Genital Edema in Patients on Continuous Ambulatory Peritoneal Dialysis

Abstract

Severe genital edema is a well-described complication of continuous ambulatory peritoneal dialysis (CAPD). Leakage of dialysate fluid from defects in the peritoneum may occur from clinically detectable and undetectable inguinal hernias, defects at the catheter insertion site, or other defects in the peritoneal membrane. We describe 3 patients (who underwent five surgical procedures), illustrating the complexity of the problem. In 2 patients, unsuccessful surgical repairs (1 catheter replacement, 1 hernia repair) were performed based on misleading radiologic findings using intraperitoneal contrast without computerized tomography (CT) scanning. The use of CT scanning with intraperitoneal contrast led to the correct diagnosis and prompt surgical correction in both patients so studied. One patient had leakage from a clinically undetectable inguinal hernia, and the other had a peritoneal defect at the Tenckhoff insertion site which was only demonstrated following a period of upright posture with a 3-liter exchange. Our experience and a review of the literature convinces us that a CT scan of the abdomen utilizing radiocontrast material added to the dialysate accurately identifies the site of leakage in CAPD patients who develop genital edema. Thus, the CT scan can help avoid unnecessary surgery and prolonged hospitalization in CAPD patients who develop genital edema.

Laparoscopy to Evaluate Scrotal Edema During Peritoneal Dialysis

“…We have found that during the period of severe edema the physical examination is difficult and inaccurate because scrotal swelling is usually bilateral, even in patients with unilateral hernias, and small hernias or PPV are not palpable. Several diagnostic measures have been tried, including peritoneal scintigraphy, 3–6 ultrasonography, 7 CT peritoneography, 2,8–15 and, most recently, magnetic resonance peritoneography, 16 all with varying degrees of success. Deshmukh and colleagues used peritoneal scintigraphy to diagnose a PPV in 3 patients with acute scrotal edema.…”

“…The diffuse edema and often small hernia size make the physical examination unreliable. A number of diagnostic imaging measures have been tried, including peritoneal scintigraphy, 3–6 ultrasonography, 7 computed tomographic (CT) peritoneography, 2,8–15 and, most recently, magnetic resonance peritoneography, 16 all with varying degrees of success. However, when planning an operative approach, the surgeon must be confident that the pathology is an inguinal hernia or PPV and be able to differentiate whether it is located right, left, or bilateral.…”

Mechanical Complications of Peritoneal Dialysis

“…Early leaks from a peritoneal tear or catheter insertion site often respond to low volume PD in a supine position or cycled [9,49]. If this fails, cessation of PD for a few weeks [7,8,10,11] allows spontaneous closure [8,12]. Unfortunately the latter requires temporary hemodialysis.…”

“…Although peritonitis and exitsite infections are the most frequent causes of technical failure in PD, dialysate leaks represent one of the major noninfectious complications. Causes include inguinal, umbilical, femoral or incisional hernias [10], peritoneal tears [11], leaks around the dialysis catheter, trauma, fluid overload and malignancy [12,13]. Early leaks often overtly manifest as pericatheter leak [9] and may be related to insertion technique, timing of the start of PD after surgery, and inherent or acquired abdominal weakness.…”

Guidelines for laparoscopic peritoneal dialysis access surgery

“…It can happen early (\30 days) or late ([30 days). Causes include Inguinal or abdominal wall hernias [35,172], peritoneal tears [173], leaks around the dialysis catheter, trauma, fluid overload and malignancy [35,174]. Early leaks commonly are from the catheter insertion site or surgical wound and may be related to insertion technique and/or the timing of the start of CAPD after surgery.…”