Pneumoscrotum: report of two cases and review of mechanisms of its development

Pneumoscrotum Caused by a Bronchopleural Fistula

Pneumoscrotum is the term used to indicate the presence of air in the scrotum and comprises scrotal emphysema and pneumatocele. It is an uncommon medical condition and encompasses multiple etiologies, some of which may be life-threatening. We present the case of a 45-year-old male who developed a pneumoscrotum seven days after undergoing a thoracoscopy with decortication, pleural biopsy, and chest tube insertion, for a loculated pleural effusion not amenable to drainage by a pigtail catheter. The patient was diagnosed with a bronchopleural fistula and was treated conservatively with negative chest tube pressure. Treatment of the fistula and of the resulting pneumothorax allowed resorption of the pneumoscrotum. The associated literature is reviewed after the case presentation. This case report underlines the importance of evaluating a pneumoscrotum that should not be underestimated.

Scrotal abscess as a manifestation of posterior duodenal perforation; a very rare presentation

Posterior perforation of duodenal ulcers is very rare; the infection may spread from the retroperitoneal space to the scrotum.

A 75-year-old male presented with painful right scrotal swelling for 2 days associated with fever. During abdominal examination there was abdominal tenderness and scrotal swelling and tenderness.

CT scan of the abdomen showed large amount of air collection in the retroperitoneal space extending to the right scrotum with contrast media passing to the retroperitoneum and right scrotum.

Laparotomy done and there was a perforation in the posterior wall of the duodenum, suturing done and right scrotal abscess drained.

Pneumoscrotum after colorectal surgery: A case report

Pneumoscrotum is a very rare complication. Currently, very little evidence-based medicine exists on treatment guidelines. We think a prophylactic antibiotic course and a 48 hours in hospital observation are justified in these rare cases.

Spontaneous Pneumoperitoneum in Pediatric Patients: Dilemmas in Management

Context:

Pneumoperitoneum is typically a surgical emergency, particularly in neonates. However, pneumoperitoneum can rarely present without gastrointestinal perforation which is known as spontaneous pneumoperitoneum.

Aims:

This study aims to analyze the outcome of pediatric patients with spontaneous pneumoperitoneum and describe our experience.

Settings and Design:

A retrospective study performed from January 2014 to May 2017.

Materials and Methods:

The study included all pediatric patients admitted in a tertiary care institute.

Results:

There were 9 patients with 5 males and 4 females, out of which 7 were neonates. At presentation, respiratory distress was a common complaint (8/9). 5 out of all patients developed abdominal distension. Associated malformations were seen in 5 patients. Pneumoperitoneum was preceded by mechanical ventilation in 5 patients. Abdominal examination revealed soft distension with relaxed abdominal wall in 7, while marked distension was present in 2 cases. Features suggestive of peritonitis were absent in all the patients. Abdominal radiographs revealed free air in all, while, radiographic evidence of pneumothorax was seen in 2 patients. Conservative management without any operative intervention was performed in 3 patients with favorable outcome. Laparotomy was performed in 1 patient; negative for any perforation and outcome was unfavorable. In 5 patients, abdominocentesis was performed followed by abdominal drain placement. No patient had any evidence of leakage of intestinal contents from gastrointestinal tract after insertion of abdominal drain. Favorable outcome was present in 5 patients. Out of 4 cases with unfavorable outcome, 3 patients were having esophageal atresia.

Conclusions:

A high index of suspicion for spontaneous pneumoperitoneum must be present when dealing with pediatric patients, especially neonates with pneumoperitoneum and without clinical signs of peritonitis. A comprehensive clinical evaluation with sepsis screen must be carried out to supplement the diagnosis. Pneumoperitoneum in pediatric patients, especially neonates, is not always an absolute indication for surgery.

ERCP-Related Duodenal Perforation Presenting as Pneumoscrotum

Duodenal perforation is a rare but life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). Duodenal perforation can cause air leak into the extraperitoneal space. In rare instances, the air in the extraperitoneal space could dissect along the fascial planes of the abdomen to reach scrotum, leading to pneumoscrotum. We present the case of a 35-year-old male patient who developed scrotal pain and swelling following ERCP. He was found to have extensive pneumoscrotum, pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed with retroperitoneal duodenal perforation. He was managed conservatively with close monitoring and supportive care.

Testicular compartment syndrome: an overview of pathophysiology, etiology, evaluation, and management

Testicular compartment syndrome (TCS) refers to the impairment of microcirculation in the testicle due to either increased venous resistance or extraluminal compression, which leads to hypoxia. TCS releases oxidants through hypoxia and ischemia/reperfusion injury (IRI). The pathophysiology, etiology, evaluation, and management of TCS are reviewed. Based on the properties of TCS, specific causes, e.g., varicocele, hydrocele, orchitis, cryptorchidism, and scrotal hernia, are suggested and categorized. The oxidant-induced stress from TCS may explain the correlations between these causes and infertility. A chief shortcoming of current imaging modalities is that they detect TCS late after it has progressed to impair the macrocirculation of the testicle. We propose frequent sequential periodic power Doppler ultrasonography to monitoring for earlier detection. Intraoperatively, TCS can be diagnosed by the dull purple appearance of a hypoxic testicle and by tissue pressures above 30 mmHg. When compartment pressure is low, the underlying etiology must be promptly treated. During acute presentation, an incision of the resilient tunica albuginea may be necessary. A great challenge of treating TCS is restoring microcirculation while minimizing IRI; concomitant antioxidant therapy secondary to treatment may be effective and harmless at the least. Because testicular oxidant stress is common in infertility and since TCS can cause such a stress, TCS may be a larger factor in infertility than currently suspected.

Critical Manifestations of Pneumoscrotum

INTRODUCTION

Pneumoscrotum is a critical, physical finding that may indicate significant morbidity and mortality. Accumulation of gas in the scrotum can be primary or secondary.

OBJECTIVE

This paper discusses rapid diagnosis and treatment options.

MATERIAL AND METHODS

PubMed searches for pneumoscrotum, etiology, diagnosis, and treatment.

RESULTS

We review the historical perspective, classification, etiology, diagnosis, and treatment options of pneumoscrotum, as well as the presentation of pneumoscrotum in neonates/infants.

CONCLUSION

It is crucial to diagnose the etiology pneumoscrotum and designing a treatment option based off that.

Pneumoscrotum, pneumomediastinum, pneumothorax, and pneumorrhachis following colon surgery

We report the case of an 80-year-old man who developed a colocutaneous fistula as a complication of anastomotic leakage following segmental colonic resection. The patient presented with an abscess of the abdominal wall, subcutaneous emphysema, pneumomediastinum, pneumothorax, pneumorrhachis, and pneumoscrotum. We discuss the possible mechanisms for these unusual clinical presentations of extraperitoneal air following anastomotic leak.

Pneumoscrotum: report of two different cases and review of the literature

Pneumoscrotum is the term used to describe the presence of air within the scrotum and includes scrotal emphysema as well as pneumatocele. The etiology varies; in some cases, pneumoscrotum may be due to life-threatening disease like pneumothorax or Fournier gangrene. Despite this, pneumoscrotum is a rarely debated issue. We present two different cases of pneumoscrotum and a review of the literature. The first case report is about a 29 year old male patient affected by Duchenne syndrome who showed pneumoscrotum after cardiopulmonary resuscitation that was performed for asphyxic crisis and cardiovascular arrest. We carried out local puncture with an 18-gauge needle, and the pneumoscrotum was successfully solved. The second case report is about a 56 year old male with pneumoscrotum due to Fournier gangrene who underwent radical exeresis of all necrotic tissues and drainage. This is why most of the scrotal skin and all of the penis skin were removed; as a result, the testicles, epididymis, and cavernosa corpora were externalized. On postoperative day one, the patient was feverless and underwent hyperbaric chamber therapy. No postoperative complications occurred. Accurate evaluation of the pneumoscrotum is always needed. Despite the benign course of most of the clinically evident pneumoscrotum cases, this condition should never be underestimated.

Pneumoscrotum after tracheal intubation

Air in the scrotum is an unusual clinical finding and a thorough search should be done in order to locate the air leak or source of gas production. We report an 81-year-old patient who developed severe acute respiratory failure after fiberoptic bronchoscopy and was intubated immediately. After tracheal intubation, excessive subcutaneous emphysema from the head to the scrotum was obvious. Chest tube thoracostomies were placed to treat pneumothorax. The emphysema was absorbed after 13 days without any sequela. Air or gas inside the scrotum may originate from intraperitoneal, extraperitoneal, or local sources. The majority of the cases can be managed conservatively, but emergent intervention is needed in life-threatening situations.

Abdominal and scrotal wall emphysema in a patient with severe ulcerative colitis

Severe ulcerative colitis can be associated with bowel perforation. Bowel perforation rarely leads on to abdominal wall and scrotal wall emphysema. Bowel perforation in such cases can be spontaneous or iatrogenic (colonoscopy-related). We report a rare scenario where a patient presented with abdominal wall and scrotal emphysema after topical corticosteroid enema-induced traumatic rectal perforation. Topical corticosteroids were stopped immediately after identification of rectal perforation. The patient was managed conservatively with intravenous antibiotics. With this report we intend to sensitise clinicians and topical enema manufacturers regarding this rare complication.

Pneumoscrotum as complication of blunt thoracic trauma: a case report

Introduction. Pneumoscrotum is a rare clinical entity. It presents with swollen scrotal sac and sometimes with palpable crepitus. It has many etiologies. One of them is due to blunt trauma of the thoracic cage, causing pneumothorax and/or pneumomediastinum. Case Presentation. We report the case of an 82-year-old male who was transferred to the Emergency Department with signs of respiratory distress after a blunt chest trauma. A CT scan was obtained, and bilateral pneumothoraces with four broken ribs were disclosed. Subcutaneous emphysema expanding from the eyelids to the scrotum was observed, and a chest tube was inserted on the right side with immediate improvement of the vital signs of the patient. Discussion. Pneumoscrotum has three major etiologies: (a) local introduction of air or infection from gas-producing bacteria, (b) pneumoperitoneum, and (c) air accumulation from lungs, mediastinum, or retroperitoneum. These sources account for most of the cases described in the literature. Treatment should be individualized, and surgical consultation should be obtained in all cases. Conclusion. Although pneumoscrotum itself is a benign entity, the process by which air accumulates in the scrotum must be clarified, and treatment must target the primary cause.

[Pneumoscrotum as a consequence of long-term ventilation]

A pneumoscrotum due to long-term ventilation is a rare entity. We present the case of a 59-year-old man with adult respiratory distress syndrome (ARDS) and long-term ventilation, who required intensive care and had severe subcutaneous emphysema and a pneumoscrotum. Computed tomography revealed subcutaneous emphysema of the neck, chest, and abdomen, emphysema of the mediastinum, a pneumoperitoneum, pneumoretroperitoneum, and pneumoperineum. A puncture of the scrotum confirmed the diagnosis of a pneumoscrotum. The patient died in the course of progressive ARDS.

Pneumoscrotum due to perforated peptic ulcer previously sutured by laparoscopy

Pneumoscrotum is a rare condition defined by the presence of gas within the scrotum. Most cases are associated with the pneumoperitoneum; the condition has been described after various diagnostic and therapeutic procedures and disease conditions. In this article, we report a case of a patient admitted to the emergency department for right-upper quadrant abdominal pain. Abdominal X-ray showed free air in the right subdiaphragm; computed tomography (CT) confirmed free air in the abdomen and detected free fluid in the pelvis. The patient underwent laparoscopy, at which time a 1-cm perforation on the anterior wall of the gastric antrum near the pylorus was identified. The perforation was sutured with three detached stitches of reabsorbable material. Approximately 2 days after the surgical procedure, physical examination of the patient showed significant scrotal swelling suspicious for the presence of subcutaneous air. A CT scan confirmed the presence of the pneumoscrotum. The patient returned to the operating room and underwent an exploratory laparotomy. A new perforation was identified beneath the previous one and was sutured with two detached stitches. The patient was discharged uneventfully after 8 days of hospitalization. Pneumoscrotum should be recognized as an early sign of recurrence in patients operated on laparoscopically for peptic ulcer.

Pneumoscrotum after blunt chest trauma

Pneumoscrotum, the accumulation of air inside the scrotum, is a rare complication associated with blunt chest trauma. We report a case of severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum after blunt chest trauma in a 44-year-old man. He presented with progressive swelling of the neck that descended to the chest, abdomen, both legs, and scrotum. Radiography and computed tomography of the chest and abdomen confirmed the diagnosis of a tracheal injury complicated by severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum. Primary repair of the tracheal injury was performed, and he was weaned successfully from the ventilator by day 5. He was discharged on day 7.

Pneumoscrotum after jejunal perforation: a case report

BACKGROUND

Pneumoscrotum is a rare disease entity in which gas is present in the scrotum. It has been described after diagnostic and therapeutic procedures, as well as with disease states. The entity itself is a benign condition, but is associated with both incidental and life-threatening conditions.

OBJECTIVES

We discuss the pathophysiology and associated conditions of pneumoscrotum.

CASE REPORT

We report a case of pneumoscrotum after jejunum perforation.

CONCLUSION

Even though pneumoscrotum is a benign, rare condition, its mere presence should signal the possibility of a severe, life-threatening disease process within the peritoneum or retroperitoneum.

[Pneumoscrotum secondary to bilateral tension pneumothorax]

We present a case of pneumoscrotum due to bilateral tension pneumothorax. Although the pneumoescrotum is an uncommon and light disease it can be a symptom of a life threatening pathology. The treatment of the pnemoescrotum is ethiological. It is necessary to treat the specific disease responsible of the pneumoescrotum.

Subcutaneous emphysema of the scrotum (pneumoscrotum) due to traumatic pneumothorax: a case report

Introduction

Subcutaneous emphysema of the scrotum due to traumatic pneumothorax is a rare medical situation and only a few cases are reported in the literature.

Case report

We present the case of a 22 year old man who was admitted to the emergency department after a motorcycle accident having a painless crepitant scrotum and chest excoriations. Further evaluation revealed subcutaneous emphysema of the scrotum caused by left pneumothorax.

Conclusion

In conclusion, subcutaneous emphysema of the scrotum (or pneumoscrotum) due to traumatic pneumothorax is not an urgent condition and assessment should be supportive with intervention directed at the etiology, e.g. the pneumothorax.

Pneumoscrotum after colonoscopy

Pneumoscrotum is an unusual problem that is very rarely associated with gastrointestinal endoscopy procedures. It has been reported to occur after colonoscopy and polypectomy. The present paper describes the case of an 81-year-old man with benign pneumoscrotum that formed after polypectomy at the site of a previous rectal polyp. The pneumoscrotum was managed with conservative treatment.

Pneumoscrotum: A rare manifestation of perforation associated with therapeutic colonoscopy

Pneumoscrotum is uncommon and also rarely reported as a complication associated with colonic perforation. A case of colonic perforation in delayed fashion associated with EMR, revealed by pneumoscrotum, is reported and the associated literatures are reviewed. A 52-year-old male received piecemeal EMR for a laterally spreading tumor 35 mm in size in our hospital. He complained of enlargement of the scrotum and revisited our hospital the day after the procedure. A diagnosis of pneumoscrotum was made, and as most such cases have been reported to be associated with pneumoperitoneum, colonic perforation was suspected. Free air but no fluid collection was found by abdominal computed tomography, and delayed colonic perforation was diagnosed. However, as there were no clinical signs of peritoneal irritation, conservative treatment was administered and the patient recovered uneventfully. Pneumoscrotum could be a sign of colonic perforation after EMR, and treatment should be carefully chosen.

[Pneumoscrotum secondary to a massive subcutaneous emphysema after expontaneous pneumothorax drainage]

We present a case of a pneumoscrotum and pneumopenis which appeared after a trocar drainage placement for treatment of a recidivated expontaneous pneumothorax. In spite of is an entity with easy diagnosis and conservative management, maybe be confused with other more aggressive entities which treatment should be invasive.

Ultrasound diagnosis of infantile scrotal emphysema

We report a 4-month-old boy who developed scrotal emphysema following removal of a chest drain. The initial diagnosis was made by ultrasonography. This report describes the sonographic findings, pathophysiological mechanisms and outcome of this rare entity.

Intestinal atresia presenting as bilateral scrotal pneumatocele: A case report

The authors report on a newborn baby with congenital hydrocele in whom pneumoscrotum developed. Air and meconium were found over the hernia sac, owing to ileal atresia with perforation. Gas in the scrotum usually is inside herniated bowel, but it can be the first sign of pneumoperitoneum.