Multiple Secondary Vesical Calculi in a Large Incarcerated Inguinoscrotal Bladder Hernia

Abstract

Background: Inguinal herniation of the urinary bladder is rare. Although in most patients it is an incidental finding during hernia repair, some patients present with complications related to herniated bladder.

Case Presentation: A 65-year-old man presented with recurrent lower urinary tract infections and multiple episodes of lithuria. He was found to have an incarcerated right inguinal hernia with a large part of the urinary bladder inside the hernial sac. He did not have any features of bladder outlet obstruction. The herniated bladder had multiple small secondary vesical calculi that had probably formed in this hernial sac. He was managed by open surgical mesh hernioplasty followed by cystoscopic stone evacuation.

Conclusion: Incarcerated bladder herniation, complicated by intravesical stone formation, is a rare clinical condition. Proper preoperative imaging with CT scan best confirms the diagnosis. Appropriate treatment includes reduction of the bladder, hernia repair, and endoscopic stone management.

Introduction

Herniation of the urinary bladder in the inguinal hernia is not common. Most cases are diagnosed intraoperatively as bladder herniation is usually asymptomatic. Only 7% of bladder hernias are diagnosed preoperatively, some may present with obstructive uropathy or chronic kidney disease (CKD). Open or laparoscopic hernioplasty is the standard of care for these patients.

We present a rare case of multiple small secondary vesical calculi that formed in an incarcerated bladder hernia.

Case Report

A 65-year-old man presented with recurrent dysuria, increased urinary frequency, and intermittent lithuria over the past 2 years. Clinical examination revealed a moderately enlarged prostate with an incidentally detected irreducible right indirect inguinal hernia. Baseline pathologic evaluation was normal, except for significant microscopic hematuria on urine microscopy. Ultrasonography confirmed normal kidneys with a 40-g prostate enlargement and minimal postvoid residual urine. Bladder wall thickness was normal. Uroflowmetry documented acceptable flow rates and normal flow pattern (peak flow rate [PFR]: 13.5 mL/s). He was a nonsmoker and his urine cytology did not show any abnormal cells.

For evaluation of microscopic hematuria, a contrast-enhanced CT scan was performed that showed normal upper urinary tracts with a large part of the urinary bladder herniated in the right scrotal sac. The herniated part of the bladder was thickened and filled with multiple small vesical calculi (Figs. 1 and 2).

FIG. 1.

Bladder herniation in the left inguinal hernia.

FIG. 2.

Thickened bladder in hernial sac with multiple calculi.

Under appropriate antibiotic coverage and regional anesthesia, open prolene mesh hernioplasty with repositioning of the urinary bladder was performed. This was followed by a cystoscopy that confirmed a normal bladder outlet with nonobstructing prostatic enlargement. Multiple small intravesical calculi were seen and these were flushed out using a Toomey syringe (Fig. 3A). The dome of the bladder (herniated portion) had thickened hyperemic mucosa (Fig. 3B). Multiple bladder biopsies were taken that showed histologic features of nonspecific chronic cystitis.

FIG. 3.

(A) Cystoscopy image showing multiple small vesical calculi. (B) Cystoscopy image showing the herniated bladder with thickened hyperemic mucosa.

The patient had a smooth postoperative course, catheter was removed in 24 hours and the patient was discharged from hospital after documenting normal voiding pattern. At 3-month follow-up, he was asymptomatic with no recurrent episodes of infection or lithuria.

Discussion

Inguinal bladder herniation is rare and is seen in 1–4% of all inguinal hernias. Most patients are either asymptomatic or are incidentally discovered during surgical hernia repair or on radiography. The intra- or postoperative diagnosis of the bladder hernias is often due to complications such as bladder injury or leakage.¹ Many serious urologic complications such as infection, obstructive uropathy, and even CKD have been described related to herniated bladder. De novo secondary calculi formation in an incarcerated herniated bladder is rare. Our patient presented with recurrent dysuria, increased urinary frequency, and intermittent lithuria.

The inguinal bladder herniation is thought to happen when a sheath of peritoneum along with the bladder gets pulled in the hernial sac.² That is why this condition is more common in older men with bladder outlet obstruction (BOO) and reduced detrusor tone. In this patient, there were no clinical signs of BOO as he did not have any lower urinary tract symptoms (LUTSs), and had normal PFR.

As is commonly observed, herniated inguinal bladder was not suspected on clinical assessment. A more anatomical diagnosis was made with a preoperative CT scan showing the herniated bladder with multiple intravesical calculi. A “dumbbell” or “dog-ear” shape of the bladder on voiding cystourethrography is diagnosis of inguinal bladder hernia, interestingly we found this classical dumbbell image on CT scan (Fig. 4).

FIG. 4.

Dumbbell-shaped bladder with herniated portion filled with calculi.

Secondary calculi in the urinary bladder can form in situations of urinary stasis, recurrent infection, and rarely foreign body. In our patient, the incarcerated hernia probably led to urinary stasis in the inguinal part of bladder, leading to recurrent infection and calculi formation. As the rest of the bladder had normal bladder wall thickness, there were no LUTSs with acceptable urinary flow rates, and there was no history of calculus disease, we suspect that the cause of stone formation in this patient was stasis in the incarcerated hernia and not BOO.

There are few reports of a solitary large vesical calculus associated with bladder herniation³; in most of these patients the calculus appears to be secondary to prostatic enlargement with BOO. Contrera et al. have reported a patient with sliding inguinoscrotal hernia with calculi in the herniated bladder.⁴ This patient had associated large distal ureteral calculus and was probably a stone former. In contrast, our patient did not have any upper tract calculi or calculi in the normal bladder.

The herniated portion of the bladder was thickened hence there was a suspicion of malignancy. This was ruled out by the urine cytology and bladder biopsy. There are reports of lipomatosis at the site of bladder herniation,⁵ in our patient it turned out to be chronic cystitis.

Surgical treatment involves bladder reduction and hernioplasty by open or laparoscopy technique. Partial cystectomy is indicated when bladder hernia is associated with bladder wall necrosis, bladder diverticulum, a tight hernial neck, or malignancy.¹ In our case, open surgical mesh hernioplasty with cystoscopic stone evacuation was performed.

Conclusions

Inguinal herniation of the urinary bladder is rare. We report an unusual case of incarcerated hernia that contained a large portion of bladder with de novo formation of multiple secondary vesical calculi in it.

Consent for Publication

Available.

Abbreviations Used

BOO

bladder outlet obstruction

CECT

contrast enhanced computerized tomography

CKD

chronic kidney disease

CT

computed tomography

LUTSs

lower urinary tract symptoms

PFR

peak flow rate

Disclosure Statement

None of the four authors have any commercial associations that might create a conflict of interest in connection with the submitted article.

Funding Information

No funding was received for this article.

Cite this article as: Maheshwari PN, Arulvanan N, Kalimkhan AS, Yadhukrishnan TP (2020) Multiple secondary vesical calculi in a large incarcerated inguinoscrotal bladder hernia, Journal of Endourology Case Reports 6:4, 487–489, DOI: 10.1089/cren.2020.0143.