A rare cause of pediatric urinary incontinence : Ventriculoperitoneal shunt with bladder perforation

We present a case of 2-year-old boy with long term dysuria and intermittent incontinence, and new onset of fever and headache. Significant past medical history includes congenital hydrocephalus with a ventriculoperitoneal shunt placement two years prior to consult. On physical examination, a tubular structure was noted underneath the prepuce suspected to be the distal tip of ventriculoperitoneal shunt, which was confirmed by kidney, ureter and bladder (KUB) X-ray and CT scan. Patient was treated with a novel approach of extraperitoneal removal of ventriculoperitoneal shunt distal tip with cystorrhaphy via a low transverse pfannenstiel incision, separate left ventriculostomy tube insertion and complete removal of ventriculoperitoneal shunt from the right ventricle. This report accounts a rare pediatric case with ventriculoperitoneal shunt perforation into a normal bladder successfully treated with mini-open surgery.


Introduction
The diversion of cerebrospinal fluid (CSF) for hydrocephalus into the peritoneal cavity for CSF absorption in ventriculo-peritoneal shunting (VPS) was introduced in 1905 by Kausch [1].Since then VPS is amongst the most frequently performed operations in the management of hydrocephalus [1].VPS used in the treatment for hydrocephalus is associated with several complications with reported incidence of 85.4% of cases will Open Access need revision in few days to 17 years postplacement [2].Abdominal complications include: peritoneal pseudocyst, intestinal volvulus, pseudotumor of the mesentery, inguinal hernia, and migration of the catheter through the vagina, scrotum, umbilicus, and intestinal tract [3,4].Bladder perforation in a normal bladder after VPS is a rare complication [5].
Voiding complaints in the pediatric patient is a broad topic with variable presentations and etiologies.Incontinence defined as continuous leakage of urine from the bladder was the 1 st sign of the perforation of the VPS into the bladder and eventually towards the urethra months before the sign of meningitis   and was removed successfully with ease from the urinary bladder.The bladder was closed as two layers using a 4-0 polyglycolic suture in a continuous interlocking manner.
occurred [6].This is a rare late complication of a VPS which bladder perforation can potentially create diagnostic and therapeutic dilemma, and there are no clear guidelines on the management of this problem.We present a rare case of pediatric ventriculoperitoneal-vesical perforation complication presenting with urinary incontinence and to describe the novel technique used in its management with discussion of literature review.Case report A 2 year old boy presented with long term dysuria (crying episodes when urinating) and continuous urine dripping (incontinence) noted from an uncircumcised penis.An incidence of a whitish tubular structure protruding from the patient's penile meatus was previously noted.The tubular structure was then pushed back and consult was done.At presentation, patient already developed 3week history of low grade fever, associated with headache and vomiting.Significant past medical and surgical history include a diagnosis of congenital hydrocephalus at 3 months of age and VPS inserted at 5 months of age.Physical examination on admission showed a bedridden, febrile, pale, asthenic, child with poor appetite.Neurological examination revealed poor sensorium and drowsy patient, arousable to pain and occasionally localize pain stimulus.Abdominal findings were soft, non-tender with no signs of peritonitis.The previous right upper quadrant surgical scar from the previous VPS insertion was noted.Further examination and retraction of the prepucial skin noted a dirty white plastic tubular structure protruding from the urethra.Impression of possible VPS migration into the genitourinary system had been entertained.Abdominal x-ray requested noting a tubular structure consistent with the tip of the VPS to be coiled within the rims and confines of the bony pelvis.CT scan of the whole abdomen was also done confirming the presence of the tip of the VPS to be coiled inside the urinary bladder [Fig. 1, 2].Urinalysis showed pyuria and bacteriuria.The urine culture taken on admission showed the presence of Klebsiella oxytica with a growth of 120,000 colonyforming unit (CFU).

Fig. 1 .
Fig. 1.X rays of the urinary tract showing VP shunt distal segment in the pelvic location.

Fig. 2 .
Fig. 2. Axial CT scan without contrast showing distal VP shunt segment with tip perforated into the bladder.

Fig. 3 .
Fig. 3. Intraoperative finding with the distal end of VP-shunt inserted into the bladder dome.

Fig. 4 . 2 .
Fig. 4. VP shunt distal end extracted from bladder with mildly encrusted surface.A Burr hole craniotomy with ventriculostomy tube inserted into the left frontal horn and exteriorized for drainage.A separate cranial incision was done at the right parietal area of the skull and the infected VPS tube was removed.The infected VPS showed intra-luminal obstruction with caked and encrusted pus impeding flow of cerebrospinal fluid and proper drainage leading to recurrence of the hydrocephalus.Specimen from the drained abscess and the VPS was sent to microbiology for culture and sensitivity.The VPS was then completely removed after the distal end was transected and removed from the urinary bladder.Patient showed immediate post-operative improvement in sensorium with spontaneous eye opening and purposeful movement of all extremities.