Beware: the inguinoscrotal hernia with urological origins
Our patient was a 64-year-old gentleman who complained of nocturia, diurnal frequency, poor flow and terminal dribbling. This was associated with and intermittent left scrotal swelling. He had a medical history of late-onset asthma, erectile dysfunction and hypertension.\nWhen seen at clinic, he was found to have a left scrotal swelling that extended into the inguinal region associated with a cough impulse. It was felt that this was either a hydrocele or a sliding hernia and an USS was arranged. His uroflometry showed that he had an obstructed flow, but he emptied his bladder on post-residual scanning. In addition to the USS, he was commenced on an alpha-blocker for bladder outflow obstruction and a flexible cystoscopy was arranged.\nHis USS diagnosed an inguinal hernia containing omental fat. At this point a referral to a general surgeon was made. His cystoscopy showed a normal urethra with a small, short prostate and a high bladder neck. The bladder itself was unusual. Upon filling a large left-sided bladder, diverticulum was seen.\nBased on this cystoscopic finding, a micturating cytogram was arranged to evaluate this diverticulum as seen in the figures provided (Figures and ). This showed an unusual huge bladder diverticulum that had herniated through his inguinal canal, filling his left hemiscrotum.\nThis was obviously contributing to his urinary symptoms by having a reservoir that could not be emptied on micturition. It was felt that this could deteriorate, and surgical excision was agreed with the patient.\nOur aim was to perform a diverticulectomy with repair of the hernia defect. For this we used a retropubic lower midline incision. Dissection was made down onto the bladder until the diverticulum was identified. Dissection was attempted to remove the diverticulum off the outer bladder surface and spermatic cord as it entered the deep inguinal ring. Unfortunately, the diverticulum was adherent to adjacent structures and this was not possible.\nTo confidently identify the neck of the diverticulum, the bladder was therefore opened and held with stay sutures. This allowed dissection of the adhesions between the outer surface of the bladder and the diverticulum. However, it was not possible to identify the spermatic cord at this stage; therefore, the neck of the diverticulum was transected in order that a point of traction was created.\nThis facilitated dissection with a combination of blunt and sharp technique. The spermatic cord was identified and safely separated from the hernial sac including the diverticulum. The plane was followed into the scrotum where the entire diverticulum was removed from the hemiscrotum. There were no adhesions within the scrotum of the diverticulum to surrounding layers, which made a secondary scrotal incision unnecessary. Haemostasis was ensured in these areas and the bladder was closed with two layers of continuous vicryl.\nTwo weeks following the procedure he underwent a trial of voiding, which he passed successfully. He was discharged home and returned 6 months later with for a follow-up ultrasound of his renal tract, which revealed no further pathology.