0749-5161/02/1801-0028 Vol. 18, No.

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PEDIATRIC EMERGENCY CARE Printed in U.S.A.
Copyright © 2002 by Lippincott Williams & Wilkins, Inc.

Ventriculoperitoneal shunt migration

presenting with vaginal discharge and
hydrosalpinx in a 16-year-old patient
E.C. WASHINGTON, MD, M. HOLMES, MD, S.J. HAINES, MD, J.W. RINGWOOD, MD
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INTRODUCTION that time, but were discontinued a short time afterward by the pa-
tient herself.
Ventriculoperitoneal (VP) shunt malfunctions and complications
On examination, the patient was a well-developed teenager, alert
are common presentations to pediatric emergency departments
and cooperative, but in moderate discomfort from abdominal pain
(ED), as is abdominal pain in adolescent females; however, abdom-
and the marked amount of vaginal discharge. Vital signs were nor-
inal pain is not usually a symptom of shunt malfunction. The usual
mal. Her abdominal examination revealed mild, diffuse tenderness
presenting features of VP shunt malfunctions are headache and
with voluntary guarding but without rebound. The abdomen was
vomiting, although the literature cites multiple unusual presenta-
soft and nondistended with normal bowel sounds. There was no he-
tions, including ascites, abdominal pseudocysts, scrotal edema, and
patosplenomegaly or other palpable mass. Most remarkable was the
nonvisceral penetrations. We report a case of a 16-year-old female
large pool of clear vaginal discharge that soaked the examination
patient with a VP shunt who presented to the pediatric ED with
table. Results of the rest of the initial examination, including head,
headache, abdominal pain, and profuse clear vaginal discharge. At
shunt reservoir, pupil, and neurologic examinations, were normal.
laparoscopy, the distal end of the patient’s VP shunt was found to be
Pelvic examination revealed normal external genitalia, normal
draining into a loculated mass encasing a right hydrosalpinx.
vaginal tissues, a small nulliparous cervix, and profuse, clear, wa-
tery cervical discharge that formed a pool in the posterior vaginal
CASE fornix. Bimanual examination revealed moderate cervical motion
tenderness. Palpation of the pelvic structures was limited by volun-
A.M., a 16-year-old white female, presented to the Medical Uni-
tary guarding; however, a fullness was noted in the right adnexa.
versity of South Carolina pediatric ED in late July 1999 with a 2-
Gram stain and wet mount microscopy revealed normal epithelial
week history of increasingly profuse clear vaginal discharge and a
cells and no evidence of infection. Potassium hydroxide prepara-
1-day history of severe lower abdominal pain, headache, nausea,
tion (KOH prep) was negative for fungal elements.
and fever to 101.2
F. She denied vomiting, diarrhea, constipation,
A transvaginal ultrasound revealed a normal-sized uterus; how-
or urinary symptoms. Her last menstrual period was 3 weeks prior
ever, the endometrial cavity contained sonolucent fluid throughout
to presentation, and the patient denied any sexual activity. About
the fundus, body, cervix, and both cornu. The amount of fluid dis-
1 week prior to the current admission, the patient was seen by a gy-
tension fluctuated during the study. Free fluid was also noted in the
necologist for the vaginal discharge. She had a normal pelvic ex-
peritoneal cavity. The right ovary measured 4.5  2.5  3.5 cm
amination, normal vaginal secretion microscopy, and negative en-
and contained multiple cysts, at least one of which contained sep-
docervical cultures. The remainder of her review of systems was
tations and internal debris. This was believed to represent a hemor-
negative.
rhagic cyst. The left ovary was 2.7  1.2  2.2 cm with a normal
Relevant past medical history included VP shunt placement in
appearance. Both ovaries were well perfused.
January 1999 for pseudotumor cerebri with persistent occipital
Laboratory testing revealed a normal shunt series, with distal tip
headaches. The surgery followed failure of conservative manage-
overlying the right true pelvis, negative serum pregnancy test, normal
ment over several months, including treatment with lumbar punc-
basic metabolic panel, normal peripheral white blood cell count,
ture, and medications including diuretics. The patient underwent
sedimentation rate of 6l mm/h, and albumin 3.4 mg/dL. Urinalysis
two shunt revisions for protruding scalp sutures. At a different in-
showed trace protein, trace blood, moderate mucus, and moderate cal-
stitution, she had also had a diagnostic laparoscopy with incidental
cium oxalate crystals. Shunt fluid revealed no white or red blood cells,
appendectomy in 1996, and a subsequent laparoscopic right ovar-
glucose 70 mg/dL, and protein 10 mg/dL. The vaginal fluid showed a
ian cystectomy in March 1999 at our institution. Oral contracep-
creatinine of 0.8 mg/dL, glucose of 48 mg/dL, and no protein.
tives were prescribed for suppression of ovarian cyst formation at
The patient was admitted overnight for observation under the di-
agnosis of hemorrhagic right ovarian cyst. Her pain and amount of
From the Departments of Pediatric Emergency Medicine and Critical vaginal discharge were somewhat improved in the morning, and
Care (E.C. Washington, J.W. Ringwood), Obstetrics and Gynecology (M. she was discharged on narcotic and nonsteroidal pain medications
Holmes), and Neurological Surgery (S.J. Haines) of the Medical University with follow-up in the gynecology clinic 1 week later. At the time of
of South Carolina, Charleston, South Carolina. follow-up, the patient reported continued profuse vaginal discharge
Address for reprints: E. Camille Washington, MD, Pediatric Emergency
Medicine and Critical Care, Medical University of South Carolina, 171
and increased pain, and she was admitted for surgical management.
Ashley Avenue, Charleston SC 29425. Diagnostic laparoscopy revealed a normal uterus, left fallopian
Key Words: Ventriculoperitoneal shunt, abdominal pain tube, and left ovary. There was a large right hydrosalpinx without

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Vol. 18, No. 1 VENTRICULOPERITONEAL SHUNT MIGRATION
identifiable fimbria, which was also involved with dense omental ad-
hesions (Fig. 1). The shunt tip was not initially visualized. Upon ly-
sis of the omental adhesions, a rush of clear fluid was released from
the loculated mass of omentum and right adnexal structures. The dis-
tal tip of the VP shunt was noted to be within this cystic loculation,
near the distal fallopian tube. The right ovary was then visualized and
noted to be entirely normal. A right salpingectomy was performed,
and the tip of the VP shunt was freed. Postoperatively, the patient re-
ceived 48 hours of intravenous antibiotics, her pain subsided, and her
discharge resolved immediately. Over 1 year out, she remains asymp-
tomatic and has had no other shunt or gynecologic problems. Due to
the right salpingectomy and remaining right ovary, the gynecology
department continues to follow her closely for fertility issues and the
increased risk of ectopic pregnancy.
DISCUSSION
Abdominal pain in teenage female patients usually implies a
large differential but does not typically include VP shunt malfunc-
tion. Likewise, VP shunt malfunction can present in a myriad of
ways, but it does not commonly present with vaginal discharge.
Both are frequent evaluations in a pediatric ED.
Important considerations in the evaluation of any type of vaginal
discharge associated with abdominal pain in an adolescent patient in-
clude infectious etiologies, particularly sexually transmitted infec-
tions, and pelvic inflammatory disease. Profuse, watery discharge is
not a common presentation, but it is associated with several serious
conditions, including fallopian tube carcinoma, cervical carcinoma,
ectopic ureter, or fistulous tracts between the urinary and reproduc-
tive tracts (1, 2). In this case, urinary tract fistula was ruled out by the
low creatinine of the vaginal fluid. Although an abnormal connection
between the distal tip of the VP shunt and the genitourinary struc-
tures was a concern in this patient, there is no simple clinical test to
discriminate cerebrospinal fluid (CSF) mixed with peritoneal fluid
and cervicovaginal secretions.
A comparison of diagnostic modalities therefore deserves atten-
tion. In this case, the patient had risk factors for adhesions (the two
previous laparoscopic procedures, most notably the right ovarian
cystectomy and appendectomy, and shunt placement itself) that led
to suspicion of an abnormal abdominopelvic process. It is of interest
FIG. 1. Appearance of shunt tip (small arrow), fallopian tube (large ar-
row), and omental adhesions upon opening of loculated adnexal mass dur-
ing laparoscopy.
29
in this case that even a transvaginal ultrasound in combination with
a shunt series did not clearly delineate the extent of the pathology of
the tuboovarian-shunt complex. Although ultrasound ruled out emer-
gent surgical etiologies, such as a large ovarian cyst causing torsion
and lack of perfusion to an ovary, or a tubal pregnancy, the patient
did undergo multiple reevaluations until the true etiology was re-
vealed under laparoscopy. Perhaps the layered mass involving sev-
eral small structures fell beyond the specificity range of ultrasound.
Thus, an initial pelvic CT, not usually in our 1st-line arsenal for
the adolescent patient with abdominal pain, might have eventually
saved resources and decreased morbidity for this more complicated
patient. A recent study using helical CT to differentiate appendicitis
from acute gynecologic conditions in 100 females found the method
to have 100 and 87% sensitivity, and 97 and 100% specificity, re-
spectively, as well as high positive and negative predictive values.
Helical CT findings resulted in a significant decrease in hospital ad-
missions and an increase in accuracy of choice of correct surgical
procedure (3). Another recent study employing CT as the diagnos-
tic tool in 57 ED patients with acute nontraumatic abdominal pain
found a 23.8% decrease in hospital admissions (4). One study used
laparoscopy to successfully combine diagnosis and treatment for
distal VP shunt malfunction in a series of 10 children (5).
Although the frequency of VP shunt malfunctions is cited up to
50% at 5 years, with the most common symptoms being headache,
vomiting, and lethargy, abdominal findings are still described as
rare (6). The most frequent types of malfunction continue to be me-
chanical obstruction and infection, but there are many interesting
reports in the literature of less usual abdominal pathology. Sum-
maries of the literature describe series of abdominal pseudocysts,
as well as cases of intussusception, volvulus, incarcerated bowel,
and perforation of bladder, stomach, colon, and gallbladder. Mi-
gration of the tubing into the mediastinum, umbilicus, and thoracic
cavity has occurred. Perforation into the colon with anal protrusion
and extraction as presumed ascaris worm, and gastric perforation
with protrusion through the mouth have been reported. Genitouri-
nary presentations are unique; intrascrotal migration with simu-
lated testicular torsion and vaginal penetration (one child, one
adult) have been reported (7). Migration to the fallopian tube has
not been reported previously.
CONCLUSIONS
The cause of the abnormal shunt migration in this case was
found to be more a factor of the patient’s postsurgical adhesions
than shunt characteristics, since type of tubing and distal site choice
were standard. VP shunts have become the preferred choice for pe-
diatric patients, owing to the capacity of the peritoneal cavity to ab-
sorb fluid, ease of placement, and lack of thromboembolic events
associated with vascular shunts (8). Other less typical sites of shunt
placement have included the pleural cavity, the ureter, and gall-
bladder. One approach even described intentionally draining CSF
into the fallopian tubes (9). Development of silastic (silicon)
catheters, which did not carry the risk of distal plugging associated
with polyethylene catheters, allowed a resurgence in the use of VP
shunts in the 1970s (10). Rates of abnormal migration for each type
of tubing are not known. A common cause for distal VP shunt mi-
gration in other cases has not been elucidated.
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