The incidence of urinary bladder herniation is rare, but several risk factors can be associated with this diagnosis including male gender, obesity, age over 50 years old and bladder outlet obstruction as seen in benign prostatic hyperplasia (5).
The majority of diagnoses are made intraoperatively, with only 7% detected preoperatively (6). However, this trend has been shifting due to the increased frequency of preoperative imaging. Most preoperative diagnoses occur in patients presenting with lower urinary tract symptoms (LUTS), particularly voiding symptoms such as pollakiuria. Additionally, many patients exhibit Mery’s sign, characterized by the sensation and visible reduction of an inguinal mass after urination. When these symptoms are present, thorough investigation is essential, with cystography being considered the gold standard diagnostic tool (7). However, CT scans are also commonly used due to their availability and also have high sensitivity (7). Ultrasound and magnetic resonance imaging (MRI) may also be employed, particularly in patients with compromised renal function. In the present case, the patient exhibited acute obstructive abdominal symptoms, prompting urgent surgical intervention without prior imaging.
Potential complications include incomplete bladder emptying, recurrent urinary tract infections, ureterolithiasis, vesicoureteral reflux, rupture, strangulation, or necrosis; such risks make the surgical treatment of bladder inguinal hernias a preferable option (8).
Castro-Rosas et al. (9) demonstrated that bladder reduction through the hernial defect, followed by Lichtenstein hernioplasty yields excellent outcomes when there is no inadvertent cystotomy and the bladder shows no signs of compromise. Additionally, there are reports of bladder herniation repairs performed via trans-abdominal pre-peritoneal (TAPP), following the same principle of bladder reduction, with favorable outcomes. In cases of unintended bladder injury, cystorrhaphy is recommended if the outer layers remain intact. Bladder resection is reserved for instances of necrosis, complex perforations, herniation involving bladder diverticulum, and can be considered in cases where the bladder neck is significantly narrowed (less than 0.5 cm in its largest diameter) (10). In the case presented, the serosal and muscular layers were viable, leading to the decision to perform cystorrhaphy and Lichtenstein hernioplasty, however, as patient persisted with symptoms and bladder necrosis was found in cystoscopy, a partial resection of the bladder was ultimately performed. Although the outcome was favorable in this scenery, it is important to highlight that a reduced bladder capacity can lead to an impact on patient’s life quality and should be assessed during follow-up visits.
Postoperative follow-up for bladder herniation is highly variable in the literature. Some professionals advocate for cystoscopy to assess bladder healing and rule out further complications, while others rely solely on physical examination and symptom monitoring; the latter method was chosen in this case.
There is no consensus regarding the optimal duration of postoperative follow-up, highlighting the need for further studies to establish guidelines for the long-term management of these cases. Despite these variations in approach, no cases of mortality related to bladder herniation have been reported in the literature.
DISCUSSION
The incidence of urinary bladder herniation is rare, but several risk factors can be associated with this diagnosis including male gender, obesity, age over 50 years old and bladder outlet obstruction as seen in benign prostatic hyperplasia (5).
The majority of diagnoses are made intraoperatively, with only 7% detected preoperatively (6). However, this trend has been shifting due to the increased frequency of preoperative imaging. Most preoperative diagnoses occur in patients presenting with lower urinary tract symptoms (LUTS), particularly voiding symptoms such as pollakiuria. Additionally, many patients exhibit Mery’s sign, characterized by the sensation and visible reduction of an inguinal mass after urination. When these symptoms are present, thorough investigation is essential, with cystography being considered the gold standard diagnostic tool (7). However, CT scans are also commonly used due to their availability and also have high sensitivity (7). Ultrasound and magnetic resonance imaging (MRI) may also be employed, particularly in patients with compromised renal function. In the present case, the patient exhibited acute obstructive abdominal symptoms, prompting urgent surgical intervention without prior imaging.
Potential complications include incomplete bladder emptying, recurrent urinary tract infections, ureterolithiasis, vesicoureteral reflux, rupture, strangulation, or necrosis; such risks make the surgical treatment of bladder inguinal hernias a preferable option (8).
Castro-Rosas et al. (9) demonstrated that bladder reduction through the hernial defect, followed by Lichtenstein hernioplasty yields excellent outcomes when there is no inadvertent cystotomy and the bladder shows no signs of compromise. Additionally, there are reports of bladder herniation repairs performed via trans-abdominal pre-peritoneal (TAPP), following the same principle of bladder reduction, with favorable outcomes. In cases of unintended bladder injury, cystorrhaphy is recommended if the outer layers remain intact. Bladder resection is reserved for instances of necrosis, complex perforations, herniation involving bladder diverticulum, and can be considered in cases where the bladder neck is significantly narrowed (less than 0.5 cm in its largest diameter) (10). In the case presented, the serosal and muscular layers were viable, leading to the decision to perform cystorrhaphy and Lichtenstein hernioplasty, however, as patient persisted with symptoms and bladder necrosis was found in cystoscopy, a partial resection of the bladder was ultimately performed. Although the outcome was favorable in this scenery, it is important to highlight that a reduced bladder capacity can lead to an impact on patient’s life quality and should be assessed during follow-up visits.
Postoperative follow-up for bladder herniation is highly variable in the literature. Some professionals advocate for cystoscopy to assess bladder healing and rule out further complications, while others rely solely on physical examination and symptom monitoring; the latter method was chosen in this case.
There is no consensus regarding the optimal duration of postoperative follow-up, highlighting the need for further studies to establish guidelines for the long-term management of these cases. Despite these variations in approach, no cases of mortality related to bladder herniation have been reported in the literature.