JK SCIENCE

CASE REPORT

Enterocutaneous Fistula of the Scrotum

Sanjay K. Bhasin, Vijay Kumar, S.L. Kachroo, Gagan Gopal Bali, Manoj Mahajan

Abstract
Inguino-scrotal hernia is a very common surgical entity. Though much common in pediatric population, yet
no age is exempted. Enterocutaneous fistula in an inguino-scrotal hernia is a very rare surgical entity in
both developing as well as developed countries. Comparatively commoner in pediatric age group but no
age is exempt, the information gathered from few cases available in the surgical literature. About 08 cases
in pediatric age group and 06 cases in adult population are available in the literature that could be revealed
from Pubmed/Medline as well as medical library shelf search. We report here two rare cases of scrotal
enterocutaneous fistula in an adult in inguinoscrotal hernia.

Key Words
Scrotum, Enterocutaneous Fistula, Incarceration

Introduction
Inguino-scrotal hernia is a very common surgical entity. background presenting as strangulated inguinoscrotal
Though much common in pediatric population, yet no age hernia with gangrenous scrotal skin.
is exempted. The diagnosis and management is also Case 1
prompt in expert surgical hands. The incarceration of 65 year old male presented in emergency unit of
inguinal hernia in children varies between 5 to 23.6% in surgery department with fecal discharge from scrotum.
many series and is more frequent in neonates and infants. The history suggested that patient went to a surgeon for
Incarceration and strangulation is more common in pain, swelling and redness of the inguinoscrotal region
developing countries probably due to not so good health for 07 days. Surgeon operated upon the patient thinking
care infrastructure and health education amongst the it as a case of scrotal abscess. The fecal discharge
comparatively less educated population (1,2,3,4).The started coming out of the cut and patient was referred to
scrotal enterocutaneous fistula following incarceration/ Government Medical College. On examination vitals of
strangulation of inguino-scrotal hernia is beyond doubt the patient were within normal limits except tachycardia
the very rare complication even in the developing world. (pulse rate of 110beats/mt) and fever 100 degree F.
(5,6).Due to rarity of this surgical entity we present here Abdominal examination revealed signs of peritonitis. It
two very rare case of scrotal enterocutaneous fistula one was a case of iatrogenic enterocutaneous fecal fistula of
following intervention by a surgeon misdiagnosing the scrotum. On further probing it was established that
strangulated inguinoscrotal hernia in a 65 years old male patient was a known case of inguinoscrotal hernia and it
and another 40 years male from very low socio-economic was incarcerated inguinoscrotal hernia that was
From the Postgraduate Department of Surgery, Govt Medical College, Jammu, J&K, India. (180001)
Correspondence to : Dr. Sanjay K. Bhasin, Assistant Professor, Postgraduate Department of Surgery, Govt Medical College, Jammu, J&K, India. (180001)

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Fig.1 Fecal matter coming out of the incision in the Fig 3. Ileostomy and Scrotal drainage (Case 1)
Scrotum (Case 1)

Fig.4 Shameful Exposure of the Scrotum After Debridement

Fig.2 Fecal matter coming out of the Scrotal Incision of Scrotal Skin Following Scrotal Enterocutaneous
(Case 2) Fistula (Case 2)
misdiagnosed by a surgeon as scrotal abscess. After freshening the perforation edges, perforation was closed
subjecting patient to necessary investigations for with vicryl 3-0 in single layer. Gangrenous scrotal skin
anesthesia, laparatomy was done. Intraopertaively a was excised. On 5th post operative day he had
perforation of 1.5 cm by 1.5 cm was present in distal anastomotic leak which was managed by ileostomy.
ileum about 45 cms from ileo-caecal valve. Fecal Discussion
contamination of peritoneal cavity was present. So, Enterocutaneous fistula in the scrotum is a very rare
ileostomy was done. Post-operatively patient had features complication of inguinoscrotal hernia in both adults and
of early septicemia that was managed with adequate children (5,6). In infants and children only 08 cases have
antibiotics and supportive treatment been reported world over till now (7-13). Similarly in adult
Case 2 population only 06 cases have been reported in the
40 years old male presented in emergency as a case literature (14-19). The causes attributed to the
of fecal discharge from the scrotum. On further probing development of scrotal fecal fistula in inguinal hernia are
patient gave history of long standing inguinoscrotal illiteracy, poverty and non-availability of not very good
swelling that became painful and tender to touch with health care delivery system especially in developing world
moderate to high grade fever. On examination, there was (15); surgical interventions (14,17,20).
gangrenous scrotal skin with fecal discharge from right Udoft (20) also reported use of prosthetic material as
scrotal sac. On Laparotomy the ileal loops were brought the cause of fecal fistula; similarly Nwabunike (14)
back to the abdominal cavity and a 1 cm by 1cm reported incision of inguinal hernia by herbalist and
perforation was note in mid ileal segment. As there was intervention by quack as a cause of faecal fistula in adults.
minimal contamination of the peritoneal cavity, hence after Contrary to all this we in our case of scrotal fecal fistula

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observed that misdiagnosis on the part of a retired surgeon 9. Kasat LS, Waingankar VS, Kamat T, Anilkumar, Bahety G,
Meisheri IV. Spontaneous Scrotal Faecal Fiatula in an Infant.
lead to scrotal fecal fistula. Second case was that of Pediatr Surg Int, 2000; 16: 443-44.
ignorance and poverty leading to delay in reporting to the
medical institution. 10. Ameh EA, Awotula PP, Amoah JN. Spontaneous Scrotal
Fecal Fistula in infants. Pediatr Surg Int 2002; 18: 524-5.
By way of these study reports and review of literature
on the subject, we conclude that the spontaneous scrotal 11. Chirdan LB, Uba AF, Iya D,.Dakum NK. Spontaneous
scrotal fecal fistula in a neonate:report of a case. Nigerian J
fecal fistula is beyond doubt a very rare surgical entity of Surgical Research 2004; 6: 1(2): 59-60.
which is attributed to poverty, not readily available surgical
health care delivery system in developing world including 12. Sowande OA, Adejuyigbe O, Ogundoyin O, Uba AF,
Chinda JY. Spontaneous Scrotal Fecal Fistula: A rare
our state as well. In adults the event is also secondary to complication of incarcerated inguinal hernia in infants. J
some attributable cause like complication of laparoscopic Indian Assoc of Ped Surgeon 2006; 11(4): 244-45.
surgery, prosthetic mesh use, intervention by the herbalist 13. Ghritlaharey Rajendra K, Shrivastava DK, Kushwaha AS.
or quacks as well as misdiagnosis even by a trained Spontaneous scrotal faecal fistula in infants: A case report
surgeon, as one of the case report is. & review of literature. J Clinical Diagnostic Research 2007;
4:303-06.
References
14. Nwabunike TO. Enterocutaneous fistula in Enugu, Nigeria.
1. Farrow GA, Thomson S. Incarcerated Inguinal hernia in Dis Colon Rectum 1984; 27(8): 522-4.
infants and children: A five years review at the hospital for
sick children; Toronto 1955-59 inclusive. Can J Surg 1963; 15. Samad A , Sheihk GM. Spontaneous fecal fistula, a rare
6: 63-67. presentation of inguinal hernia. J Ayub Med Col Abbottabad
2005; 17(4): 1-3.
2. Harvey MH, Johnstone MJ, Fossad DP. Inguinal
herniotomy in children: A five years Survey. Br J Surg 16. Klein AM, Banever TC. Enterocutaneous fistula as a post
1985; 72: 485-7. operative complication of Laparoscopic inguinal hernia
repair. Surg Laparosc Endosc 1999; 9(1): 60-2.
3. Kiesewetter WB. Early surgical correction of inguinal hernia
in infancy and children. Am J Dis Child 1958; 96: 362-7. 17. Koshariya M, Naik S, Rai A. Incarcerated inguinal hernia
presenting as spontaneous scrotal faecal fistula. Hernia
4. Tam PK, Tsang TM, Saing H. Inguinal hernia in Chinese 2006; 10(5): 434-5.
children. 1988; 58: 403-6.
18. Mohd Raashid Sheikh, Umeer Ashraf. Scrotal
Enterocutaneous Fistula, a rare complication of Inguinal
5. Rowe MI, Clathworthy HW. Incarcerated and strangulated
Hernia: Case Report and Literature Review. The Internet
hernia in children. Arch Surg 1970; 101:136-9. Journal of Surgery 2010;Volume 25 Number 2.

6. Rahim MM, Quadri A, Dwivedi HN. Scrotal faecal fistula. 19. Rajamanickam S, Yadav A, Singh D, SonkarAA. A
J Indian Med Assoc 1979; 73: 192-4. complicated true sliding hernia presenting as a spontaneous
enteroscrotal fistula in adults. J Emerg Trauma Shock 2010;
7. Gupta DK, Rohatgi M. Inguinal hernia in children: an Indian 3: 62-5)}
Experience. Pediatr Surg Int 1993; 8: 466-8.
20. Udoft SU. Multiple Faecal & Urinary Fistula as a
8. Rattan KN, Garg P. Neontal Scrotal Fecal Fistula. Pediatr complication of native treatment of Inguinal Hernia. Trop
Surg Int 1998; 13: 440-8. Geogr Med 1991; 43(1-2): 105-7.

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