|Year : 2013 | Volume
| Issue : 3 | Page : 324-326
Surgical repair of giant inguinoscrotal hernia containing the urinary bladder
Suryapratap Singh Tomar, Saranjeet Singh Bedi
Department of Neurosurgery, NMCH, Nellore, Andhra Pradesh, India
|Date of Web Publication||5-Jul-2013|
Suryapratap Singh Tomar
Registrar, Department of Neurosurgery, NMCH, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Inguinal hernia repair is one of the commonest operations in surgical practice. Unusual contents of hernia sac are uncommon, but are likely to be encountered by a surgeon in his career due to the frequency of hernia repair. The bladder is involved in less than 4% of inguinal hernias. These patients usually present with frequent episodes of urinary tract infection, difficulty in walking and difficulty in initiating micturition because of incarceration of the urinary bladder into the scrotum. The incidence may reach 10% among obese men who are 50-70 years old. Most cases are asymptomatic and are usually found incidentally during radiographic evaluation or at the time of herniorrhaphy. Massive inguinoscrotal bladder hernia, also known as scrotal cystocele, is very rare. In India, there was only few reported case of inguinoscrotal bladder hernia. Here we report a case of left inguinoscrotal bladder hernia who presented with a scrotal mass. We also provide a review of the relevant literature.
Keywords: Inguinal hernia, peritoneum, scrotal cystocele, urinary bladder
|How to cite this article:|
Tomar SS, Bedi SS. Surgical repair of giant inguinoscrotal hernia containing the urinary bladder
. Med J DY Patil Univ 2013;6:324-6
| Introduction|| |
Patients with inguinoscrotal hernia containing the urinary bladder are very rare. Inguinoscrotal bladder hernias are asymptomatic most of the time. However, they can result in in complications, like necrosis of bladder, renal failure, etc., Pre-operative diagnosis is important to reduce bladder injury intra-operatively. To the best of our knowledge, only a few cases have been reported in the literature to date.
Here we report the case of a man patient who presented with a left scrotal mass. Ultrasonography of the scrotal mass showed a cystic mass and contrast-enhanced retrograde cystography (CERC) showed the urinary bladder was incarcerated into the scrotum. During surgery, the mass was a herniated urinary bladder. Surgical repair of the hernia done with mesh and restoration of the urinary bladder to its normal physical position.
Patient was discharged on the tenth postoperative day. No other post-operative complication noted.
| Case Report|| |
A 54-year-old male patient presented with complaint of pain at inguinoscrotal region during walking, strangury, difficulty in micturition since 15-20 days and left scrotal mass since 10-12 years [Figure 1]. His past history included chronic obstructive pulmonary disease, hypertension with coronary heart disease and recurrent episodes of urinary tract infection (UTI). On clinical examination a left direct inguinoscrotal hernia found. The mass was not reducible. Testes were not palpable. His prostate was enlarged. Clinically the presen tation was likely to be irreducible inguinoscrotal hernia. On ultrasonography cystic mass was suggestive of fluid cavity and finally CERC proved that the urinary bladder was into the scrotum [Figure 2]. The results of blood and urine tests were suggestive of UTI. With all preoperative preparation and Foleys catheter, surgical repair of hernia done. Under general anaesthesia, the hernia was initially approached through a left groin incision. The cystic mass was surrounded by fat and was connected to the pelvic cavity. The bladder was dissected from the inguinal canal and was found to have directly herniated through the rectus muscle [Figure 3]. The bladder was repositioned at pelvic without injury, and the inguinal floor repaired by mesh. Post-operative cystography performed. He was discharged on the tenth postoperative day without complication. Patient is doing well in follow-up.
|Figure 2: Contrast-enhanced retrograde cystography. The incarcerated urinary bladder into the scrotum is shown|
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|Figure 3: The urinary bladder after the adhesiolysis at the bottom of the hernia sac|
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| Discussion|| |
Inguinal hernias are common surgical problem which may sometimes surprise the surgeon with its unusual content. Inguinoscrotal hernias containing the urinary bladder are very rare, and their repair is a real challenge for surgeons.  The bladder is involved in less than 4% of all inguinal hernias. ,,, Although it is important to make the diagnosis preoperatively to reduce complications, less than 7% of bladder hernias are diagnosed before surgery, 16% are diagnosed postoperatively owing to complications, and the remaining cases are diagnosed perioperatively. , They are uncommon in developed countries, and patients with such problems usually present with frequent UTI after years or even decades of neglect.  Most bladder hernias are direct, with a 70% male predominance, and most cases occur on the right side.  Our case is rarest because of left side scrotal cystocele and the bladder hernia was diagnosed perioperatively. In most of the cases UTIs are of a recurrent nature. , Kraft et al. noted four cases of Inguinoscrotal bladder hernia with UTI. , In cases of inguinoscrotal bladder hernias, the patients present with double stage micturition, involving spontaneous bladder emptying with a second stage of manual compression of the hernia. ,, Inguinoscrotal bladder hernia according to the relation with the parietal peritoneum can be paraperitoneal, intraperitoneal, and extra peritoneal type. The paraperitoneal type, in which the extra peritoneal portion of the bladder lies medially to the hernia sac, is the most common. , In our case, the bladder was herniated directly without being covered by the peritoneum, which can be classified as the extra peritoneal type. Other important methods under radiology are cystography, intravenous pyelography (IVP), computed tomography (CT) scan, or ultrasonography. A dumb-bell-shaped bladder on cystography and displacement of bladder and incomplete visualization on IVP has diagnostic value. , CT scan and ultrasonography have good role in diagnosis of herniated bladder and related complications. The surgical treatment of inguinoscrotal bladder hernia is reduction with exploration and repair of defect and if reduction is not possible, resection of the herniated bladder followed by surgical repair. , The best choice of the surgical technique is variable with presentation of patient. The most common and safe method is Lichtenstein open tension-free hernioplasty. In this method, the application of mesh was at preperitoneal region. The mesh improves the strength of the weak abdominal wall and reduces the risk of hernia recurrence. Huze hernia produces postoperative raised intra abdominal pressure.  Postoperative ileus also a common problem which creates high intra-abdominal pressure and leads to wound dehiscence and recurrence of the hernia.  The fine pre-operative evaluation, the sincere radiological examinations and the best surgical approach chosen by the surgeon can all lead to a successful outcome. 
| Conclusions|| |
The surgical repair of an Inguinoscrotal hernia containing the urinary bladder is a big challenge for surgeons in daily practice. This case report highlights the typical presentation, evaluation and surgical approach with potential risk in cases of an incarcerated urinary bladder into the scrotum. The clinical examination and CERC is the good method to solve this problem. Surgical therapy is the best treatment that can offer these patients a normal life.
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[Figure 1], [Figure 2], [Figure 3]