0022-534 7 /79/1214-0541$02. 00/0
Vol. 121, April
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
SCROTAL CYSTOCELE JOHN H. CROUSHORE
AND
ROBERT B. BLACK
From the Department of Urology, Grandview Hospital, Dayton, Ohio
i
I,
I' I
ABSTRACT
Massive inguinoscrotal bladder herniation is a surgical rarity. A 2-stage voiding pattern is typically noted. Excretory urography and retrograde cystography are extremely helpful in verifying the diagnosis of bladder herniation. A case of scrotal cystocele is reported.
Fm. 1. A, colon x-ray after IVP reveals residual contrast medium still present within herniated bladder. B, IVP demonstrates small asymmetrical bladder. C, IVP reveals large inguinoscrotal bladder hernia.
Scrotal cystocele is a term coined by Levine in 1951 to describe the rare clinical condition in which massive inguinoscrotal herniation of the bladder occurs. 1 However, inguinal hernias containing some portion of the bladder are not rare, since statistically approximately 1 to 3 per cent of all inguinal hernias contain some portion of the bladder. 1 Herniation can occur in other areas, such as obturator, suprapubic, ischiorectal and Gironcoli hernias. 2 However, true inguinoscrotal bladder hernias are rare, with only 49 cases reported in the current literature. CASE REPORT
R. N., a 59-year-old white man, was hospitalized on April 19, 1978 for evaluation of right hemiscrotal enlargement during a 4-month period. The enlargement seemed to parallel the patient's complaint of difficulty with voiding and slowing of the urinary stream. The ability to void was so impaired that the patient had to lie on his left side and flex the right leg on the abdomen to void. He had no antecedent history of inguinoscrotal trauma, venereal diseases, prostatitis or prostatism. Physical examination revealed a moderately obese man Accepted for publication August 4, 1978.
with a prominent right inguinoscrotal mass extending to the right mid thigh region. Examination of the contralateral hemiscrotal contents revealed a normally descended testis without any evidence of an associated hydrocele, varicocele or inguinal hernia. The right hemiscrotal mass was approximately 20 cm. in widest diameter and extended superiorly to the scrotal inlet. Auscultation of the scrotum failed to reveal any bowel sounds and there was no transmission of a cough impulse on palpation. Digital rectal examination revealed grade 1 enlargement of the prostate. Laboratory studies included complete blood count, blood chemistry studies, urinalysis and urine cultures. The only significant findings were a serum uric acid level of 8.6 mg./1. and a urine culture that yielded a non-hemolytic streptococcus. Radiologic studies included chest x-rays, lower gastrointestinal series, excretory urogram (IVP) and a 35 mm. cine radiogram of the bladder. The chest x-ray was normal and the lower gastrointestinal x-ray failed to show any loops of bowel in the scrotal sac (fig. 1, A). However, the IVP did reveal a large sliding inguinoscrotal hernia of the bladder. Almost total herniation of the bladder occurred into the scrotum when the patient was standing. Even the distal right ureteral 541
542
CROUSHORE AND BLACK
segment appeared to extend into the inguinal hernia sac (fig. I, B and C). Cine studies were done after cystourethroscopy and after the hernia was reduced. Consequently, the study showed only beaking of the bladder in the region of the right internal inguinal ring (fig. 2). Cystourethroscopic evaluation revealed a mildly enlarged prostate with a small capacity bladder. A funneling stoma was noted on the right lateral wall of the bladder. There was some lateral displacement of the ureteral orifice but the ureter was not in the stoma. Retrograde catheterization of the left ureter was successful but it failed on the right side. As noted previously, reduction of the scrotal cystocele was done while the patient was under general anesthesia during the cystourethroscopy. To ensure retropubic placement of the bladder indwelling Foley catheter drainage was instituted after cystourethroscopy. After preparatory x-rays, and laboratory and cystourethroscopic studies exploration of the right inguinal region was done through a standard right inguinal incision. A probable paraperitoneal bladder hernia and a large lipoma of the spermatic cord were noted. The inguinal sac was firmly adherent to the bladder and was returned to the peritoneal cavity with reduction of the bladder hernia. The internal inguinal hernia ring and floor of the inguinal canal were then repaired. The indwelling Foley catheter was removed 3 days Fm. 3. IVP 1 month postoperatively shows normal bladder postoperatively. Convalescence was uneventful and the patient was discharged from the hospital 4 days postoperatively. An IVP 1 month postoperatively revealed a normally placed with poor supporting structures. 3 bladder (fig. 3). Inguinoscrotal bladder hernias are usually asymptomatic. However, when present the symptoms are typical, with 2DISCUSSION stage voiding as a particularly significant finding. 3 Diagnostic Hernias of the bladder are classified into 3 groups according procedures that should be done to verify bladder hernias are to the relationship with the peritoneum: paraperitoneal, ex- retrograde cystography with post-voiding films and IVP. 3 traperitoneal and intraperitoneal. A paraperitoneal hernia is Routine IVPs do not ordinarily 'visualize bladder hernias the most common and has an indirect or direct inguinal hernia unless erect or prone films are done. 2 Reardon and Lowman sac adjacent to the herniated bladder. The next most common mention a diagnostic triad for radiologic diagnosis of bladder is the intraperitoneal hernia. The bladder is invested com- herniation by IVP: 1) lateral displacement of the distal third pletely by peritoneum as it herniates into the inguinal canal. of 1 or both ureters, 2) a small asymmetrical bladder and 3) The extraperitoneal hernia is the least common and is unas- incomplete visualization of the bladder base when associated with an inguinal hernia. 4 However, retrograde cystography is sociated with any peritoneal sacs. 3 It is believed that 2 factors contribute to the development of the most helpful in verifying the diagnosis. Better visualizaan inguinoscrotal bladder hernia: the presence of a urinary tion of the herniated bladder can be obtained by retrograde outlet obstruction, such as prostatitis, vesical neck contrac- filling of the bladder with a radiopaque contrast medium. ture of the bladder or urethral strictures, and a flaccid bladder Routine cystograms are even recommended by some for all patients more than 50 years old with inguinal hernias to exclude the possibility of bladder herniation. 5 Operative intervention is the treatment of choice for inguinoscrotal hernias. Most surgeons approach the repair of the herniated bladder through a standard inguinal incision. However, others recommend a special low transverse incision to expose better the bladder and hernia during the repair. 6 Once the bladder hernia is exposed it is returned to its normal retropubic position. Any other associated inguinal hernia is treated in the standard manner. REFERENCES
1. Levine, B.: Scrotal cystocele. J.A.M.A., 147: 1439, 1951.
Fm. 2. Cine-radiogram demonstrates beaking of bladder at right internal inguinal ring.
2. Becker, J. A.: Hernia of the urinary bladder. Radiology, 84: 270, 1965. 3. Soloway, H. M., Portney, F. and Kaplan, A.: Hernia of the bladder. J. Urol., 84: 539, 1960. 4. Reardon, J. V. and Lowman, R. M.: Massive herniation of the bladder: "the roentgen findings". J. Urol., 97: 1019, 1967. 5. Hinman, F.: Urology. Philadelphia: W. B. Saunders Co., 1935. 6. Redman, J. F., Williams, E. W., Meacham, K. R. and Scriber, L. J.: The treatment of massive scrotal herniation of the bladder. J. Urol., 110: 59, 1973.
Vol. 121, April
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
SCROTAL CYSTOCELE JOHN H. CROUSHORE
AND
ROBERT B. BLACK
From the Department of Urology, Grandview Hospital, Dayton, Ohio
i
I,
I' I
ABSTRACT
Massive inguinoscrotal bladder herniation is a surgical rarity. A 2-stage voiding pattern is typically noted. Excretory urography and retrograde cystography are extremely helpful in verifying the diagnosis of bladder herniation. A case of scrotal cystocele is reported.
Fm. 1. A, colon x-ray after IVP reveals residual contrast medium still present within herniated bladder. B, IVP demonstrates small asymmetrical bladder. C, IVP reveals large inguinoscrotal bladder hernia.
Scrotal cystocele is a term coined by Levine in 1951 to describe the rare clinical condition in which massive inguinoscrotal herniation of the bladder occurs. 1 However, inguinal hernias containing some portion of the bladder are not rare, since statistically approximately 1 to 3 per cent of all inguinal hernias contain some portion of the bladder. 1 Herniation can occur in other areas, such as obturator, suprapubic, ischiorectal and Gironcoli hernias. 2 However, true inguinoscrotal bladder hernias are rare, with only 49 cases reported in the current literature. CASE REPORT
R. N., a 59-year-old white man, was hospitalized on April 19, 1978 for evaluation of right hemiscrotal enlargement during a 4-month period. The enlargement seemed to parallel the patient's complaint of difficulty with voiding and slowing of the urinary stream. The ability to void was so impaired that the patient had to lie on his left side and flex the right leg on the abdomen to void. He had no antecedent history of inguinoscrotal trauma, venereal diseases, prostatitis or prostatism. Physical examination revealed a moderately obese man Accepted for publication August 4, 1978.
with a prominent right inguinoscrotal mass extending to the right mid thigh region. Examination of the contralateral hemiscrotal contents revealed a normally descended testis without any evidence of an associated hydrocele, varicocele or inguinal hernia. The right hemiscrotal mass was approximately 20 cm. in widest diameter and extended superiorly to the scrotal inlet. Auscultation of the scrotum failed to reveal any bowel sounds and there was no transmission of a cough impulse on palpation. Digital rectal examination revealed grade 1 enlargement of the prostate. Laboratory studies included complete blood count, blood chemistry studies, urinalysis and urine cultures. The only significant findings were a serum uric acid level of 8.6 mg./1. and a urine culture that yielded a non-hemolytic streptococcus. Radiologic studies included chest x-rays, lower gastrointestinal series, excretory urogram (IVP) and a 35 mm. cine radiogram of the bladder. The chest x-ray was normal and the lower gastrointestinal x-ray failed to show any loops of bowel in the scrotal sac (fig. 1, A). However, the IVP did reveal a large sliding inguinoscrotal hernia of the bladder. Almost total herniation of the bladder occurred into the scrotum when the patient was standing. Even the distal right ureteral 541
542
CROUSHORE AND BLACK
segment appeared to extend into the inguinal hernia sac (fig. I, B and C). Cine studies were done after cystourethroscopy and after the hernia was reduced. Consequently, the study showed only beaking of the bladder in the region of the right internal inguinal ring (fig. 2). Cystourethroscopic evaluation revealed a mildly enlarged prostate with a small capacity bladder. A funneling stoma was noted on the right lateral wall of the bladder. There was some lateral displacement of the ureteral orifice but the ureter was not in the stoma. Retrograde catheterization of the left ureter was successful but it failed on the right side. As noted previously, reduction of the scrotal cystocele was done while the patient was under general anesthesia during the cystourethroscopy. To ensure retropubic placement of the bladder indwelling Foley catheter drainage was instituted after cystourethroscopy. After preparatory x-rays, and laboratory and cystourethroscopic studies exploration of the right inguinal region was done through a standard right inguinal incision. A probable paraperitoneal bladder hernia and a large lipoma of the spermatic cord were noted. The inguinal sac was firmly adherent to the bladder and was returned to the peritoneal cavity with reduction of the bladder hernia. The internal inguinal hernia ring and floor of the inguinal canal were then repaired. The indwelling Foley catheter was removed 3 days Fm. 3. IVP 1 month postoperatively shows normal bladder postoperatively. Convalescence was uneventful and the patient was discharged from the hospital 4 days postoperatively. An IVP 1 month postoperatively revealed a normally placed with poor supporting structures. 3 bladder (fig. 3). Inguinoscrotal bladder hernias are usually asymptomatic. However, when present the symptoms are typical, with 2DISCUSSION stage voiding as a particularly significant finding. 3 Diagnostic Hernias of the bladder are classified into 3 groups according procedures that should be done to verify bladder hernias are to the relationship with the peritoneum: paraperitoneal, ex- retrograde cystography with post-voiding films and IVP. 3 traperitoneal and intraperitoneal. A paraperitoneal hernia is Routine IVPs do not ordinarily 'visualize bladder hernias the most common and has an indirect or direct inguinal hernia unless erect or prone films are done. 2 Reardon and Lowman sac adjacent to the herniated bladder. The next most common mention a diagnostic triad for radiologic diagnosis of bladder is the intraperitoneal hernia. The bladder is invested com- herniation by IVP: 1) lateral displacement of the distal third pletely by peritoneum as it herniates into the inguinal canal. of 1 or both ureters, 2) a small asymmetrical bladder and 3) The extraperitoneal hernia is the least common and is unas- incomplete visualization of the bladder base when associated with an inguinal hernia. 4 However, retrograde cystography is sociated with any peritoneal sacs. 3 It is believed that 2 factors contribute to the development of the most helpful in verifying the diagnosis. Better visualizaan inguinoscrotal bladder hernia: the presence of a urinary tion of the herniated bladder can be obtained by retrograde outlet obstruction, such as prostatitis, vesical neck contrac- filling of the bladder with a radiopaque contrast medium. ture of the bladder or urethral strictures, and a flaccid bladder Routine cystograms are even recommended by some for all patients more than 50 years old with inguinal hernias to exclude the possibility of bladder herniation. 5 Operative intervention is the treatment of choice for inguinoscrotal hernias. Most surgeons approach the repair of the herniated bladder through a standard inguinal incision. However, others recommend a special low transverse incision to expose better the bladder and hernia during the repair. 6 Once the bladder hernia is exposed it is returned to its normal retropubic position. Any other associated inguinal hernia is treated in the standard manner. REFERENCES
1. Levine, B.: Scrotal cystocele. J.A.M.A., 147: 1439, 1951.
Fm. 2. Cine-radiogram demonstrates beaking of bladder at right internal inguinal ring.
2. Becker, J. A.: Hernia of the urinary bladder. Radiology, 84: 270, 1965. 3. Soloway, H. M., Portney, F. and Kaplan, A.: Hernia of the bladder. J. Urol., 84: 539, 1960. 4. Reardon, J. V. and Lowman, R. M.: Massive herniation of the bladder: "the roentgen findings". J. Urol., 97: 1019, 1967. 5. Hinman, F.: Urology. Philadelphia: W. B. Saunders Co., 1935. 6. Redman, J. F., Williams, E. W., Meacham, K. R. and Scriber, L. J.: The treatment of massive scrotal herniation of the bladder. J. Urol., 110: 59, 1973.
