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CASE REPORTS
POLSKI
PRZEGLĄD CHIRURGICZNY 10.1515/pjs-2016-0007
2015, 87, 11, 587–591
SURGICAL TRAP OF A ROUTINE PROCEDURE. SCROTAL HERNIA
WITH CONCOMITANT SLIDING OF THE URINARY BLADDER – CASE
REPORT
Department of Surgery and Gastroenterology SPZOZ in Grodzisk Wlkp.
Ordynator: lek. A. wach
The content of the hernial sac may comprise peritoneal cavity elements, such as small and large
bowel loops, visceral adipose tissue, the greater omentum, appendix (amyand hernia), and Meckel's
diverticulum. The sliding of part of the urinary bladder wall to the inguinal canal is rare, being observed
in 1%-4% (0.5%-3%) of inguinal hernia cases. Complete migration of the urinary bladder to the scrotum
is considered a rare anomaly. As of today, 100 such cases have been described.
Key words: scrotal hernia, sliding hernia, sliding of the urinary bladder, scrotal cystocele
During life the risk of full symptom inguinal
hernia development is observed in 27% of male
and 3% of female cases (1).
Considering epidemiology, the sliding of the
urinary bladder to the inguinal hernia sac is
observed in 0.5-4% of cases (2, 3, 4). A large
scrotal hernia of the urinary bladder is even
rarer (5, 6). The term scrotal cystocele domi-
nates in english literature data, proposed by
Levin in 1951 (7). Since the above-mentioned
date, Levin described 32 such cases.
Hernia repair procedures are the most com-
mon surgical interventions in Poland. Hernia
plasty is one of the rst surgical procedures
performed. During surgical training the young
adept is obliged to perform 55 hernia plasty
operations on his own, and in 15 cases be the
assisting surgeon.
The aim of the study was to present a rare
anatomical variant, which the surgeon might
encounter during elective inguinal hernia
surgery. In most cases proper inguinal hernia
repair does not pose a problem for the surgeon.
In selected cases the routine procedure might
prove to be a challenge.
Preoperative physical examination, surgical
alertness, and imaging diagnostics (cystogra-
phy) enabled to diagnose scrotal cystocele,
considered a rare pathology.
CASE REPORT
A 61-year old male patient was admitted to
the Department of Surgery for treatment of
left-sided inguinal hernia sliding to the scro-
tum. The patient had a history of arterial
hypertension and pacemaker implantation.
Stage II obesity was diagnosed with the BMI
amounting to 38.74.
During the physical examination the pa-
tient complained of pain, left-sided inguinal
and scrotal discomfort. On admission, we ob-
served an enlarging pathological mass in the
vicinity of the left inguinal ligament. Pain
symptoms and the size of the hernia signi-
cantly intensied during the past 6 months.
The patient complained of unspecic symp-
toms, such as reduction of the size of the hernia
after miction, increased miction after compres-
sion of the scrotal area, ischuria paradoxa,
incomplete urinary bladder emptying, and
periodic symptoms of dysuria.
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588 B. Cybułka et al.
Imaging examinations showed the cysto-
scopic image of the mucous membrane free of
pathology. The ultrasound examination
showed a homogenous, well-limited hipoecho-
genic uid reservoir located in the left ingui-
nal and scrotal area. The uid reservoir was
present even after urinary bladder emptying.
Laboratory results showed no abnormali-
ties.
Final diagnosis was based on ascending
cystography, which showed the presence of a
massive, left-sided, inguinoscrotal bladder
hernia (g. 1).
Due to persistent symptoms reported by the
patient, signicant cosmetic defect, and hy-
gienic problem of the inguino-scrotal area the
patient was qualied for surgery. After the
introduction of spinal anesthesia an oblique
inferior incision was performed in the left
groin, the lower pole of the wound being ex-
tended to the antero-lateral wall of the scro-
tum. After opening the left inguinal canal the
hernial sac containing the sliding scrotal blad-
der hernia was subject to preparation (g. 2).
The apex of the oblique hernial sac after cross-
ing the deep inguinal ring migrated to the left
testicular level (g. 3). Under visual control
the deep inguinal ring was subject to prepara-
tion and dilatation.
Without violating the continuity of the uri-
nary bladder walls the excessive content of the
hernial sac was reduced to the abdominal cav-
ity. Due to the vascular pedicle of the left
testicle, surgery was extended to left-sided
orchiectomy (g. 4). Previously, the patient
was informed in detail about the possibility of
surgical extension. He consented in writing to
the removal of the left testicle.
The inefcient posterior wall of the ingui-
nal canal was supplied by redoubling the
Fig. 1. Preoperative ascending cystography
Fig. 2. Hernial sac with urinary bladder content
Fig. 3. Dissected hernial sac and urinary bladder and
isolated left testicle
transverse fascia and placing a continuous
suture between the internal oblique muscle
and inguinal ligament. Hernioplasty was
performed applying a polypropylene mesh,
10x5 cm in size by means of Lichtenstein’s
method (g. 5). The area above the external
oblique muscle aponeurosis was secured by a
suction Redon 14 Fr drain. Additionally, a
gravitational drain was left inside the scrotal
sac at the site of the orchiectomy. The opera-
tive wound was closed by means of inter-
rupted, adaptation sutures.
Intraoperative blood loss was insignicant.
During the procedure bipolar electrocoagula-
tion was used, due to the presence of a cardiac
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Surgical trap of a routine procedure. Scrotal hernia with concomitant sliding of the urinary bladder
pacemaker. During the postoperative period
antibiotics were administered (Tarfazolin 1,0
i.v. Metronidazol 1,0 i.v.). Foley’s catheter (18
Fr) was inserted into the urinary bladder.
During the postoperative period the Redon
drain was removed after three days. Eight days
after surgery the patient was discharged from
the hospital in good general condition.
Control ascending cystography performed
30 days after surgery showed proper localiza-
tion of the urinary bladder above the pubic
symphysis (g. 6). The volume capacity of the
bladder after repair surgery was not reduced
amounting to approximately 350 ml.
During postoperative monitoring we ob-
served wound inammation. The control ex-
amination showed the presence of two uid
compartments, one in the lower pole of the
wound and one in the left scrotal area. Both
uid compartments required surgical inci-
sions, revision, and drainage. There was no
evidence of polypropylene mesh infection. The
bacteriological material showed no signicant
Staphylococuss haemoliticus MRS growth. The
methicillin-resistant strain showed suscepti-
bility to clindamicin and dapromicin. Dress-
ings, wound drainage, and target antibiotics
proved effective. Supervision over the wound
healing process was under ambulatory control.
Sixty-three days thereafter, the wound was
considered as healed.
DISCUSSION
Surgery in case of an inguinal hernia is one
of the most commonly performed procedures
Fig. 4. Dissected left testicle with elements of the
spermatic cord
Fig. 5. Supplied posterior wall of the inguinal canal by
means of a polypropylene mesh: tension – free
technique
Fig. 6. Control cystography 30 days after surgery
in general surgery around the world. It is es-
timated that each year approximately 20 mil-
lion of such operations are performed. In Po-
land, there are more than 40 thousand such
procedures performed. For comparison, in the
United States there are more than 700 thou-
sand such procedures. Inguinal hernia surgery
predominates, accounting for 70% of cases. The
second most frequent surgical interventions
concern femoral hernias in the female popula-
tion, accounting for 12% of cases (8).
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Proper diagnosis, appropriate treatment
strategy, and postoperative care in most cases
take place without negative complications.
The most important risk factors of scrotal
bladder hernias include the following:
– obesity (9),
– past injuries of the pelvis, especially associ-
ated with damage to the pelvic ligament,
supporting the urinary bladder. Damage to
the symphisis barrier for the migration of
the urinary bladder (10),
– previous abdominal wall and inguino-pubic
area operations,
– subbladder obstruction (prostatic hypertro-
phy, urethral stricture, prostatitis, bladder
neck stenosis, and in selected cases chronic,
untreated phimosis),
– urinary bladder wall pathology (weakening
muscular membrane, presence of bladder
diverticula, chronic inammation, malig-
nancy),
– advanced age,
– general factors, such as smoking, COPD,
congenital anomalies in collagen soft tissue
structures.
Anatomically, retroperitoneal bladder
translocation predominates. Considering the
localization of the hernial sac in relation to the
inferior abdominal vessels, medial hernias
predominate (direct, simple). The above-men-
tioned pathology is more frequently observed
in men. Right-sided scrotal cystocele is ob-
served more frequently. Unfortunately, more
than twice as often diagnosis is established
intraoperatively, or during the postoperative
period (2, 5, 11).
Diagnosis is based on a detailed medical
history concerning disorders of urination. It is
necessary to thoroughly assess the hernial ring
and analyse the contents of the hernial sac.
Amongst useful imaging examinations one
should mention the following:
– ascending cystography considered as the
„golden standard”,
– cystoskopy,
– abdominal ultrasound of the inguinal area
and scrotal sac (12, 13),
– abdominal and pelvic CT,
– urography more rarely, due to poor visual-
ization of the hernial sac.
Currently, in the PubMed database the
term „scrotal cystocele” is cited in 30 articles.
The term „bladder hernia” was observed in 155
cases, while „inguinal hernia with bladder”
might be present in 509 studies.
CONCLUSIONS
Scrotal cystocele is very rarely encountered.
In most cases the above-mentioned disease
entity is diagnosed during the postoperative
period, based mainly on the presence of per-
sistent urinary bladder leakage, and patho-
logical urine secretion from the operative
wound (14, 15). This prompts the surgical team
to expand the urological diagnosis. Delayed
diagnosis is often the cause of costly postop-
erative complications (16). It is extremely
important for the surgeon to know the ana-
tomical variant decribed earlier. This enables
efcient preparation and hernial plasty, so
important for the patient (tab. 1).
Table 1. Scrotal cystocele-management scheme
Opening of the inguinal canal and scrotal sac
Preparation of the hernial sac and its contents
Reduction of the hernial sac to the retropubic space
Resection of part of the urinary bladder (advanced
inammatory lesions, suspicion of neoplastic growth,
narrow urinary bladder neck < 0,5 cm)
Hernioplasty using tension techniques (Bassini,
Halsted)
The use of tension-free techniques with mesh
implantation (Lichtenstein)
Hemostasis
Operative wound drainage (groin, scrotum)
Urinary bladder protection through prolonged urinary
catheterization
Measurable benets of perioperative antibiotics
Postoperative control of the surgical efcacy
(cystography, cystoscopy, USG)
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Surgical trap of a routine procedure. Scrotal hernia with concomitant sliding of the urinary bladder
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Received: 25.10.2015 r.
Adress correspondence: 62-065 Grodzisk Wlkp., ul. Mossego 17
e-mail: b.cybulka@wp.pl
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