Bladder hernia

Clinical History

An 80-year-old man, with non-insulin dependent diabetes and a history of obstructive lithiasis was referenced to ultrasound due to increased testicular volume and polaquiuria.
The patient had no history of previous surgical procedures.
There was a palpable testicular and inguinal tumefaction on the objective exam.

Imaging Findings

Ultrasound imaging revealed herniation of most of the bladder lumen, to the right scrotal compartment through the inguinal canal.
After voiding, we observed incomplete emptying of the pre-voiding volume, most of it remaining in the herniated portion located in the scrotal compartment.

Discussion

Herniation of the urinary bladder is not rare. It was reported that 1–3% of all inguinal hernias involve the bladder [1]. Most bladder hernias involve the inguinal and femoral canals, though herniations through ischiorectal, obturator, and abdominal wall openings have been reported. The presence of a large bladder hernia with descent into the scrotum was termed by Levine [2] in 1951 "scrotal cystocele". This type of herniation has right side predominance.

Bladder hernias are normally asymptomatic and an incidental finding during imaging for other purposes or surgery. Lower urinary tract symptoms like dysuria, urgency, nocturia, haematuria have been referred, but their origin could point to other coexisting conditions. Patients with very large hernias (like the case we described) may have specific symptoms, like the two-stage micturion characterized by the patients’ need to provide compression in the hernia sac for voiding after he spontaneously emptied the normal bladder [1, 3-5].

Possible causes include chronic bladder distension, loss of bladder tone, pericystitis, perivesical fat protrusion, space-occupying pelvic mass lesions.

In suspected cases, imaging helps in confirmation of diagnosis, to look for potential complications (strangulation) and planning surgery. Retrograde and voiding cystourethrogram, USG, multidetector computed tomography, and magnetic resonance imaging are equally successful in establishing the diagnosis [3, 7]. MRI identifies bladder hernias during pelvis and abdomen scans for unrelated purposes or clarifies findings of urography or sonography. Sagittal and/or coronal images provide better appreciation of the relationships of the herniated bladder in patients with large lesions clarifying the relation with the epigastric vessels. CT is however the gold standard as an imaging modality in this case, as it can identify the hernia content, and rule out strangulation and hydronephrosis. Some authors recommend that if there is a strong clinical suspicion of bladder hernia, imaging (Cystography/CT) should be performed as preoperative delineation of the sac anatomy and its content can help reduce the risk of serious injury during herniorraphy [6, 8]. Surgical repair is the standard treatment for inguinal hernias involving the bladder [6].

It is crucial to monitor the patient's postoperative recovery to see if the symptoms resolve and if there is need for any kind of additional therapy. A postoperative cystogram to evaluate the bladder is mandatory.
These hernias not only give the patient a lot of discomfort but have a potential risk of incarcerateration due to their size, so a quick approach and screening is mandatory.

Differential Diagnosis List

Final Diagnosis

Inguino-scrotal bladder hernia

URL:	https://www.eurorad.org/case/13198
DOI:	10.1594/EURORAD/CASE.13198
ISSN:	1563-4086