Abstract

BackgroundDistal migration of ventriculoperitoneal (VP) shunt catheters to the scrotum is a rare yet significant complication in pediatric neurosurgery. It presents a unique challenge due to the anatomical predisposition observed in children.

Case DescriptionThis case series elucidates three pediatric cases in which distal VP shunt migration to the scrotum manifested with varied presentations, including scrotal swelling, vomiting, and seizures. Each patient’s medical history included prior VP shunt insertion for the management of hydrocephalus, with migration occurring within months of placement. Imaging studies confirmed scrotal positioning of the distal catheter tips, necessitating distinct management strategies: shunt repositioning, conversion to a ventriculoatrial (VA) shunt, and high ligation of a patent processus vaginalis (PPV) in cases associated with scrotal herniation. Factors such as rapid pediatric growth, high activity levels, and anatomical features, including a PPV, may facilitate catheter migration from the abdomen to the scrotum. These cases reflect diverse management approaches tailored to individual presentations and anatomical considerations, with repositioning and catheter shortening serving as viable strategies for recent, less severe cases, while VA shunt conversion and processus vaginalis ligation address more complex scenarios.

ConclusionRecognizing scrotal VP shunt migration as a potential complication is essential for early diagnosis and effective intervention. Timely and individualized management strategies are critical to preventing recurrence and ensuring optimal outcomes in the pediatric treatment of hydrocephalus with VP shunts.

Keywords: Scrotal swelling, Shunt migration, Shunt revision

INTRODUCTION

Distal migration of ventriculoperitoneal (VP) shunt catheters, particularly to the scrotum, is rare but represents a critical and serious complication in pediatric neurosurgery, warranting careful examination. Among these, distal catheter migration to the scrotum specifically is an unusual occurrence but one with potentially serious implications. The complication rate for extra-abdominal catheter migration is indeed low, around 1–5% of cases, with scrotal migration accounting for a small but significant portion of the pediatric demographic.[ 9 ] The incidence of scrotal migration is 14% common, usually within the first few months after shunt placement, with the majority of cases taking place within the first 6 months after surgery.[ 6 ]

Pediatric patients are particularly vulnerable due to factors such as rapid physical growth, high activity levels, and differences in abdominal wall structure and compliance compared to adults. This unusual migration occurs due to several anatomical factors unique to the pediatric population, such as the patent processus vaginalis (PPV), which can act as a pathway for the catheter to move from the peritoneal cavity to the scrotum. This particular type of migration may cause scrotal pain, edema, and infection; it may also compromise testicular health or result in the creation of a hydrocele.[ 2 , 10 ]

In this case series, several cases of distal scrotal migration of VP shunts in pediatric patients are described, along with their presentations, difficulties in diagnosis, and treatment approaches. The goal of the series is to understand this uncommon consequence better, increase the accuracy of the diagnosis, and guide surgical methods to prevent similar outcomes in children with VP shunts by considering these cases.

CASE PRESENTATION

Case 1

A 5-month-old male patient complained of the palpable distal catheter in his scrotum accompanied by swelling 10 days before admission. Initially, the shunt tube could return to the abdomen and was not palpable in the scrotum. There was no fever or seizure, and the patient only had a vomiting episode. The patient underwent VP shunt surgery 4 months ago. Scrotal edema was discovered during the physical examination. The babygram radiologic analysis revealed that the distal tip had extended into the left scrotum. After that, the patient had the shunt shortened and repositioned. After treatment, the patient was discharged 3 days later with no postoperative problems. The illustration of case 1 can be seen in Figure 1 .

Figure 1:

(a) Positive transillumination test, (b) clinical findings indicating scrotal swelling, (c) and babygram examination revealed distal migration of the tip to the scrotum.

Case 2

A 10-month-old male patient with a primary complaint is seizure. The seizure appeared 1 day before admission. The patient had a generalized type of seizure and was not conscious. The infant regained consciousness after the episode. The patient had a VP shunt insertion 11 months ago after being diagnosed with non-communicating hydrocephalus caused by aqueduct stenosis. Physical examination revealed an enlarged scrotum with no signs of inflammation. A babygram radiologic examination revealed a distal tip protrusion in the right scrotum. The patient then underwent distal catheter tip exteriorization and a switch from the VP shunt into the ventriculoatrial (VA) shunt. The patient was released 3 days following treatment with no postoperative problems. The illustration of case 2 can be seen in Figure 2 .

Figure 2:

(a) Positive transillumination test (b) clinical findings indicating scrotal swelling, and (c) babygram examination revealed distal migration of the tip to the scrotum.

Case 3

A 5-month-old male presented with a chief complaint of vomiting. The baby showed less milk consumption than usual. There were no symptoms of fever or convulsions. The infant exhibited a scrotal protrusion localized to the left side of the site of tube insertion site without an inflammation sign. The baby had VP shunt insertion surgery 6 months prior after being diagnosed with communicating hydrocephalus due to ventriculitis, bacterial meningoencephalitis, and a Dandy–Walker malformation variant. Scrotal examination revealed swelling of the scrotum, non-erythematous skin, tense texture, and a palpable solid mass suggestive of scrotal herniation. A distal tip shunt was seen in the scrotum using babygram imaging. Pediatric surgery performed a high ligation of the processus vaginalis after the patient had a shunt revision procedure with shortening of the distal catheter. Without any issues, the patient was released on the third day following treatment. The illustration of case 3 can be seen in Figures 3 and 4 . A summary of each case can be seen in Table 1 .

Figure 3:

(a) Clinical findings indicating scrotal swelling and (b) babygram examination revealed distal migration of the tip to the right scrotum.

Figure 4:

Intraoperative image showing the ligation of the vaginalis process performed by mini laparotomy.

Table 1:

Case summary of VP shunt to scrotum migration.

DISCUSSION

VP shunts are a common neurosurgical intervention for the treatment of hydrocephalus. They provide a reliable and effective means of draining excess cerebrospinal fluid (CSF) from the ventricles into the peritoneal cavity. However, despite their widespread use, complications associated with VP shunts, such as migration, infection, and obstruction can occur.[ 4 ]

Shunt migration, in particular, can result in a variety of clinical manifestations, including persistent or recurrent hydrocephalus, intracranial hemorrhage, and, as demonstrated in our case series, scrotal migration. While less common, scrotal migration can cause significant discomfort and may require surgical intervention.[ 7 , 14 ]

Three pediatric cases of distal VP shunt migration to the scrotum demonstrate the variability of presentation, severity of symptoms, and subsequent management approaches. Even though distal migration to the scrotum is uncommon, there is a possibility of infection, herniation, and testicular compromise.[ 3 ] Each case demonstrates tailored management to address specific patient needs and anatomical considerations.

VP shunt migration can occur due to various factors such as inadequate fixation of the distal catheter, abdominal wall laxity, increased intra-abdominal pressure, or congenital anomalies such as PPV.[ 3 , 5 ] PPV is a contributing factor to complications as the peritoneal catheter might pass through the inguinal canal and subsequently reach the scrotum, leading to scrotal herniation of the shunt.

Failure of the processus vaginalis (PV) to close is considered the main mechanism for inguinal complications in infants, and the continued patency of the PV is required to allow the VPS to migrate to the scrotum.[ 12 ] A small volume of peritoneal cavities in pediatric patients also contributes to the mechanism of VPS migration to the scrotum. Various authors have reported migration of the distal end of the peritoneal catheter into the scrotum through patent PVs.[ 1 ] Further increased abdominal pressure due to CSF infusion in the peritoneal cavity through the shunt system may prevent the obliteration of the PVs, and chronic catheter irritation and fluid flow from the tubing may be responsible for the scrotal swelling. Studies have shown that migration to the scrotum is more likely to occur in younger pediatric patients, as the processus vaginalis remains patent in up to 80–90% of infants born preterm and in approximately 20–30% of full-term infants.[ 8 , 13 ]

Scrotal migration typically presents with a palpable mass in the scrotum. This mass may be tender and associated with pain or discomfort. In some cases, patients may experience symptoms of hydrocephalus, such as headache, vomiting, or altered mental status. Herniation of the peritoneal catheter of the VP shunt into the scrotum is a rare phenomenon, with only a few case reports in the literature. It has been emphasized that the development of scrotal swelling or hydrocele in a child with a VP shunt should raise the possibility of a shunt complication. All of our cases exhibited scrotal swelling, which was confirmed by a babygram that showed shunt migration to the scrotum.

In one case, repositioning and shortening of the distal catheter were chosen, which is a common approach in cases where migration is recent and minimal complications are present. Literature suggests that repositioning alone often yields favorable outcomes, particularly in patients without significant abdominal complications.[ 7 ] This approach minimizes surgical invasiveness and generally has a low recurrence rate, particularly if there are no anatomical predispositions such as a PPV.

The following case involved a 10-month-old patient who presented with generalized seizures and scrotal catheter migration, signaling a more severe complication profile. In response, the shunt was converted to a ventriculoatrial system, removing the catheter from the abdominal cavity to prevent further abdominal complications. VA shunt is a valid alternative for shunt revision when peritoneal access is compromised due to intra-abdominal adhesions, local sepsis, or scarring from previous surgeries.[ 11 ]

In another case, the presence of scrotal herniation necessitated both shortening of the catheter and high ligation of the PPV in collaboration with a pediatric surgeon. High ligation effectively addresses the underlying anatomical predisposition, thereby reducing recurrence risk. Current data suggest that recurrence rates post-processus vaginalis ligation are extremely low, making this approach particularly beneficial for patients with anatomical factors contributing to shunt migration.

The management of scrotal VP shunt migration depends on the specific clinical presentation and the extent of migration. In cases where the shunt tip is only partially migrated into the scrotum, repositioning or shortening the catheter may be sufficient. However, in cases of complete migration or significant obstruction, a more complex surgical procedure may be necessary, such as shunt revision or replacement. The recurrence rate of VP shunt migration can be influenced by various factors, including the underlying cause of the migration, the surgical technique used to correct the problem, and the patient’s overall health status. While it is difficult to provide a precise estimate of the recurrence rate, it is generally believed to be relatively low, especially when appropriate surgical techniques are employed. Together, these cases highlight the importance of individualized management approaches in VP shunt migration, guided by symptom severity, anatomical features, and recurrence prevention strategies.

CONCLUSION

Scrotal migration of VP shunts is a relatively uncommon but potentially serious complication of hydrocephalus treatment. The surgeon should consider the possibility of distal catheter migration in patients with a history of VP shunt implantation who are candidates for surgery. This complication can occur as early as at the time of shunt placement or delayed. Early diagnosis and appropriate management are essential to prevent complications and ensure optimal patient outcomes.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Basaran R, Senol M, Efendioglu M, Onoz M, Isik N, Kaner T. Scrotal migration as an unusual complication of ventriculoperitoneal shunt case report. J Neurol Sci. 2014. 31: 408-12

2. Chan AC, Woo PY, Au YK, Chan KY, Wong HT. Scrotal migration of a ventriculoperitoneal shunt. Surg Pract. 2019. 23: 161-6

3. Chanchlani R, Sharma PK, Gunasekaran V. Kasundra A Scrotal migration of peritoneal end of ventriculoperitoneal shunt in an infant-A rare entity. J Neurosci Rural Pract. 2023. 14: 365-7

4. Dahal A, Sah RP, Gupta RK, Malla JJ, Singh AK, Sah B. A study of ventriculoperitoneal shunt in management of pediatric hydrocephalus. J BP Koirala Inst Health Sci. 2023. 6: 3-7

5. Hauser T, Auer C, Ludwiczek J, Senker W, Rauch PR, Kargl S. Treatment options for scrotal migration of ventriculoperitoneal shunts: Case Illustration and systematic review of 48 cases. Oper Neurosurg (Hagerstown). 2021. 21: 87-93

6. Javed MA, Khan NA, Saba AU, Sana H. Shunt migration into scrotum: A case report. Pak J Neurol Surg. 2021. 25: 194-8

7. Kashyap S, Singh SK, Gupta G. Scrotal migration of a ventriculoperitoneal shunt. BMJ Case Rep. 2024. 17: e260380

8. Kim SJ. Undescended testis: Importance of a timely referral to a surgical specialist. Clin Exp Pediatr. 2020. 63: 429-30

9. Moges KT, Zewdie K. Distal shunt migration; A case series. SVOA Neurol. 2023. 4: 50-5

10. Nawaz A, Chaudhry MB, Mirza WA. Cerebrospinal fluid hydrocele caused by scrotal migration of a ventriculoperitoneal shunt. BMJ Case Rep. 2018. 2018: bcr-2018-224698

11. Park KJ, Lim YC, Yoon SH. Shunt revision to ventriculoatrial shunt due to long-term abdominal distension complicated by neonatal necrotizing enterocolitis and cerebrospinal fluid overproduction after ventriculoperitoneal shunt for the management of post-hemorrhagic hydrocephalus: A case report. Nerve. 2019. 5: 90-3

12. Paterson A, Ferch R. Infant with recurrent ventriculoperitoneal shunt migration to right scrotum. J Clin Neurosci. 2018. 51: 65-6

13. Simpson M, Sundaram V. Urologic conditions in infants and children: Inguinal hernia, hydrocele, and cryptorchidism. FP Essent. 2020. 488: 16-20

14. Singh A, Yadav A, Yadav P, Ojha BK. Cranial migration of a VP shunt-A routine procedure with a rare complication!. Indian J Neurosurg. 2023. 12: 26