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Scrotal cystocele in a 2-year-old Nigerian child
Journal of Pediatric Surgery (2009) 44, E19–E20
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Scrotal cystocele in a 2-year-old Nigerian child Iheanyi Okoro ⁎, Angelica Anele Department of Surgery, Imo State University Teaching Hospital, PMB 2000, Orlu, 460001 Imo State, Nigeria Received 18 March 2009; revised 5 June 2009; accepted 5 June 2009
Key words: Bladder; Scrotal cystocele; Inguinal hernia
Abstract Total herniation of the urinary bladder into the scrotum, also known as scrotal cystocele, is a rare condition. It has mostly been described in elderly patients, who often have obstructive symptoms. We report a case of scrotal cystocele in a 2-year-old Nigerian child with no evidence of obstructive uropathy. The diagnosis was made at operation. The bladder was reduced into the abdominal cavity followed by a herniorrhaphy. The child has remained symptom-free 8 months after the procedure. © 2009 Elsevier Inc. All rights reserved.
The involvement of the urinary bladder in inguinal hernias is not infrequent and has been reported to occur in approximately 4% of cases [1,2]. However, in men older than 50 years, it may be as high as 10% [3]. Most cases involve only a small part of the bladder or diverticula of the bladder. Involvement of the entire urinary bladder in a sliding inguinoscrotal hernia, which is known as scrotal cystocele, is a rare clinical condition [4]. Most cases have been reported in elderly people and are usually associated with obstructive symptoms [5]. To the best of our knowledge, none has thus far been reported in children. We describe a case of scrotal cystocele in a 2-year-old Nigerian child.
1. Case report A 2-year-old male child was brought by his parents to the surgical outpatient department at the General Hospital, Owerri, Nigeria, with a 6-month history of ⁎ Corresponding author. College of Medicine, Imo State University, P.M.B. 2000, Owerri. Tel.: +2348033274149. E-mail address: [email protected] (I. Okoro). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.016
right inguinoscrotal swelling that was gradually increasing in size. It was initially reducible but for the last 3 months had remained permanently irreducible. He had no urinary symptoms. On examination, the child was apparently in good health. The only positive finding was on abdominal examination where a partially reducible right inguinoscrotal hernia was found. A clinical diagnosis of congenital right inguinoscrotal hernia was made. His hemoglobin level was 10.5 g/dL. The urinalysis was normal, and he was HIV-negative. He was taken to the operating theater for hernia repair. At the time of the operation, the sac was found to be thick, extending from the deep inguinal ring to the scrotum. Further evaluation of the sac revealed that the hernia was of the sliding type with the urinary bladder forming part of the sac (Fig. 1). This was confirmed by passing a size 6F feeding tube through the urethra into the bladder. This yielded clear urine. The excess part of the sac was excised, and the portion adherent to the bladder was closed with a purse-string Vicryl suture. The urinary bladder and the closed sac were then reduced into the peritoneal cavity. The widened deep inguinal ring was closed snugly around the spermatic cord with interrupted 4/0 Prolene sutures. The external oblique aponeurosis was closed with 2/0 Vicryl suture. He made an
E20
Fig. 1 Hernial sac content. Shows the urinary bladder (arrow) and the rest of the sac containing a loop of bowel (L).
uneventful recovery and was discharged on the fourth postoperative day. He has done well at 8 months follow-up without evidence of hernia recurrence.
2. Discussion Congenital inguinal hernias are among the most common surgical cases in pediatric practice [6,7]. They are usually of the indirect type resulting from persistence of the patent processus vaginalis. The ovary and fallopian tube have been commonly reported as unusual contents of sliding inguinal hernias in female children [8]. Part of the bladder as a content of a pediatric hernia has been rarely reported [9]. However, massive herniation of the urinary bladder into the scrotum has not been reported in a child to the best of our knowledge. The index patient may well be the first reported case. Several factors have been implicated in the pathophysiology of bladder herniation. They include obesity, urinary outlet obstruction (which in babies may include posterior urethral valves), loss of bladder tone, and weakness of supporting tissues surrounding the bladder [1]. None of these findings were present in our patient. He was observed to have a good urinary stream in the postoperative period, which clinically rules out posterior urethral valve.
I. Okoro, A. Anele In the adult, scrotal cystocele may be associated with 2staged micturition [10]. If the patient presents that way, a preoperative diagnosis may be arrived at by investigating the patients with ultrasonography, computed tomographic scan, and retrograde cystography [1,3]. However, in most patients, the diagnosis is made intraoperatively with attendant injury to the bladder occurring in some patients. Children are often not able to give a good history of their symptoms. Therefore, a high index of suspicion is needed to arrive at a preoperative diagnosis. A child presenting with an irreducible inguinoscrotal hernia should be investigated as mentioned above. The surgical management of the herniated bladder has been variously described by some workers. Although some advocate resection of the herniated bladder [11], others believe that simple reduction and herniorrhaphy are adequate [12]. However, if there is infarction of the bladder wall, the affected part should be resected, and if there is associated urinary outlet obstruction, it should also be corrected. Our patient did well after simple reduction and herniorrhaphy. We have observed him for 8 months after the procedure, and there is no hernia recurrence, and he is without urinary symptoms. We are of the opinion that more cases will need to be treated before a definitive statement can be made on the optimal surgical management of this rare condition.
References [1] Dario Casas J, Mariscal A, Barluenga E. Scrotal cystocele: US and CT findings in 2 cases. Comput Med Imaging Graph 1998;22:53-6. [2] Gomella LG, Spires SM, Burton JM, et al. The surgical implication of herniations of the urinary bladder. Arch Surg 1985;120:964-7. [3] Postma MP, Smith R. Scrotal cystocele with bladder calculi. case reportAJR 1986;147:287-8. [4] Carrieri P, Nardi S, Basili GC, et al. The involvement of the urinary tract in inguinal hernias. Ann Ital Chir 1998;69:795-7. [5] Prisco R, Apolinario J, Fraga A, et al. Vesico-scrotal hernia. Report of a clinical case. Acta Urol Esp 1997;21(5):514-8. [6] Aiken JJ, Oldham KT. Inguinal hernias. Kliegman. Nelson textbook of paediatrics. 18th ed. Saunders; 2007. p. 683-7. Chapter 343. [7] Abatanga FA, Amaning EP. Paediatric elective surgical conditions as seen at a referral hospital in Kumasi, Ghana. ANZ J Surgery 2002;72: 890-2. [8] Gurer A, Ozdogan M, Ozlem N, et al. Uncommon content in groin hernia sac. Hernia 2006;10:152-5. [9] Fowler CL. Sliding indirect hernia containing both ovaries. J Pediatr Surg 2005;40:13-4. [10] Croushore JH, Black RB. Scrotal cystocele. J Urol 1979;121:541-2. [11] Ojea Calvo A, Rodriguez Alonso A, Perez Garcia D, et al. A massive hernia of the bladder into the scrotum. A report of a case. Acta Urol Esp 1999;23:79-82. [12] Thompson Jr JE, Taylor JB, Nazarian N, et al. Massive inguinal scrotal bladder hernias: a review of the literature with 2 new cases. J Urol 1986;136:1299-301.
www.elsevier.com/locate/jpedsurg
Scrotal cystocele in a 2-year-old Nigerian child Iheanyi Okoro ⁎, Angelica Anele Department of Surgery, Imo State University Teaching Hospital, PMB 2000, Orlu, 460001 Imo State, Nigeria Received 18 March 2009; revised 5 June 2009; accepted 5 June 2009
Key words: Bladder; Scrotal cystocele; Inguinal hernia
Abstract Total herniation of the urinary bladder into the scrotum, also known as scrotal cystocele, is a rare condition. It has mostly been described in elderly patients, who often have obstructive symptoms. We report a case of scrotal cystocele in a 2-year-old Nigerian child with no evidence of obstructive uropathy. The diagnosis was made at operation. The bladder was reduced into the abdominal cavity followed by a herniorrhaphy. The child has remained symptom-free 8 months after the procedure. © 2009 Elsevier Inc. All rights reserved.
The involvement of the urinary bladder in inguinal hernias is not infrequent and has been reported to occur in approximately 4% of cases [1,2]. However, in men older than 50 years, it may be as high as 10% [3]. Most cases involve only a small part of the bladder or diverticula of the bladder. Involvement of the entire urinary bladder in a sliding inguinoscrotal hernia, which is known as scrotal cystocele, is a rare clinical condition [4]. Most cases have been reported in elderly people and are usually associated with obstructive symptoms [5]. To the best of our knowledge, none has thus far been reported in children. We describe a case of scrotal cystocele in a 2-year-old Nigerian child.
1. Case report A 2-year-old male child was brought by his parents to the surgical outpatient department at the General Hospital, Owerri, Nigeria, with a 6-month history of ⁎ Corresponding author. College of Medicine, Imo State University, P.M.B. 2000, Owerri. Tel.: +2348033274149. E-mail address: [email protected] (I. Okoro). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.016
right inguinoscrotal swelling that was gradually increasing in size. It was initially reducible but for the last 3 months had remained permanently irreducible. He had no urinary symptoms. On examination, the child was apparently in good health. The only positive finding was on abdominal examination where a partially reducible right inguinoscrotal hernia was found. A clinical diagnosis of congenital right inguinoscrotal hernia was made. His hemoglobin level was 10.5 g/dL. The urinalysis was normal, and he was HIV-negative. He was taken to the operating theater for hernia repair. At the time of the operation, the sac was found to be thick, extending from the deep inguinal ring to the scrotum. Further evaluation of the sac revealed that the hernia was of the sliding type with the urinary bladder forming part of the sac (Fig. 1). This was confirmed by passing a size 6F feeding tube through the urethra into the bladder. This yielded clear urine. The excess part of the sac was excised, and the portion adherent to the bladder was closed with a purse-string Vicryl suture. The urinary bladder and the closed sac were then reduced into the peritoneal cavity. The widened deep inguinal ring was closed snugly around the spermatic cord with interrupted 4/0 Prolene sutures. The external oblique aponeurosis was closed with 2/0 Vicryl suture. He made an
E20
Fig. 1 Hernial sac content. Shows the urinary bladder (arrow) and the rest of the sac containing a loop of bowel (L).
uneventful recovery and was discharged on the fourth postoperative day. He has done well at 8 months follow-up without evidence of hernia recurrence.
2. Discussion Congenital inguinal hernias are among the most common surgical cases in pediatric practice [6,7]. They are usually of the indirect type resulting from persistence of the patent processus vaginalis. The ovary and fallopian tube have been commonly reported as unusual contents of sliding inguinal hernias in female children [8]. Part of the bladder as a content of a pediatric hernia has been rarely reported [9]. However, massive herniation of the urinary bladder into the scrotum has not been reported in a child to the best of our knowledge. The index patient may well be the first reported case. Several factors have been implicated in the pathophysiology of bladder herniation. They include obesity, urinary outlet obstruction (which in babies may include posterior urethral valves), loss of bladder tone, and weakness of supporting tissues surrounding the bladder [1]. None of these findings were present in our patient. He was observed to have a good urinary stream in the postoperative period, which clinically rules out posterior urethral valve.
I. Okoro, A. Anele In the adult, scrotal cystocele may be associated with 2staged micturition [10]. If the patient presents that way, a preoperative diagnosis may be arrived at by investigating the patients with ultrasonography, computed tomographic scan, and retrograde cystography [1,3]. However, in most patients, the diagnosis is made intraoperatively with attendant injury to the bladder occurring in some patients. Children are often not able to give a good history of their symptoms. Therefore, a high index of suspicion is needed to arrive at a preoperative diagnosis. A child presenting with an irreducible inguinoscrotal hernia should be investigated as mentioned above. The surgical management of the herniated bladder has been variously described by some workers. Although some advocate resection of the herniated bladder [11], others believe that simple reduction and herniorrhaphy are adequate [12]. However, if there is infarction of the bladder wall, the affected part should be resected, and if there is associated urinary outlet obstruction, it should also be corrected. Our patient did well after simple reduction and herniorrhaphy. We have observed him for 8 months after the procedure, and there is no hernia recurrence, and he is without urinary symptoms. We are of the opinion that more cases will need to be treated before a definitive statement can be made on the optimal surgical management of this rare condition.
References [1] Dario Casas J, Mariscal A, Barluenga E. Scrotal cystocele: US and CT findings in 2 cases. Comput Med Imaging Graph 1998;22:53-6. [2] Gomella LG, Spires SM, Burton JM, et al. The surgical implication of herniations of the urinary bladder. Arch Surg 1985;120:964-7. [3] Postma MP, Smith R. Scrotal cystocele with bladder calculi. case reportAJR 1986;147:287-8. [4] Carrieri P, Nardi S, Basili GC, et al. The involvement of the urinary tract in inguinal hernias. Ann Ital Chir 1998;69:795-7. [5] Prisco R, Apolinario J, Fraga A, et al. Vesico-scrotal hernia. Report of a clinical case. Acta Urol Esp 1997;21(5):514-8. [6] Aiken JJ, Oldham KT. Inguinal hernias. Kliegman. Nelson textbook of paediatrics. 18th ed. Saunders; 2007. p. 683-7. Chapter 343. [7] Abatanga FA, Amaning EP. Paediatric elective surgical conditions as seen at a referral hospital in Kumasi, Ghana. ANZ J Surgery 2002;72: 890-2. [8] Gurer A, Ozdogan M, Ozlem N, et al. Uncommon content in groin hernia sac. Hernia 2006;10:152-5. [9] Fowler CL. Sliding indirect hernia containing both ovaries. J Pediatr Surg 2005;40:13-4. [10] Croushore JH, Black RB. Scrotal cystocele. J Urol 1979;121:541-2. [11] Ojea Calvo A, Rodriguez Alonso A, Perez Garcia D, et al. A massive hernia of the bladder into the scrotum. A report of a case. Acta Urol Esp 1999;23:79-82. [12] Thompson Jr JE, Taylor JB, Nazarian N, et al. Massive inguinal scrotal bladder hernias: a review of the literature with 2 new cases. J Urol 1986;136:1299-301.