An 83-year-old gentleman presented to the emergency department complaining of lower abdominal pain extending into his back since the previous day. The attending clinician was concerned that the gentleman was in acute urinary retention, with a palpable bladder and inserted a 16Ch Foley urinary catheter. Clear urine was obtained.
The patient was referred surgically for investigation and admission. The patient had a past medical history of ischaemic heart disease, with a previous myocardial infarction, and a degree of congestive cardiac failure as well as being in atrial fibrillation. He also suffered from Paget’s disease. His previous surgical history included bilateral inguinal hernia repairs and a transurethral resection (TUR) of the prostate for benign hyperplasia.
The admitting surgical team noted on examination a tense, tender, irreducible lump in the right inguinal region beneath the old scar. The patient was able to inform the team that he had a recurrence of his inguinal hernia on the right side, but elective surgery had been declined due to his extensive co-morbidities.
The provisional diagnosis of an incarcerated, recurrent inguinal hernia was made. In light of his abdominal pain extending into the back, as well as concerns regarding the patient’s fitness for surgery due to extensive comorbidities, a CT scan was organised, prior to surgical exploration of the right groin.
CT scanning of the abdomen and pelvis revealed the tip and the inflation balloon of the urinary catheter to be present in the right inguinal hernia sac, with part of the bladder (Figures 1 & 2).There was no evidence of large or small bowel in the hernia. A wedge compression fracture of T11 vertebral body was identified which accounted for his back pain, as well as sacral changes in keeping with Paget’s disease.
The catheter was immediately deflated by the surgical team and withdrawn out of the hernia, but not removed. The lump instantly disappeared and the discomfort in the inguinal region settled. The gentleman’s symptoms improved, the catheter was removed and he was passing urine comfortably. Elective repair of the hernia was deemed inappropriate due to his extensive comorbidities. His back pain settled with analgesia and he was subsequently discharged home.
Inguinal hernias can contain a wide variety of intra-abdominal organs, such as the ovaries, fallopian tubes, appendix, as well as large and small bowel.1 Occasionally herniae present with unusual intra-abdominal pathology, such as metastatic peritoneal disease2, pseudomyxoma peritonei syndrome3 and also adenocarcinoma of the bowel4. There are many well described eponyms for inguinal hernias, such as Amyand’s hernia containing the appendix, or Littre’s hernia containing a Meckel’s diverticulum.
Sliding inguinal hernias involving the bladder are relatively rare, with estimates ranging between 1-4% of all inguinal herniae.5,6 Large herniations of the bladder into the scrotal sac have been termed ‘scrotal cystocoeles’.7 The literature reveals one case report of a male with a scrotal mass who needed to manually compress his scrotum in order to void.8
Many factors can contribute to the presence of the urinary bladder in a hernia, including urinary outlet obstruction causing chronic bladder distension and contact of the bladder wall with the hernial orifices as well as loss of bladder tone9. These are all features that may have been present in this patient as he had previously undergone a TUR of prostate for obstructive symptoms.
This case demonstrates the need to be vigilant when placing a urinary catheter in an individual with a history of groin hernias and to be suspicious of an acute hernia in catheterised patients. If we had proceeded to surgical exploration on clinical findings alone, the patient would have undergone an arguably unnecessary urgent operation and been exposed to significant anaesthetic risks given his poor cardiac status. It also highlights the potential benefit that CT scanning can provide in cases with an unusual clinical history and presentation.