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Three Dimensional Computerized Tomography Imaging of an Incidentally Detected Inguinoscrotal Bladder Hernia

We report a case of massive inguinoscrotal bladder hernia confirmed with three-dimensional CT imaging. 

Authors: RIFAIOGLU Murat Mehmet1; BAYAROGULLARI Hanefi2; AKKUCUK Seckin3; AYDOGAN Akin3; DAVARCI Mursel1; DEMİRBAS Onur1; YETIM Ibrahim3

1. Mustafa Kemal University, Faculty of Medicine, Department of Urology, Serinyol, Antakya, TURKEY.
2. Mustafa Kemal University, Faculty of Medicine, Department of Radiology, Serinyol, Antakya, TURKEY.
3. Mustafa Kemal University, Faculty of Medicine, Department of General Surgery, Serinyol, Antakya, TURKEY.

Corresponding Author: Murat M RIFAIOGLU, MD, Mustafa Kemal University, Faculty of Medicine, Department of Urology, 31005, Serinyol, Antakya, Hatay, TURKEY.  Tel: +90 326 229 10 00-3317   E-mail: [email protected]

 

Abstract
Bladder related inguinal hernias are seen in less than 4% of cases. Computed tomography (CT) appears to be the best choice to outline the details of herniation. We report a case of massive inguinoscrotal bladder hernia confirmed with three-dimensional CT imaging. A 55-year-old man presented complaining of lower urinary symptoms and inguinal discomfort. Ultrasonography of the testes revealed a large cystic mass in the right hemiscrotum that was greater than 9 cm in size. Three-dimensional CT scanning revealed deviation of the right lateral wall of the urinary bladder into the right inguinal canal and scrotum. The bladder was reduced into the abdominal cavity without complication. The Prolone Hernia System repair that was described by Gilbert was used for the inguinal hernia repair and the patient had an uneventful postoperative course. Three-dimensional CT is the best imaging technique to reveal bladder hernia and also has the advantage of being non invasive.

 

Introduction
 
Bladder related inguinal hernias are seen in less than 4% of cases [1, 2]. Massive scrotal cystoceles are very rare, with less than 30 cases published in the literature. Early diagnosis with radiologic imaging is important to avoid complications during surgery. Computed tomography (CT) appears to be the best choice to outline details of the herniation [3]. Here we report a case of massive inguinoscrotal bladder hernia confirmed with three-dimensional CT imaging in a 55-year-old man.

 

Case Report 
A 55-year-old man presented complaining of low urinary tract symptoms, with  urgency and inguinal discomfort over a 10 month period. Physical examination revealed a left lumbar incision and three laparoscopic port incision scars from a left simple nephrectomy and laparoscopic cholecystectomy, ten years and two months ago, respectively. His abdomen was soft without any palpable masses, and no flank tenderness was evident. A 13-cm right sided scrotal mass was present that was soft, non tender, did not transilluminate, was without bowel sounds, and was not reducible. The right testis could not be palpated. The patient’s serum blood urea nitrogen was 30 mg/dL, with a baseline creatinine of 1.7 mg/dL. His body mass index was 33.1 kg/m2, and his PSA was 0.25 ng/mL. His prostate volume was 21.3 cc on abdominal ultrasonography. On uroflowmetry, his maximum flow rate (Qmax) was 15 mL/s and the voided volume was 320 cc. The uroflow curve was bell-shaped. Ultrasound scan of his bladder revealed no residual urine. The results of laboratory tests, including urinalysis and urine cultures, were normal. Urinary tract ultrasonography revealed a 10.5 mm stone  in the lower pole of the right kidney. A non-contrast CT was performed to investigate whether any other renal calculi were present. The scan revealed right renal calculi and that the patient’s right bladder wall was herniated into the scrotum. Ultrasound of the testes revealed a large cystic mass in the right hemiscrotum that was greater than 9 cm in size, without any solid portion or vascularity, and no definite connection to the pelvic cavity (Fig. 1).

 

Figure 1. Axial (a) and sagittal (b) plane ultrasonography examination of the inguinal region showed a cystic mass.

 

Three-dimensional CT was performed with intravenous contrast enhancement and revealed a solitary right kidney, lateral deviation of the right lateral wall of the urinary bladder, and a fluid-filled structure in the right inguinal canal and scrotum. The volume of the pelvic component of the bladder was measured at 255 ml; the scrotal component volume was 252 ml (Fig. 2).

 

Figure 2. Multislice spiral computerized tomography (MSCT) (a-c) and three-dimensional MSCT images (d-f) which demonstrated subtotal prolapse of the whole bladder into the scrotum.

 

On three-dimensional CT, the craniocaudal diameter of the internal inguinal ring was measured at 26 mm; transverse diameter was measured at 25 mm..
After informed consent was taken, a midline laparotomy performed under general anesthesia identified right inguinoscrotal herniation of the bladder. The bladder was dissected from the inguinal canal and intraoperative inspection demonstrated no evidence of bladder necrosis or hernia neck. The bladder was reduced into the abdominal cavity without complication. The Prolone Hernia System repair that was described by Gilbert was used for the inguinal hernia repair and the patient had an uneventful postoperative course (Fig. 3)[4].

 

Figure 3. Intraoperative appearance of the herniated bladder (arrow) (a). Image of the herniated bladder after reduction (b). Using Prolone Hernia System repair in primary inguinal hernia (B: bladder, HB: herniated bladder, M: mesh) 

 

A follow-up cystogram on day 15 demonstrated no recurrent hernia (Fig. 4).

 

Figure 4. Cystogram demonstrated no recurrent hernia

 

After 1 month of Tamsulosin therapy, the patient had normal urinary voiding with moderate frequency and no evidence of hernia recurrence. He will require follow up for his renal calculus.

 

Discussion
The bladder is involved in less than 4% of all inguinal hernias, and most cases are not diagnosed prior to surgical repair [1-3, 5]. Most bladder hernias are direct, with a 70% male predominance, and most cases occur on the right side [6]. Bladder hernias are anatomically classified into paraperitoneal, which is the most frequently occurring type, intraperitoneal and extraperitoneal [7, 8]. Our case was a paraperitoneal indirect hernia where the extraperitoneal portion of the bladder lies along medial to the right sided hernial sac. The factors involved in the pathophysiology of bladder hernias include bladder outlet obstruction (e.g. benign prostatic hyperplasia, or strictures of the bladder neck or urethra), obesity and decreased bladder tone and weakness of the pelvic musculature as occurs in the aging population [7, 9, 10]. In our case, infravesical obstruction in terms of prostate hyperplasia might be the reason for the herniated bladder.
Small bladder hernias are usually asymptomatic and are commonly diagnosed incidentally at the time of surgery [7]. Large inguinoscrotal bladder hernias classically present with two-stage micturition, where the first-stage occurs spontaneously, but the second-stage requires active manual compression of the hernia by the patient for  the residual urine to void. Non-specific urinary symptomatology, such as frequency, urgency, nocturia, dysuria and hematuria may occur secondary to bladder outlet obstruction or infection [7-10]. In the present case, inguinal tenderness during micturition, because of right groin soft tissue enlargement due to the hernia, was the patient’s complaint.
The diagnosis is made on clinical findings, with history, physical examination and radiological evaluation. Radiologic imaging is crucial in the diagnosis of bladder hernia, and the methods used are ultrasound, cystography, intravenous pyelography or CT scanning [7, 9]. CT and ultrasound, which are the current investigative modalities for scrotal cystoceles, can identify the anatomical deformity and any potential complications, such as bladder or bowel infarction. However, bladder hernia should be in the differential diagnosis if a fluid collection is identified in the groin on ultrasound. Other key diagnostic points include tissue in the hernia canal and scrotum with similar echogenicity to bladder tissue, alteration in the dimensions of the inguinal contents before and after voiding, and a visible bladder connection [9].
Imaging modalities, including CT, are rarely used to outline the details of inguinal hernias in practice, because surgical consultants generally proceed to surgery without imaging [11]. However, CT is the most important diagnostic modality, as it can identify the content of hernia (bowel/omentum) and rule out associated complications such as  strangulation. Imaging is not indicated in all cases of inguinal hernia, and the majority of bladder hernia are diagnosed incidentally during imaging performed for other indications. Some authors recommend that if there is a strong clinical suspicion of a bladder hernia, imaging (cystography or CT) should be performed preoperatively to delineate the anatomy of the sac and its contents to help reduce the risk of serious injury during herniorraphy [9, 12]. Gadodia et al. and Ansari et al. remarked that CT is the preferred imaging modality with high spatial resolution, not only to detect herniation, but also to show associated pathologies such as the content of the hernia (bowel, omentum), strangulation, and hydronephrosis [13, 14]. Our case gave us an idea about the evaluation of the herniated bladder with three-dimensional CT, which provides a less invasive method compared with cystography for assessing the relationship of the hernial sac with the bladder. In addition, three-dimensional CT can help preoperative surgical management and decrease the peroperative complication risk.
The standard treatment of inguinoscrotal bladder hernia is either reduction or resection of the herniated bladder followed by surgical repair. Bladder resection is recommended only for cases with bladder necrosis, a hernia neck of less than 0.5 cm in diameter, or a bladder diverticulum or tumor in the herniated bladder [8]. In our case, on three-dimensional CT, the  hernia neck was measured 2.8 cm in diameter and the reduction of bladder hernia was effortless without requiring bladder resection.

 

Conclusion
In conclusion, although conventional CT and cystography offer the routine imaging approach to locating a herniated bladder; three-dimensional CT is the best imaging technique and is also less invasive than cystography. In the near future, three-dimensional CT might replace all of these imaging modalities in order to demonstrate bladder herniation.

 

References
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Date added to bjui.org: 24/03/2012


DOI: 10.1002/BJUIw-2011-143-web

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