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CASE REPORT
Year : 2022 | Volume
: 21
| Issue : 3 | Page : 288-290
Recurrent inguinal hernia containing the urinary bladder: A rare occurrence
Friday Emeakpor Ogbetere1, Udoka Imoisili2
1 Department of Surgery, Edo University, Iyamho; Consultant Urologist, Edo Specialist Hospital, Benin City, Edo State, Nigeria
2 Consultant Family Physician, Central Hospital, Auchi, Edo State, Nigeria
Correspondence Address:
Friday Emeakpor Ogbetere
Department of Surgery, Edo University, KM 7, Auchi - Abuja Expressway, PMB 04, Iyamho, Auchi, Edo State
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_100_20
Abstract
Inguinal bladder hernia (IBH) is an extremely rare occurrence and remains a challenge to the surgeon in the preoperative, intraoperative, and in the postoperative period. Its diagnosis requires a high index of suspicion, especially in the high-risk patients: elderly overweight/obese males with a recurrent hernia and lower urinary tract symptoms. Here, we report the case of a 78-year-old overweight male who presented with a bilateral direct inguinal hernia with the right being recurrent and irreducible. The diagnosis of IBH was made incidentally during the hernia repair. The patient was managed successfully by the replacement of the bladder in the pelvic position and inguinal herniorrhaphy done using the modified Bassini technique. The left groin hernia was also repaired using the modified Bassini technique. Our goal here is to reawaken the consciousness of the surgeons involved in inguinal hernia repair about IBH, particularly in high-risk patients.
Abstract in French Résumé
L'hernie inguinale de réservoir souple (IBH) est une occurrence extrêmement rare et demeure un défi au chirurgien dans le préopératoire, peropératoire, et dans la période postopératoire.Son diagnostic exige un index élevé de soupçon, particulièrement dans les patients à haut risque : vieux mâles de poids excessif/obèses avec une hernie récurrente et des symptômes inférieurs d'appareil urinaire.Ici, nous rapportons le cas d'un mâle de poids excessif de 78 ans qui s'est présenté avec une hernie inguinale directe bilatérale avec le droit étant récurrent et irréductible.Le diagnostic d'IBH a été fait fortuit pendant la réparation d'hernie.Le patient a été contrôlé avec succès par le remplacement du réservoir souple en position pelvienne et herniorrhaphy inguinal fait utilisant la technique modifiée de Bassini.L'hernie gauche d'aine a été également réparée utilisant la technique modifiée de Bassini.Notre but ici est de réveiller la conscience des chirurgiens impliqués dans la réparation inguinale d'hernie au sujet d'IBH, en particulier dans les patients à haut risque.
Mots-clés: vessie, herniorrhaphie, hernie de la vessie inguinale, symptômes des voies urinaires inférieures, hernie récurrente
Keywords: Bladder, herniorrhaphy, inguinal bladder hernia, lower urinary tract symptoms, recurrent hernia
Introduction 
Inguinal bladder hernia (IBH) is an uncommon clinical entity seen in 1%–4% of inguinal hernias in the general population, with an increasing incidence among the elderly overweight/obese males with recurrent hernia and lower urinary tract symptoms.[1] Its modes of presentation range from asymptomatic groin swelling to life-threatening symptoms.[2],[3] IBH is difficult to diagnose: about 7% is diagnosed preoperatively, 16% diagnosed postoperatively due to complications, while the rest are detected intraoperatively.[1],[4],[5]
In this article, we present our experience with an elderly male who had a bilateral direct inguinal hernia with a right IBH that was successfully managed without bladder injury.
Case Report Mr. AA was a 78-year-old overweight male who presented to the emergency unit with a long-standing history of lower urinary tract symptoms and a subsequent occurrence of bilateral groin swelling of 1-year duration. He has had right inguinal herniorrhaphy 10 years previously. The patient used to reduce both swellings manually. However, 4 h before the presentation, the right groin swelling became irreducible and painful necessitating his presentation to our facility. He had no medical history of diabetes or hypertension but had a background history of cough of 2 weeks duration.
The physical examination revealed bilateral inguinal hernias. The right hernia was tender and irreducible with a previous right groin scar that healed with primary intention. The left was reducible and nontender. The rectal examination revealed an enlarged prostate with benign features. His body mass index was 27.5 kg/m2. His international prostate symptoms score was 16, whereas the prostate-specific antigen result was 3.7 ng/ml and the prostate volume was 89.8 ml. Urinalysis, serum electrolytes, urea and creatinine, Chest X-ray, and electrocardiogram done were within the normal range.
A preoperative provisional diagnosis of right irreducible recurrent and left reducible inguinal hernia on the background of benign prostatic hyperplasia was made. The patient gave informed consent only for the repair of both inguinal hernias and favored medical treatment of the benign prostatic enlargement. He underwent surgical exploration of both groins under spinal anesthesia [Figure 1]. The bladder was found to be the sole content of the hernia sac which was confirmed by aspiration of urine [Figure 2]. Upon the discovery of the inguinal bladder, a urethral catheter was passed and urine drained. The herniated bladder was dissected from the inguinal canal and returned to the pelvic position. The repair of the inguinal floor was done using a modified Bassini technique. The repair of the left inguinal hernia was also done using the same technique. The postoperative period was uneventful. The urethral catheter was removed on the 2nd day and he was discharged on the third postoperative day. He is currently being followed up in the clinic without any recurrence or urological sequelae and presently doing well on the medical treatment of benign prostatic enlargement. The patient gave written informed consent for the publication of this case report.
Figure 1: Intra-operative findings of nylon sutures in situ from previous repair
Figure 2: A direct hernia sac containing the urinary bladder with urine aspirated Discussion IBH is a rare finding, accounting for about 1%–4% of inguinal hernias.[1] Described in the elderly patients in most instances, it is more common in males and often seen on the right side.[6] Most patients with IBH are usually in their sixth decades and above.[2],[6] Our index patient was in his eighth decade and had a bilateral direct inguinal hernia with the right being recurrent.
The pathophysiology of IBH has been linked to some neglected co-morbid conditions such as obesity, chronic obstructive pulmonary disease, weakness of pelvic floor and abdominal wall muscles, and bladder outlet obstruction from benign prostatic hyperplasia and carcinoma of the prostate.[1],[5],[6] This index patient had a background history of cough, previous hernia repair on the right groin as well as clinical benign prostatic hyperplasia.
In general, IBH is rarely associated with complications. Nonetheless, vesicoureteric reflux, hydronephrosis, obstruction, and bladder strangulation with resultant infarction may be seen.[1],[2],[6] In a review of 190 cases of IBH by Oruç, et al., they noted a complication rate of 23.5%, whereas genitourinary malignancies were seen in 11.2% of the cases.[1]
The majority of IBHs are discovered intraoperatively. About 7% of IBHs are diagnosed preoperatively and usually during investigation for comorbidities and associated complications, while approximately 16% are diagnosed postoperatively as a result of complications. Preoperative diagnosis of IBH may ensure optimal preparation and prevent intraoperative bladder injuries which are seen in about 12% of cases.[1],[2],[5] This can be achieved by investigating elderly obese patients with previous groin surgeries and lower urinary tract symptoms with this pathology in mind. That said, the mode of presentation varies from asymptomatic and incidental discovery to two-stage urination which entails spontaneous urination in the first stage and manual compression of the groin swelling in the second stage or a decrease in the size of the scrotum after urination in advanced cases.
Imaging investigations are not generally performed in the preoperative workup of patients with groin hernia. However, in suspected cases, imaging investigations will depend on availability, associated comorbidity, and surgeon's choice. That said, of the various imaging modalities available, ultrasound is readily accessible and should be the first-line investigation.[7] The gold standard diagnostic imaging modality for IBH, however, is the voiding cystography which shows a dog-ear-shaped bladder. Cystoscopy is helpful in evaluating the bladder and the prostate and its indicated in high-risk patients with lower urinary tract symptoms and/or hematuria.[6] Furthermore, a computed tomography scan which is useful in the precise and prompt evaluation of IBH as well as other associated complications is indicated in overweight/obese, elderly males with recurrent inguinal hernia as in the case of our patient [Figure 1].[5],[8],[9] These investigations were however not done as the patient presented in obstruction.
The gold standard treatment for IBH is open surgical repair.[3],[5],[6] Urethral catheterization should be done before surgery. However, when discovered intra-operatively, urethral catheterization should be done. The most critical step of the operation and in all hernia repairs generally is the succinct identification of the various anatomic elements within the hernia sac.[5] The herniated bladder is identified, aspirated if in doubt [Figure 2], reduced from the hernia sac, and repositioned in its anatomical location. Repair of the defect with a mesh is the best option for surgical management.[2],[5] However, our patient had tissue repair as the surgery was done in emergency and mesh was not readily available. Bladder resection may be done if there is necrosis of the bladder neck, presence of bladder tumour, or bladder diverticulum.[1],[2],[5],[6]
Bladder injury during inguinal hernia repair is quite common, with a reported rate of 12% in all IBHs.[6] Preoperative or intraoperative identification of IBH leads to reduced morbidity associated with inguinal hernias.[9] As a fundamental rule, surgeons should pay utmost attention during surgery to avoid injuring the bladder or other contents of the sac as lack of care could result in serious complications postoperatively.
Conclusion All doctors involved in the repair of inguinal hernia should be aware of this rare condition during the surgical repair. Overweight or obese elderly patients with recurrence of inguinal hernia and lower urinary tract symptoms are at high risk of this pathology and should be investigated with this in mind. Second, a careful dissection of the hernia sac with precise identification of each anatomic element is advocated. Finally, we suggest abstaining, as much as possible, from resection of hernia content, particularly in obese participants where the subcutaneous fat and the intact external oblique aponeurosis may hide a small IBH.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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