A Rare Case Report of Neonatal Pneumoperitoneum Leading to Pneumoscrotum

1. Senior Resident, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 2. Professor, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 3. Professor, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 4. Postgraduate Student, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 5. Senior Resident, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.

Abstract

The collection of air in the scrotal area is known as a pneumoscrotum. It is uncommon for pneumoperitoneum and pneumoscrotum to coexist, which presents challenges for diagnosis and treatment. Air in the scrotum as a concurrent sign is rare and patient typically exhibits symptoms of intraperitoneal sepsis. An unusual and serious ailment is in which a newborn has acute swelling of the scrotum that usually includes testicular torsion, trauma, inguinal hernia, hydrocele and, rarely, intestinal perforation or adrenal haemorrhage. Acute scrotum in an emergency needs attention. Neonates undergoing rigorous resuscitation or mechanical ventilation, as well as those with significant respiratory distress, may also exhibit this condition. The simultaneous occurrence of pneumoperitoneum and pneumoscrotum in a newborn is even more uncommon. Hereby, the authors present a case of one-day-old male neonate born by normal vaginal delivery who cried immediately after birth. The baby initially presented with respiratory distress and mild scrotal swelling. The antenatal scan had shown enlarged genitals with echogenic debris and calcifications. Evaluation for increasing scrotal swelling and progressive abdominal distension revealed gas under diaphragm and pneumoscrotum. Surgical exploration showed a wide perforation in transverse colon. The postoperative course was uneventful. A properly done radiological examination can help detect and identify the pathology and determine the source of an acute scrotum. The purpose of the present study is to present and assess the authors approach to treating pneumoperitoneum and provide insight into its presence in newborns and infants.

Computed tomography, Necrotising enterocolitis, Spontaneous intestinal perforation, X-ray

Case Report

A 2.5 kg one-day-old male neonate, born to a G2A1 mother at 37 weeks gestational age via normal vaginal delivery, was admitted to Neonatal Intensive Care Unit (NICU) with respiratory distress and mild scrotal enlargement. The neonate cried immediately after birth. An antenatal scan at 36.5 weeks gestation {by Last Menstrual Period (LMP)} showed enlarged genitals with echogenic debris and calcifications, along with severe oligohydramnios (liquor index 4.8). He passed meconium within few hours of birth and enteral feeds were started, which were well-tolerated.

The neonate developed generalised abdominal distension of the abdomen that was tense and gradually increasing in size. The distension was associated with gradually enlarging scrotal swelling. Reddish-green gastric aspirates were noted via the orogastric tube, hence, the child was kept Nil By Mouth (NBM). There were no maternal co-morbidities, and the mother was not on any antenatal medications.

On examination, the baby was irritable and tachypnoeic with mild intercostal retractions. Heart rate was 156 beats/min, respiratory rate 68/min. Downe’s score was 4, hence child was placed on nasal Continuous Positive Airway Pressure (CPAP) for four hours after birth. Abdomen was distended and tense, with audible bowel sounds. A large, irreducible, soft swelling that extended proximally to the inguinal area was present at the scrotum. The skin over the scrotum appeared glossy and discoloured (Table/Fig 1). It was not possible to palpate both testes. Transillumination test was positive (Table/Fig 2).

Laboratory parameters showed Haemoglobin (Hb): 22.2 g/dL, Total Leucocyte Count (TLC): 10,100/mm³, C-reactive Protein (CRP): negative and the initial septic screen was negative.

A chest X-ray was done in view of respiratory distress, showed right upper lobe consolidation suggestive of congenital pneumonia. Antibiotics were started: injection Ampicillin 50 mg/kg/dose 6-hourly,

injection Gentamicin 5 mg/kg/day and later injection Metronidazole 7.5 mg/kg/dose 8-hourly was added in view of increasing abdominal distension (Table/Fig 3).

Ultrasound of the abdomen suggested bilateral hydrocele with suspicion of periorchitis. Due to the increasing size of scrotum and progressive abdominal distension, a repeat X-ray and Computed Tomography (CT) of the abdomen and pelvis was done which was suggestive of gross pneumoperitoneum with scrotal collection of air-fluid levels, suggestive of pneumoscrotum (Table/Fig 4), (Table/Fig 5), (Table/Fig 6).

With the suspicion of gut perforation, the neonate was referred to a paediatric surgeon and a laparotomy was performed. A wide perforation measuring around 2-3 cm at the level of transverse colon. As it was difficult in approximating the structures due to wide perforation, transverse loop colostomy was done. The fluid showed growth of Staphylococcus aureus. Rest of the peritoneal cavity appeared clean and the remaining gut was healthy. Baby was allowed orally on 6th postoperative day. Currently, the baby is on full feeds with no postoperative complications. The patient was successfully discharged and followed up after one week and baby is doing well haemodynamically. The patient was discharged from the hospital and referred to a paediatric surgeon for surgical management.

Discussion

An air build-up in the scrotal area is known as a pneumoscrotum. Although neonatal pneumoscrotum is recognised as a rare clinical entity and exact incidence and prevalence data are lacking due to its infrequent occurrence and reliance on case reports. A 2010 report described a neonate with pneumoscrotum secondary to gastric perforation (1). Another case involved a neonate developing pneumoscrotum following resuscitation, leading to pneumothorax, pneumoperitoneum and subcutaneous emphysema (2).

Its source may be localised, such as testicular torsion, trauma, or adrenal haemorrhage, or it may be extra- or intraperitoneal (3). Neonates undergoing rigorous resuscitation or mechanical ventilation, as well as those with significant respiratory distress, may also exhibit it.

Bowel perforation: This is the most common cause in neonates, often resulting from conditions like Necrotising Enterocolitis (NEC) or other intestinal problems.

Intra-abdominal or thoracic conditions: Air can track from the abdomen or chest cavity into the scrotum.

Infections: Gas-producing infections, like Fournier’s gangrene, can also cause pneumoscrotum.

Trauma: Direct trauma to the scrotum may introduce air.

Iatrogenic causes: Air can be introduced during surgical procedures or diagnostic interventions.

Bronchopleural fistula: A rare cause is a fistula (abnormal connection) between the lung and chest wall allows air to leak into the scrotum (4),(5),(6),(7).

Pneumoperitoneum typically indicates perforation of an intra-abdominal organ and usually necessitates emergency laparotomy. While it is primarily of perforating origin, it can also be idiopathic or bacterial. Seldom occurring and posing serious diagnosis and treatment issues is the combination of pneumoperitoneum and pneumoscrotum is rare in neonates and poses serious diagnostic and treatment challenges, particularly of bacterial aetiology (6). In some cases, scrotal exploration is needed to diagnose and treat neonates with idiopathic causes (8).

Air leak syndromes, characterised by air escaping into tissues where it is not normally present, can result from alveolar rupture, gastrointestinal perforation, open cranial wounds, or iatrogenic causes. These syndromes may occur in babies with vigorous respiration at birth or due to high mechanical ventilator pressures during the treatment for conditions like respiratory distress syndrome, meconium aspiration syndrome, birth asphyxia, vigorous cardiopulmonary resuscitation by untrained staff or due to gastrointestinal ischaemia, or congenital/acquired obstruction (1),(2).

Pneumoperitoneum in babies can present in various ways, ranging from a sick infant with evident abdominal signs to a stable newborn with minimal or no abdominal symptoms. It is most commonly a symptom of gastrointestinal perforation, though, rarely, it may result from extra-abdominal causes. Benign pneumoperitoneum, with no surgical or medical cause, is very infrequent (1). The co-existence of pneumoscrotum and pneumoperitoneum is particularly rare in neonates.

Khan YA and Akhtar J reported a similar case of day 4, term neonate brought with fever and scrotal swelling. When the peritoneal cavity was explored, two small perforations along the greater curvature of the posterior stomach were identified (1).

Another case of a three day-old male infant with basithoracic subcutaneous emphysema and left inguino-scrotal oedema, along with a skin ulceration was reported by Bonny R et al., following surgery, an examination revealed a large air bubble in the left inguino-scrotal area, a substantial scrotal haematoma and Klebsiella pneumonia growth. They concluded that it was bacterial in origin (6).

Kouame YGS et al., reported a case of a 4-day-old neonate presenting with inguinal ecchymosis and an acute scrotum, which was found to be associated with an adrenal gland haematoma (3). Adding to the similarity to the present case, it was noted that in this case the perforation likely happened antenatally as seen in the antenatal ultrasound.

Pneumoscrotum can originate from three sources: extra-peritoneal, intra-peritoneal, or local. In cases of thoracic trauma, pneumothorax, or pneumomediastinum, extra-peritoneal air may spread from the thorax. Intra-peritoneal air is often due to perforation of a hollow organ, while local origins include direct trauma to the scrotum or gas production by bacteria, leading to diffusion through subcutaneous tissues (6).

Diagnosis of pneumoscrotum involves palpation of the scrotum, with X-rays used to detect and locate the air. Ultrasound can reveal infections such as epididymitis or abscesses, while Doppler tests assess the vascularisation of the spermatic cord (2),(9).

Prematurity, infection and severe birth asphyxia are the primary risk factors linked to ischemic stomach perforations in neonates (10). Management is surgical if the pneumoscrotum is due to bowel perforation or other severe conditions, surgery is often required to repair the damage and address the underlying cause (5). If infection is suspected, antibiotics may be administered. Depending on the underlying cause, additional supportive measures, such as ventilation or fluid resuscitation, may be necessary. Pneumoscrotum is often the primary and discernible sign of bowel perforation in preterm neonates and serves as a crucial radiographic sign for timely diagnosis (11).

At presentation, the patient had scrotal swelling with palpable crepitus and associated abdominal signs suggestive of peritonitis. Given the presence of pneumoscrotum, a rare but important clinical finding, the provisional diagnosis considered was a hollow viscus perforation leading to pneumoperitoneum with air tracking into the scrotum. Differential diagnoses included thoracic sources such as pneumomediastinum or pneumothorax causing subcutaneous emphysema extending to the scrotum, especially in ventilated or trauma patients. Local causes, such as gas-forming infections (e.g., Fournier’s gangrene), scrotal trauma, or post-procedural air introduction, were also considered. However, the absence of chest symptoms, local signs of infection, or recent instrumentation made these less likely. Imaging confirmed free intraperitoneal air with evidence of air tracking through the inguinal canal, supporting a gastrointestinal perforation as the primary pathology, which was intraoperatively confirmed to be a perforation in the transverse colon.

Conclusion

It is very uncommon for a neonate to have both pneumoscrotum and pneumoperitoneum. Neonates are more likely than older infants to present with pneumoperitoneum. Prenatal bowel perforations should be suspected based on the presentation at delivery. The coexistence of pneumoperitoneum and pneumoscrotum of bacterial aetiology is rare and may be difficult to diagnose because it can mimic other conditions. Acute scrotal swelling or pain in neonates should always be investigated with an abdomen and scrotal ultrasonography to ensure timely and accurate diagnosis.

DOI and Others

DOI: 10.7860/JCDR/2026/78441.24296

Date of Submission: Feb 03, 2025
Date of Peer Review: Mar 12, 2025
Date of Acceptance: Jun 19, 2025
Date of Publishing: Sep 01, 2026

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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ETYMOLOGY: Author Origin

EMENDATIONS: 6