Scrotal Centesis: Due to Anasarca in an End-stage Pancreatic Cancer Patient

Dear Sir,

A 43-year-old interior worker, married and having three children, was diagnosed with carcinoma of pancreas with lung metastasis for 6 months duration. He had received several cycles of chemotherapy but due to disease progression and poor performance status, he was referred to our palliative department for best supportive care.

The quality of life of the patient was assessed with the WHO performance status scale.^[1] His chief complaints were pain (VAS score 7), due to oedema of the scrotum resulting in difficulty in urination and ambulation with a WHO performance status score of 4.

His blood investigations showed elevated total counts and hypoalbuminaemia. Further investigations showed pleural effusion and ascites.

After the initial evaluation, the patient was started on oral and iv medications including opioid analgesics, antibiotics and diuretics. However, after 2 days of treatment, the patient had worsening symptoms, so after taking consent pleural and abdominal centesis were performed.

After the procedure, the patient showed relief in shortness of breath, but his scrotal oedema persisted and was increasing in size causing difficulty in ambulation and micturition, with pain and discomfort. It greatly interfered with his quality of life (the WHO performance status score of 3). Hence, we decided to perform a bedside scrotal centesis.

After taking consent, the patient was lying supine in his bed with an inclination of 45°, and the scrotal area was disinfected with betadine and chlorhexidine solution. Using a tuberculin syringe, local anaesthetic 2% lidocaine was infiltrated to the scrotal skin on either side, two 18-gauge needles were inserted to about 1.5 cm to the scrotal skin on either side and the fluid was drained in two disposable paper cups and transferred to a measuring jar [Figure 1].

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Figure 1:

Palliative centesis of scrotum.

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During the procedure, about 2 L of straw-coloured fluid were drained. The patient was comfortable during the entire period of the procedure. On evaluation after the procedure, his scrotal oedema reduced considerably and the patient expressed significant improvement in his symptoms, and he was able to walk and micturate without much difficulty (the WHO performance status score of 2), there were no complaints of pain during or after the procedure. On evaluation, after a week of the procedure, there was a mild increase in swelling but did not require any further centesis. The patient was discharged after 7 days of the procedure and was kept under follow-up.

In end-stage cancer due to malnutrition and cytokine-related inflammatory response, anasarca is a common clinical sign, and in males, one of the sites for fluid accumulation is the scrotal area.^[2]

Scrotal anasarca can persist even after diuretic therapy; hence, there is a need for a non-diuretic treatment option to alleviate the discomfort. It is a common practice in palliative care where abdominal paracentesis and pleural taps are done to bring symptom control. Scrotal centesis is rarely attempted by palliative physicians due to a lack of evidence. In this patient, this procedure helped to enhance the quality of life in the last days of his life.