AJR 2004; 183:1091-1092
© American Roentgen Ray Society
Massive Inguinoscrotal Vesical Hernia Complicated by Bladder Rupture: Preoperative Sonographic and CT Diagnosis
Laura Maria Minordi1,
Paoletta Mirk,
Adolfo Canadé and
Giuseppina Sallustio
1 All authors: Department of Radiology, Catholic University of the Sacred Heart,
Largo A. Gemelli, 8, Rome 00168, Italy.
Received June 24, 2003;
accepted after revision January 14, 2004.
Address correspondence to L. M. Minordi.
We report on a case of massive inguinoscrotal vesical hernia complicated by
perforation in which the preoperative diagnosis was correctly established by
means of sonography and CT.
A 51-year-old man was admitted from the emergency department because of
septic fever, abdominal pain, strangury, and macroscopic hematuria. At
physical examination, a massive left-sided inguinoscrotal hernia was observed.
Sonography documented a normal left testis and the epididymis distally
displaced by an elongated fluid mass, extending from the inguinal canal
downward, with thickened scrotal bursae and intrascrotal fluid effusion.
Because the cranial margins of the mass could not be identified, the presence
of an inguinoscrotal vesical herniation was hypothesized
(Fig. 1A). Examination of the
lower abdomen showed vesical wall interruption along the left anterior margin
by peripheral fluid (urine) effusion (Fig.
1B).
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Fig. 1A. —51-year-old man who presented with septic fever, abdominal
pain, strangury, and macroscopic hematuria. Sonograms show large fluid mass
(between calipers, A) that extends from inguinal canal into
scrotum, resulting from urine effusion peripheral to herniated bladder
(A) and vesical wall interruption (approximately 1 cm) along left
anterior margin with peripheral fluid in paravesical spaces (B).
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Fig. 1B. —51-year-old man who presented with septic fever, abdominal
pain, strangury, and macroscopic hematuria. Sonograms show large fluid mass
(between calipers, A) that extends from inguinal canal into
scrotum, resulting from urine effusion peripheral to herniated bladder
(A) and vesical wall interruption (approximately 1 cm) along left
anterior margin with peripheral fluid in paravesical spaces (B).
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The sonographic findings led to the decision to perform abdominal CT
without IV contrast administration (because of the patient's high blood
creatinine concentration). CT repeated after retrograde vesical filling with
iodinated contrast medium (CT cystography) showed that the bladder was grossly
altered in shape, with its left wall pronating longitudinally from the bladder
base and herniating as an ill-defined hypodense mass into the left scrotum
(Fig. 1C). Intra- and
retro-peritoneal effusion was also seen. After retrograde opacification, a
defect of the anterior bladder wall was confirmed, with contrast material
extravasation into the perivesical spaces and thickening of perivesical fat
tissues (Fig. 1D). Surgery
confirmed that the bladder herniated into the scrotum, with a partial necrosis
of the bladder wall and intrascrotal urine collection.
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Fig. 1C. —51-year-old man who presented with septic fever, abdominal
pain, strangury, and macroscopic hematuria. CT scans obtained after bladder
opacification show left bladder wall is interrupted along its anterior margin
(C) and is herniated inferiorly into scrotum, with contrast agent
extravasation (D).
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Fig. 1D. —51-year-old man who presented with septic fever, abdominal
pain, strangury, and macroscopic hematuria. CT scans obtained after bladder
opacification show left bladder wall is interrupted along its anterior margin
(C) and is herniated inferiorly into scrotum, with contrast agent
extravasation (D).
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Inguinal vesical hernias are typically found in older men. They are rarely
identified preoperatively but are frequently found at herniorrhaphy, with a
consequent greater risk of perforation. To lower this risk, Hinman et al.
[1] suggested performing
cystography in all cases of inguinal hernias, especially cases involving large
hernias, in men over the age of 50 years. Depending on how the patients are
positioned during the radiographic examination, the accuracy of cystography
varies from 30% (supine) to 50% (prone decubitus) to 100% (standing).
Occasionally, the diagnosis can be established during excretory urography
performed for other reasons.
In the literature, only a few cases of preoperative sonographic
[2] or CT
[3,
4] diagnosis of vesical hernia
have been described in patients with massive inguinoscrotal involvement.
Reported CT findings range from simple anterior and inferior angulation of the
bladder base below the pubic bone to massive inguinoscrotal involvement
[3,
4].
We know of no case to date in which the preoperative diagnosis of
perforated vesical hernia documented on sonography and CT has been described.
In the case reported, the combination of these procedures allowed us to
establish the correct diagnosis. Sonography documented herniation and bladder
rupture, whereas CT cystography confirmed these findings and revealed urine
effusion into the scrotum, peritoneal cavity, and retro-peritoneal space. Both
sonography and CT provided information about the surrounding structures that
is not supplied by conventional cystography. In addition, because IV
administration of iodinated contrast medium is not required, these procedures
are particularly useful in patients with renal failure who cannot undergo
contrast-enhanced CT.
References
- Hinman F. Principles and practice of
urology. Philadelphia, PA: Saunders, 1935:923
- Shelef I, Farber B, Hertzanu Y. Massive bladder hernia:
ultrasonographic imaging in two cases. Br J Urol1998; 81:492
-493[Medline]
- Catalano O. Computed tomography findings in scrotal cystocele.
Eur J Radiol1995; 21:126
-127[Medline]
- Vindlacheruvu RR, Zayvan K, Burgess NA, Wharton SB, Dunn DC.
Extensive bladder infarction in a strangulated inguinal hernia. Br
J Urol 1996;77:926
-927[Medline]
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