Rare giant inguinal hernia causing end-stage dialysis-dependent renal failure

Background

Inguinal hernias are one of the most common surgical issues however only 1% to 3% of these hernias are of the bladder.1 A bladder hernia is often asymptomatic but may present with non-specific symptoms such as lower urinary tract symptoms or urinary tract infections.1 2 However, rare but severe complications of a bladder hernia include potentially life-threatening acute renal failure if not promptly treated.3 4

This report describes the case of a man that presented with haematuria, weight loss and urinary retention. His presentation was initially suspicious for an obstructing bladder cancer which impeded his true diagnosis. We think it is important that there is more awareness about this rare type of hernia as this will facilitate better management of patients with this condition, where early diagnosis and surgery may be able to prevent end-stage renal failure.

Case presentation

A 72-year-old man presented to Accident and Emergency at Newham University Hospital in 2019 with haematuria, nausea and vomiting, lethargy and weight loss. He had no cough, no chest pain, no fever, no dysuria, no night sweats and reported no pain. His past medical history involved only a right-sided inguinal hernia and he had no regular medications. He lived with his sister and reported no smoking or alcohol intake. On examination, he was thin, and his skin was pale and slightly yellow. He was afebrile and his observations were all normal, his chest was clear, heart sounds were normal and his abdomen was soft but tender in the epigastric area with reduced bowel sounds. He had a large painless reducible hernia in his right inguinal area.

Differential diagnosis

Initially the medical team caring for him were suspicious of an obstructive uropathy from a possible bladder tumour or malignancy due to his symptoms of weight loss, urinary retention and haematuria. This differential diagnosis was supported as initial investigations showed that he had a severe acute kidney injury and bilateral hydronephrosis with a thickened bladder wall. Only later did it become clear that his hernia was the cause of his urinary symptoms.

Investigations

He was found to be in a severe acute kidney injury (AKI) with a creatinine of 1305 μmol/L, urea of 46.8 mmol/L and estimated glomerular filtration rate of 3 mL/min/1.73 m². His haemoglobin was 71 g/L, sodium was 135 mmol/L and potassium 5.5 mmol/L and infection markers were all normal. Chest radiograph was normal, abdominal radiograph showed an atypical bowel gas pattern but no signs of perforation. He was admitted under the medical team and started on intravenous (IV) fluids for his AKI. An ultrasound scan of the kidneys, ureters and bladder showed ‘bilateral gross hydroureteronephrosis with poor corticomedullary differentiation, no obstructing calculi’ were noted and the bladder wall was reported as ‘grossly thickened with slightly increased vascularity’. It was assumed that he had chronic bladder outflow obstruction, thought likely to be due to a malignancy.

At this point, he was referred to the urology team, a three-way catheter was inserted and bladder washouts performed and he was booked for a CT scan. A non-contrast CT scan of the urinary tract was done which showed that both kidneys were atrophic with severe hydronephrosis and hydro-ureters (up to 32 mm diameter) with perinephric stranding (figures 1 and 2).

Furthermore, the CT showed that the inguinal hernia contained the bladder with the catheter in situ and a slightly enlarged prostate. It is likely that the ‘thickened bladder wall’ reported on ultrasound scan was actually the enlarged prostate due to the anatomical abnormality created by the large bladder hernia making the ultrasound images difficult to interoperate.

Overnight the hernia doubled in size, became erythematous, acutely tender and irreducible. He became more confused and was unable to present a reliable verbal history. At this point he stated to the surgeons that he’d had the hernia since he was 15 years old and it had not changed in size recently. However, a repeat non-contrast CT abdominal scan was performed which showed that the bladder had increased from 75 mm × 43 mm × 47 mm to a size of 135 mm × 110 mm × 130 mm and the catheter tip and balloon was no longer in the bladder and was now in the prostate preventing it from draining urine (see figure 3). The catheter balloon was deflated and pushed further into the bladder and re-inflated which allowed over 1 litre of urine to be drained and the hernia quickly shrunk and became reducible again. He was given more IV fluids and his AKI and uraemia started to resolve, as did his confusion and he explained that he had actually had the hernia for 15 years, not since he was 15 years old and that it had become acutely painful over the last couple of days. An urgent hernia repair was booked and the patient was taken to theatre that day.

Treatment

The patient was anaesthetised with a general anaesthetic and his right inguinal hernia was opened up (see figure 4). The small bowel hernia was found to be both direct and indirect (a pantaloon hernia) and the bladder was stuck to the bowel wall. A rigid cystoscopy was also performed at the time of the operation to help locate and reduce the bladder hernia and be sure there was no urine leak. A mesh repair was performed and the incision was closed.