Giant anterior urethral diverticulum with a calculus masquerading as left inguinal hernia: A missed diagnosis, a lesson to learn
A 3-year-old boy presented with a large left-sided hemi-scrotal swelling and a history of urine discharge from the suture line of left inguinal herniotomy []. The urinary leak was exacerbated during and immediately after micturition.\nOn detailed evaluation, it was elicited that the boy had a history of poor urinary stream since birth, which was neglected. Three months back, an intermittent swelling was observed in the left inguino-scrotal region. The fluctuation in size of the swelling was related to micturition and not to cough impulse. However, the condition was misdiagnosed as left inguinal hernia, and left-inguinal herniotomy was performed by another surgeon. Urine discharge from the surgical site was noted from the first post-operative day. He also had recurrence of scrotal swelling. The swelling was tense, non-tender, with limited mobility and involved the upper half of left hemi-scrotum and reached up to the midline, base of penis, extending cranio-laterally up to the pubic tubercle. On exerting pressure, the swelling disappeared with dribbling of urine from the external meatus and from the inguinal wound and reappeared at the next act of micturition. A hard oval structure resembling a calculus could be palpated within the swelling once deflated.\nSonography revealed dilatation of both the ureters in the lower half. Voiding cystourethrogram (VCUG) revealed the presence of a urethral diverticulum arising from the bulbar urethra with bilateral Grade IV vesicoureteric reflux []. The posterior urethra was also mildly dilated. Urinary bladder was normal. The typical description of an acute angle forming between the proximal part of dilated portion and the ventral floor was conspicuous by its presence.\nA midline incision was made from the mid-penile region to the middle of the scrotal raphe []. A thick-walled diverticulum with a contained stone was appreciated in close proximity to the penile urethra. The diverticulum was extending beyond the confines of the corpus spongiosum into the left inguinoscrotal region. The diverticulum was canulated with an infant feeding tube to facilitate dissection and skeletonised along with the cutaneous fistulous tract communicating with the herniotomy incision []. On opening the diverticulum, an elliptical mustard-colored calculus about 1 × 0.8 × 0.7 cm was identified []. The diverticulum was opening into the ventral surface of the bulbar urethra with a narrow mouth (0.7 × 0.6 cm). A lip of tissue was appreciated along the mouth of the diverticulum. The fistula was disconnected from the inguinal region and the wound was repaired. The diverticulum was divided at its neck and the bulbar urethra was repaired with 5-0 vicryl over a no. 8 silicone catheter. The postoperative recovery was uneventful. The urinary catheter was removed on 7thpostoperative day. Postoperative urinary stream was good.\nHistopathology of the diverticulum wall revealed all the layers of the urethra (true diverticulum) with mucosal ulcerations and chronic inflammatory cell infiltrates and congested blood vessels in the muscular layer. The sections from the portion of the diverticulum extending into the inguinal region revealed a fibrous wall lined by ulcerated squamous epithelium (pseudodiverticulum) with features of chronic inflammation.