Intraoperative discovery of bladder herniation in a known inguinoscrotal hernia during open cystolithotomy, prostatectomy and hernioraphy : a case report and review of diagnostic pitfalls.

Abstract

Background: Inguinoscrotal herniation of the urinary bladder (ISHB) is a rare but underdiagnosed condition, accounting for 1-4% of inguinal hernias and discovered intraoperatively in more than 80% of cases. Recognised predisposing factors include advanced age, obesity, and chronic infravesical obstruction, of which benign prostatic hyperplasia (BPH) is the most common. Failure to identify ISHB preoperatively exposes the surgeon to the risk of inadvertent vesical injury, reported in up to 12% of unprepared herniorrhaphies.

Case presentation: A 61-year-old man was admitted for obstructive lower urinary tract symptoms complicated by chronic urinary retention, in association with a right inguinoscrotal swelling. Ultrasonography demonstrated a 145 g prostatic enlargement and a 43 × 27 mm vesical calculus. A combined procedure was planned: transvesical open cystolithotomy, prostatectomy, and inguinoscrotal hernia repair. During inguinal dissection, the absence of a true peritoneal sac prompted meticulous exploration, which identified the bladder as the hernial content. The bladder was safely reduced into the pelvic cavity without iatrogenic injury, and a Bassini herniorrhaphy was performed. The postoperative course was uneventful. At 10 months, the patient reported marked voiding improvement, with a maximum urinary flow rate of 18 mL/s.

Conclusions: In male patients aged over 50 years presenting with an inguinal hernia in the setting of BPH, LUTS, or vesical calculus, selective preoperative imaging (CT or cystography) should be considered when clinical examination or risk factor profiling raises suspicion of bladder herniation. When the diagnosis is not established preoperatively, meticulous intraoperative dissection remains the cornerstone of safe herniorrhaphy and the principal safeguard against iatrogenic vesical injury. Simultaneous management of ISHB and coexisting urological conditions is feasible and advantageous, particularly in resource-limited settings.