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BostonGuy -> RE: saline injections (9/8/2005 2:10:27 PM)
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To my knowledge there has been one peer-reviewed publication of complications of saline scrotal infusion in the medical literature (see below; I did not include the literature references from the paper as they are not terribly relevant).
Of note, there are a number of inaccuracies in some of the statements, above.
• With respect to the comments about saline, in addition to infused saline being sterile, any saline that is infused MUST also be free of endotoxin. This simply cannot be done using anything except medical-grade sterile saline, since endotoxin (a component of gram-negative bacteria) is not destroyed by autoclaving. The complications of endotoxin infusion are known to include fever, shock, organ damage, and death. This has been very well worked out both in challenge experiments in animals and in clinical experience with patients.
In addition, there is an incomplete discussion of the potential infectious complications in the article below. What follows is not a complete list of the complications, but is meant to give the reader some sense of the potential downside of this procedure.
• In some men there is an incomplete closure anatomically between the scrotum and the intra-abdominal cavity. Thus, if there is the development of an infection in fluid that is within the scrotum (a serious condition that requires urgent medical attention) there is the possibility that it may track upward into the abdomen and cause peritonitis. This may well be due to more than a single species of bacteria, as the skin is colonized with a polymicrobial flora. Cellulitis, an infection of the skin, is noted in the article below. The possibility of Fournier’s gangrene is noted in the article. This is a devastating condition in which the skin, subcutaneous tissue, and muscles in the area are destroyed by infection due to a variety of bacteria, resulting in necrosis of tissue. It can also occur in women. It may occur as a result of the introduction of bacteria through a breach in the integrity of the skin, which is precisely what would occur with a scrotal infusion. It is more common in people with diabetes and a number of other underlying diseases and requires both urgent surgery and antibiotics. It can be fatal. Other complications worth considering are that a local infection, such as cellulitis, may result in bacteria seeding the bloodstream (causing bacteremia) and, potentially, septic shock. Septic shock has a significant mortality rate.
• There are far more bacteria on the skin of the scrotum than there are on the skin of the forearm or the dorsum of the hand. In addition, the structure of the skin of the scrotum, which inserts into the dartos muscle and is ruggose, may make it difficult to disinfect. As a result, it is logical to assume that efforts to clean and remove bacteria from the scrotal skin are more likely to fail than is the case with simply placing an intravenous catheter in a person's forearm. Insertion of intravenous lines in hospitals are associated with numerous infections annually. Certainly this can be minimized by minimizing the time during which the intravenous catheter is present in the vein, but there remains a risk of infection.
• Even in the setting of appropriate aseptic technique in an operating room in clean surgery (such as surgery involving the hip joint which is normally sterile) there is a known risk of postoperative infection. Operating rooms have no carpeting, have a specificied numer of air exchanges per hour, and have highly trained personnel. To have a saline infusion performed in a room that may have carpeting, where each step generates an aerosol of bacteria and fungi, performed by someone who may or may not be trained in aseptic technique is something for which there is a risk of infection, though the risk has never been quantitated.
Each of us makes a decision regarding the benefits and risks of activities. The activities may be watching a television show on the couch (relatively low risk) or something with far greater risk. I do not engage in scrotal infusion though I am not able to quantitate the risk of complications. This is because the complications are of such severity that, for me, the risks clearly outweigh the benefits. Your assessment may vary.
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Summers, J.A. A Complication of an Unusual Sexual Practice. Southern Medical Journal 96(7):716-717 (July 2003).
Abstract: A patient presented with scrotal cellulitis as a complication of infusing 900 ml saline into his scrotum. He had obtained a kit along with explicit instructions for performing the infusion through the Internet. This practice may be more widespread than expected. An Internet search revealed many references to this procedure, but a MEDLINE search showed virtually no information in the medical literature. Patients who are considering scrotal inflation, as it is called in the lay literature, should be warned of the potential complications of this procedure.
Case Report A 37-year-old man presented to the office with a painful, swollen scrotum. He reported that he had always had the impression that his genitalia were smaller than desired, and as a result he had searched the Internet for a solution. He found a web site that supplied him with a “scrotal inflation kit” consisting of a 1-L bag of saline, tubing, and needle-catheter combination. The stated purpose of using such a kit is the infusion of saline into the scrotum to cause significant scrotal enlargement. The patient had been told that the infused fluid would be reabsorbed during a 2- to 3-day period. Unfortunately, the patient still had enlargement of the scrotum 4 days after the infusion, and it was quite painful. He stated that he had infused 900 ml fluid before the needle popped out of his scrotum. He was initially pleased with the results, but then he developed erythema and pain during the next 2 days. His request at the office visit was to have the fluid aspirated from his scrotum.
An examination revealed that the patient was afebrile. He had a greatly enlarged, erythematous, tender, warm scrotum. The swelling of the scrotum completely consumed his penis. He was promptly referred to a urologist, who prescribed cephalexin 500 mg qid for 7 days, and ultrasonography of the scrotum was performed. The ultrasonographic scan revealed diffuse scrotal swelling but no distinct fluid collection or mass. At 2-week follow-up, the patient’s erythema had nearly resolved, and his scrotum was reduced to approximately 20% of its size at presentation.
Discussion
A review of the web site where the patient obtained his kit revealed illustrated, step-by-step instructions for the infusion of saline into the scrotum. To investigate how widespread such practices may be, Google searches were performed with the terms scrotal inflation and scrotal infusion, which produced 516 and 1,390 web pages. Most of these pages were associated with web sites dealing with sadomasochism and fetishes, but several revealed that scrotal inflation procedures have been addressed in the alternative press.
A review of the medical literature, however, showed that much less attention has been devoted to the potential complications of this procedure. Although the term scrotal inflation seems to be common in the lay literature, the only references to such a term in the MEDLINE database refer to gaseous inflation of the scrotum. MEDLINE searches with the term scrotal infusion and the combination of cellulitis and scrotum produced similarly limited results, and none of the articles displayed discussed a case such as the one described in this article. The patient’s activity essentially constituted a clysis procedure, however, and a 25% minor local infection rate has been described in a nursing home population with clysis. Given the frequency with which infection occurs in clysis, one would expect that the infection rate in people who self-administer this procedure might be even higher. Although the condition of the patient described here did not progress to Fournier’s gangrene, this possible additional complication must be considered. The physician’s discussion with patients who may have such proclivities should include warnings regarding the potential complications of such activities, including scrotal cellulitis.
Key Points
• Scrotal inflation with saline is a sexual practice not commonly discussed in the medical literature.
• Scrotal inflation can result in complications such as cellulitis.
• Remarkably, the equipment required for scrotal inflation can be obtained over the Internet without a prescription.
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