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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 245-248

Neglected inguinoscrotal hernia complicated by scrotal fecal fistula in an infant: A case report and review of literature


Department of Surgery, Paediatric Surgery Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria

Date of Submission22-Aug-2019
Date of Decision01-Aug-2020
Date of Acceptance17-Sep-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Jideofor Okechukwu Ugwu
Paediatric Surgery Unit, Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, P.M.B. 5025, Nnewi, Anambra State
Nigeria
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DOI: 10.4103/smj.smj_42_19

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  Abstract 


Spontaneous scrotal fistula is an extremely rare complication of incarcerated hernia, especially in children. To date, only 12 cases in children have been reported in the literature worldwide. We present the case of a 31-day-old male infant who had scrotal fecal discharge from an irreducible right inguinoscrotal swelling. Inguinal exploration revealed an incarcerated right inguinal hernia containing a segment of the ileum with a 3 cm perforation on its antimesenteric border. Segmental resection and end-to-end anastomosis along with debridement and closure of the scrotal wound were successful in the management of this index patient. This complication appeared to be the result of a neglected inguinoscrotal hernia. This report aims to highlight the morbidity associated with this complication and to review the available literature. We conclude that early repair of inguinal hernias in infants and children of all ages would reduce this complication and its attendant morbidity and mortality.

Keywords: Enteroscrotal fistula, infants, inguinal hernias


How to cite this article:
Ugwu JO, Ugwunne CA, Ekwunife OH, Osuigwe AN. Neglected inguinoscrotal hernia complicated by scrotal fecal fistula in an infant: A case report and review of literature. Sahel Med J 2020;23:245-8

How to cite this URL:
Ugwu JO, Ugwunne CA, Ekwunife OH, Osuigwe AN. Neglected inguinoscrotal hernia complicated by scrotal fecal fistula in an infant: A case report and review of literature. Sahel Med J [serial online] 2020 [cited 2021 Mar 6];23:245-8. Available from: https://www.smjonline.org/text.asp?2020/23/4/245/310022




  Introduction Top


Inguinal hernia is a common condition encountered in pediatric surgery. The reported incidence of inguinal hernia varies from 0.8% to 4.4% in children.[1] Inguinal hernia in children results from failure of the processus vaginalis to obliterate. Boys are 10–12 times more likely to be affected than girls.[2] Most pediatric inguinal hernias are readily reducible into the abdominal cavity, but some could become incarcerated and difficult to reduce. The incidence of incarcerated inguinal hernias in children <10 years of age is 10%–17% and two-thirds of such cases occur in infancy and half of these infants are <3-month-old.[3] Spontaneous scrotal fistula is an extremely rare complication of incarcerated hernia in children, and only 12 cases have been reported in the world literature to the best of our knowledge. This is a report of an additional case to highlight the morbidity associated with this complication and to review the available literature.


  Case Report Top


A 31-day-old term male infant, the second of a set of twins, presented through the children emergency room with a 9-day history of initially reducible bilateral inguinal swellings. The right inguinal swelling had become irreducible and painful, with redness of the skin overlying the groin and scrotum 7 days before presentation. This was associated with irritability, bilious vomiting, abdominal distension, and constipation. The swelling spontaneously ruptured, with the discharge of feces from the scrotum after 3 days. This was followed by reduction in abdominal distension and cessation of vomiting. There was no fever. The baby was initially managed at a private hospital with intravenous and intramuscular medications and was referred to our center at the onset of fecal discharge from the scrotum. Physical examination showed a small for age male infant with weight of 1.6 kg, dehydrated with a temperature of 37.5°C. His heart rate was 160 bpm; heart sounds and chest examination were normal. His abdomen was full, nontender with normoactive bowel sounds. There was a right inguinoscrotal swelling with shiny, hyperemic overlying skin. There were two fistulae on the ventrolateral surface of the right scrotum discharging feces [Figure 1]. The packed cell volume, electrolytes, urea, and creatinine were all within normal limits. Dehydration was corrected and intravenous broad-spectrum antibiotics were administered.
Figure 1: Two scrotal fecal fistula

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At surgery through a right groin incision, the incarcerated right inguinal hernia contained a loop of ileum adherent to the scrotum at the point of the fistulae. The ileum had a 3 cm wide perforation on the antimesenteric border; however, the right testis was viable [Figure 2]. The loop of the ileum was freed from the scrotum by blunt dissection with resection of the fistulous segment and end-to-end anastomosis was performed. Herniotomy was performed and groin wound closed. The scrotal wound was debrided and closed with a sheet drain in situ. A left groin exploration and herniotomy were also done. Postoperatively, the right groin wound and scrotal wound developed deep surgical site infection which was controlled with local wound care and antibiotics. The child did well and was discharged home after 8 days.
Figure 2: Ileal perforation

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  Discussion Top


Incarcerated inguinal hernia results from the entrapment of viscera within the hernia sac. This commonly occurs at the level of the internal ring. Incarceration is more common in the first 6 months of life, with an incidence of 60%.[4] With early presentation, incarcerated inguinal hernia could be managed conservatively by gentle reduction under light sedation and herniotomy performed later , usually after 48-72h.[5] Unrelieved incarceration may be followed by strangulation and perforation. The rate of strangulation has been reported to be 4.8% in Nigeria.[6] In the instance of strangulation or perforation, emergency inguinal exploration is indicated.

Scrotal fecal fistula resulting from an incarcerated inguinal hernia is extremely rare. Only 12 cases have been reported in the literature.[2],[5],[7],[8],[9],[10],[11],[12],[13],[14],[15] These are summarized in [Table 1]. This rare complication has been reported only in developing countries (India, Nigeria, and Pakistan)[2],[5],[7],[8],[9],[10],[11],[12],[13],[14],[15] with late presentation identified as the major cause as seen in this index case. This reflects the poor health-seeking behaviors of parents of these children owing to poverty, ignorance, poor primary health-care services, and timely referrals for specialist care. Of the 13 cases (including index case), 11 involved the right side, whereas 2 were on the left [Table 1]. This may be because inguinal hernias occur more on the right in children. The ipsilateral testis is always at risk of ischemia/necrosis in incarcerated inguinal hernia due to compression of the spermatic cord structures, however only two cases required orchidectomy due to gangrenous testes [Table 1]. In our case, the testis was normal. This may have been due to decompression through the fecal fistula serving as a “pop off mechanism,” thereby reducing the pressure on the cord structures unrelieved intestinal obstruction or delay in intervention could lead to septic complications and death as seen in two of the reported cases.
Table 1: Summary of cases of spontaneous scrotal fecal fistula in infants and neonates

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Contralateral groin exploration and herniotomy on the left side performed in the index case was indicated by the history of bilateral groin swellings. This anyways ran the risk of surgical site infection in an otherwise clean surgery, however careful asepsis and good antibiotic coverage mitigated against infection. Hence, it is not routine to perform contralateral groin exploration in a unilateral incarcerated groin hernia.[16] In our patient, we performed a contralateral inguinal exploration and herniotomy which was indicated by the history of bilateral inguinal swelling.


  Conclusion Top


We advocate early repair policy for all pediatric inguinal hernias, especially in infants. Furthermore, there should be an emphasis on awareness to prevent this complication and to avoid morbidity and mortality as seen in the reported cases of spontaneous scrotal fecal fistula in infants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Glick PL, Boulanger SC. Inguinal hernias and hydroceles. In: Grosfeld JL, O'Neill JA, Fonkalsrud EW, Coran AG, editors. Pediatric Surgery. 6th ed. Philadelphia: Mosby-Elsevier; 2006. p. 1174.  Back to cited text no. 1
    
2.
Ghritlaharey Rajendra K, Shrivastava DK, Kushwaha AS. Spontaneous scrotal faecal fistula in infant: A case report and. J Clin Diagn Res [Serial Online] 2007;4:303-6.  Back to cited text no. 2
    
3.
Rowe MI, Clatworthy HW. Incarcerated and strangulated hernias in children. A statistical study of high-risk factors. Arch Surg 1970;101:136-9.  Back to cited text no. 3
    
4.
Haynes JH. Inguinal and scrotal disorders. Surg Clin North Am 2006;86:371-81, ix.  Back to cited text no. 4
    
5.
Ameh EA, Awotula OP, Amoah JN. Spontaneous scrotal faecal fistula in infants. Pediatr Surg Int 2002;18:524-5.  Back to cited text no. 5
    
6.
Ameh EA. Incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria. East Afr Med J 1999;76:499-501.  Back to cited text no. 6
    
7.
Gupta DK, Rohatgi M. Inguinal hernia in children: An Indian experience. Pediatr Surg Int 1993;8:466-8.  Back to cited text no. 7
    
8.
Rattan KN, Garg P. Neonatal scrotal faecal fistula. Pediatr Surg Int 1998;13:440-1.  Back to cited text no. 8
    
9.
Kasat LS, Waingankar VS, Kamat T, Bahety G, Meisheri IV. Spontaneous scrotal faecal fistula in an infant. Pediatr Surg Int 2000;16:443-4.  Back to cited text no. 9
    
10.
Chirdan LB, Uba AF, Iya D, Dakum NK. Spontaneous scrotal faecal fistula in a neonate: Report of a case. Nigerian J Surg Res 2004;6:59-60.  Back to cited text no. 10
    
11.
Sowande OA, Adejuyigbe O, Ogundoyin OO, Uba AF, Chinda JY. Spontaneous scrotal faecal fistula: A rare complication of incarcerated inguinal hernia in infancy. J Indian Assoc Pediatr Surg 2006;11:244.  Back to cited text no. 11
  [Full text]  
12.
Roshan Khan T, Maletha M, Tandon R. Neonatal incarcerated inguinal hernia with spontaneous scroto-fecal fistula. J Pediatr Surg 2009;44:1846-7.  Back to cited text no. 12
    
13.
Sharif M, Ijaz L, Iqbal S, Sheikh A. Enteroscrotal fistula: A rare complication of incarcerated inguinal hernia. APSP J Case Rep 2010;1:21.  Back to cited text no. 13
    
14.
Ezomike UO, Ekenze SO, Okafor DC, Nwankwo EP. Spontaneous scrotal enterocutaneous fistula: A case report and review of literature. Niger J Med 2012;21:111-2.  Back to cited text no. 14
  [Full text]  
15.
Raj P, Birua H, Prasad VK. Enteroscrotal fistula in a neonate following incarcerated inguinal Hernia. J Neonatal Surg 2017;6:71.  Back to cited text no. 15
    
16.
Shabbir J, Moore A, O'Sullivan JB, Delaney PV, Drumm J, Flood H, et al. Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia. Irish J Med Sci 2003;172:18.  Back to cited text no. 16
    


    Figures

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    Tables

  [Table 1]



 

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