Presentation
Large left sided scrotal swelling, urinary retention and hematuria.
Patient Data
A large cystic structure is noted expanding the left hemi-scrotum with tapering upper pole at the scrotal neck.
Bilateral mild hydronephrosis with reflux nephropathy.
Gallbladder stone.
A large segment of the urinary bladder is herniated within the left scrotum through the left inguinal canal and part of omental fat. The urinary bladder shows diffuse mural thickening. This is associated with subtle surrounding fat stranding. Few small diverticula are noted at the left lateral wall of the urinary bladder.
The prostate is enlarged with concretions.
Bilateral mild scrotal hydrocele is noted, more on the right.
Few bilateral renal cortical simple cysts are noted, largest is seen at the left upper pole (3 cm).
Both kidneys show grade II hydronephrosis with mildly dilated ureters. No evidence of dense obstructing stone along the urinary tract (secondary vesicoureteric reflux is suggested).
Scans through the rest of the abdomen show tiny gallbladder stone, upper splenic pole cyst.
Right side perianal fistula is noted.
The organs appeared in opposite position as the patient is in prone position with applying the same technique of scanning.
Case Discussion
Scrotal cystocele is a type of urinary bladder hernia, where the bladder herniates into the scrotum. Chronic bladder distension (e.g. prostatism) may be a predisposing factor in such a case as there is associated prostatic enlargement. It is important to differentiate this condition in males older than 50 years from inguinal hernia of bowel to avoid bladder injury during herniorrhaphy.
Herniation of bladder is seen in 1-3% of inguinal hernias. Delayed CT urography or retrograde CT cystography is the best modality for confirmation and prone position can enhance its visualization. Ultrasonography may identify the communication of the scrotal sac with the urinary bladder which gives a beaked appearance.
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