A sliding hernia has any organ inside its sac (usually the large intestine and, less frequently, the bladder, ovaries or tubes)²; inguinal bladder hernia is a rare condition, occurring more commonly in men between 50 and 70 years (70%)¹. Right-sided hernias are more common, with an incidence of 60%³. The main factors associated with the pathophysiology are bladder defects, weakness of the abdominal wall in the inguinal canal, obesity, raised intra-abdominal pressure and prostatic hypertrophy. Symptoms are unspecific and the diagnosis is usually made during surgery⁴.

Radiography is not routinely performed in the evaluation of inguinal hernias, and cystography is the gold standard, with the highest diagnostic value for assessing the bladder wall. Computed tomography (CT) could provide detailed information for surgical planning⁵.

We report the case of a 64-year-old male patient with a history of Parkinson’s disease, reducible left-sided inguinal hernia 5 years before, and a surgical history of right inguinal hernia repair 9 years before. The patient sought medical advice due to abdominal pain of moderate intensity, with increased volume in the left inguinoscrotal region evolving progressively over 3 days. Superficial palpation was not possible due to pain. The patient did not complain of urinary tract symptoms. The ultrasound showed an oval, fluid-filled lesion within the scrotum measuring 12 cm × 7 cm that continued upwards and joined the intra-abdominal portion of the bladder, and grade I/IV prostatic hypertrophy.

Once the diagnosis of left inguinal bladder hernia was made, open surgery was decided. Surgical exploration was performed via a left oblique anterior inguinal incision; the spermatic cord was identified attached to a large direct hernia sac due to failure of the transverse fascia, and dissected (Fig. 1). The hernia contents included the lateral wall of the bladder fully attached with signs of distress, and part of the omentum with signs of ischemia (Fig. 2). As the hernia was incarcerated, it was difficult to reduce, requiring an exploratory laparotomy. Thus, the hernia sac was reduced with excision of the devitalized omentum and part of the lateral bladder wall was repaired with two-layer absorbable suture 3.0. A urinary catheter was placed. Then, the procedure continued with anterior hernia repair with indirect and direct closure of the defect using nonabsorbable suture and placement of a polypropylene mesh (Lichtenstein technique). The patient was monitored for 48 hours and was discharged without complications. He attended follow-up visits and the urinary catheter was removed on postoperative day 17. After 3 months, he remained with favorable outcome, without bladder complications or hernia recurrence.

Figure 1 Hernia sac 

Figure 2 Bladder wall 

Bladder inguinal hernia is a multifactorial entity that occurs progressively with age and is associated with comorbidities. Because its clinical presentation is somewhat unspecific and occasionally absent, its diagnosis is not made until surgery in a large percentage of cases, with high risk of bladder injury. For this reason, it is very important to perform a detailed physical examination in case of clinical suspicion of this condition, particularly in men >50 years and with urinary tract symptoms. Interestingly, despite our patient presented a large inguinal bladder hernia, he had no symptoms during urination, and his level of prostatic hypertrophy was not high enough to cause this type of hernia.

In conclusion, ultrasound was sufficient to make the diagnosis, and we chose open surgery instead of laparoscopy due to the time of hernia progression, acute condition, and large size. In addition, due to the size of the hernia defect, we preferred to reinforce the wall with a polypropylene mesh. The postoperative course was uneventful and 3 months after surgery the patient evolved with favorable outcome.