of CAPD. Adv Perit Dial 1988;4:138-43. |
|3.||Bernardini J. Peritoneal dialysis catheter complications. Perit Dial Int 1996;16(suppl 1): S468-71. [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. [PUBMED] |
|5.||Charytan C, Spinowitz BS. Dialysate leaks. In: Dialysis Therapy, in Nissenson AR, Fine RN (eds). Hanley and Belfus, 1993:188-9. |
|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. |
|7.||Bargman JM. Complications of peritoneal dialysis related to increased intra-abdominal pressure. Kidney Int 1993;43(suppl 40):S75-80. |
|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. [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. |
|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, |
|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. [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. [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. [PUBMED] |
Abdullah K Al-Hwiesh
Consultant Nephrologist, Assistant Profesor, Chief of Peritoneal Dialysis Unit, King Fahad University Hospital, Al-Khobar, Kingdom of Saudi Arabia
[Figure 1], [Figure 2]