Urethral migration of a ventriculoperitoneal shunt in a 6-month-Old female infant: A rare complication of hydrocephalus management

Abstract

Hydrocephalus, occurring in 0.9–1.8 per 1000 births, is managed through ventriculoperitoneal shunt placement. This intervention carries potential complications, with migration and infection being predominant concerns.

6-month-old female infant presented with VP shunt migration through the urethra, 5 months after hydrocephalus treatment. Clinical manifestations included irritability, mild fever, vomiting, and tense, bulging fontanelle. Laboratory findings revealed elevated white blood cell count of 21,000/mm ³ and positive microbiological cultures. Surgical intervention involved catheter removal, and shunt revision.

This rare case of VP shunt urethral migration highlights the critical importance of vigilant monitoring and prompt, multidisciplinary intervention in pediatric neurosurgery.

1 Introduction

Hydrocephalus, with an incidence of 0.4–2.5 per 1000 live births globally, is characterized by increased cerebrospinal fluid volume causing ventricular enlargement and elevated intracranial pressure. Ventriculoperitoneal (VP) shunt placement remains an effective treatment for diverting cerebrospinal fluid into the peritoneal cavity. Complications following implantation are diverse, including shunt obstruction, infection, migration, and organ perforations, with infection and obstruction being most common. ^,

Migration of the distal VP shunt catheter into the urinary bladder with per-urethral extrusion is exceptionally rare, with only 24 reported cases in medical literature. Up to 49.6 % of complications occur in patients younger than 6 months, with a positive correlation between shunt complications and patient age. Clinical presentations range from asymptomatic to symptomatic, emphasizing the critical need for prompt diagnosis and management to prevent potentially fatal outcomes like peritonitis and meningitis.

2 Case report

A case of ventriculoperitoneal (VP) shunt migration through the urethra is reported in a 6-month-old female infant. The shunt had been placed 5 months prior for hydrocephalus at another institution. The patient presented with a one-week history of irritability, for which she had received medication. Five hours before presentation, the mother noticed an abnormal tube protruding from the infant’s genital area. Examination revealed approximately 5 cm of shunt protrusion from the urethra ( Fig. 1 ).

On admission, the patient exhibited mild fever and had experienced emesis twice before and once during examination. The fontanel was tense and bulging, though vital signs remained stable. The infant was alert and not in acute distress. Laboratory findings showed an elevated white blood cell count of 21,000/mm ³ . VP shunt flow was noted to be weak. Cerebrospinal fluid (CSF) was obtained from the ventriculopleural shunt for Gram stain and culture. Thoracoabdominopelvic radiography demonstrated an intact shunt along its entire length( Fig. 2 ).

Surgical intervention was performed via a Pfannenstiel incision, approaching the bladder extraperitoneally. The intravesical portion of the shunt was visualized ( Fig. 3 ), and the catheter was transected proximal to its bladder entry point. The distal segment was completely removed. The shunt’s entrance site, bladder incision, and midline opening were repaired in two layers. Through a small incision at the previous abdominal scar site, the remaining abdominal portion of the shunt was extracted ( Fig. 4 ). Urine and CSF samples were cultured, both yielding positive results. Intravenous antibiotic therapy was initiated based on these findings.