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Unusual Videourodynamic Finding: Massive Scrotal Cystocele
Images in Clinical Urology Unusual Videourodynamic Finding: Massive Scrotal Cystocele Chandy Ellimoottil, Michael Ross, Spencer T. Hart, and John Milner Urinary bladder involvement within inguinal hernias occurs in up to 4% of patients. However, massive extension of the bladder into the scrotum, or scrotal cystocele, is very rare, with less than 30 reported cases. The presenting symptoms vary. Most patients will have some element of voiding dysfunction. However, some patients will present with renal failure, sepsis, or bladder necrosis, although others will remain asymptomatic.1-4 We report a patient who presented with irritative voiding symptoms and a large, right-sided hydrocele. On evaluation of his voiding symptoms, he was found to have a large scrotal cystocele. UROLOGY 80: e53– e54, 2012. Published by Elsevier Inc.
Figure 1. Videourodynamics revealed right-sided scrotal cystocele. Images show (A) scout and (B) filling phase.
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rinary bladder involvement within inguinal hernias occurs in ⱕ4% of patients.1 However, massive extension of the bladder into the scrotum, or scrotal cystocele, is very rare, with ⬍30 reported cases. The presenting symptoms vary. Most patients will have some element of voiding dysfunction. However, some patients will present with renal failure, sepsis, or bladder necrosis, although others will remain asymptomatic.1-4 We report a patient who presented with irritative voiding symptoms and a large, right-sided hydrocele. On evaluation of his voiding symptoms, he was found to have a large scrotal cystocele.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Loyola University Medical Center, Maywood, Illinois Reprint requests: Chandy Ellimoottil, M.D., Department of Urology, Loyola University Medical Center, 2160 South First Avenue, Fahey Center, Room 261, Maywood, IL 60153. E-mail: [email protected] Submitted: June 13, 2012, accepted (with revisions): August 6, 2012
Published by Elsevier Inc.
CASE REPORT A 67-year-old man with a history of renal transplantation presented with irritative voiding symptoms and an increasing creatinine of 3.4 mg/dL from a baseline of 2.1-2.9 mg/dL. A renal ultrasound scan showed marked hydroureteronephrosis of his transplanted kidney down to the level of the bladder. The patient was taking both tamsulosin and finasteride. He denied gross hematuria, stones, or urinary tract infections. The physical examination revealed an obese man with a benign 60-g prostate and findings consistent with a large, right-sided hydrocele. Other than the creatinine level, the laboratory findings were normal. His postvoid residual urine volume measured using ultrasonography was ⬎250 mL. The patient started self-catheterization, and a repeat renal ultrasound scan showed decreased hydroureteronephrosis. A scrotal ultrasound scan demonstrated normal bilateral testes and a fluid collection adjacent to, but discrete from, the right testis. Video urodynamic testing was performed. As the bladder filled, the patient’s scrotum enlarged, revealing 0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.08.010
e53
Figure 2. Coronal view of computed tomography cystogram confirming diagnosis of large, right-sided inguinal hernia containing urinary bladder, or scrotal cystocele.
a large scrotal cystocele (Fig. 1). This was confirmed by computed tomography cystography (Fig. 2). Scrotal cystocele is typically managed surgically using an inguinal approach for defect repair and cystocele reduction.1-4 This case demonstrates rare images of a massive scrotal cystocele and reiterates that scrotal cystocele should be considered in the differential diagnosis of scrotal swelling, especially in the context of voiding dysfunction. Acknowledgment. To Audre Stersic, R.N., and Andrea Heinz, R.N.
e54
References 1. Bisharet M, O’Donnell ME, Thompson T, et al. Complications of inguinoscrotal bladder hernias: a case series. Hernia. 2009;13:81-84. 2. Uchio EM, Calderon JS, Hwang JJ. Laparoscopic repair of inguinal cystocele using cystoscopic light test. Urology. 2012;79:725727. 3. Regensburg RG, Klinkhamer S, van Adrichem NP, et al. Micturation related swelling of the scrotum. Hernia. 2012;16:355357. 4. Panagiotakis GI, Spyridakis KG, Chatziioannou MN, et al. Repair of an inguinoscrotal hernia containing the urinary bladder: a case report. J Med Case Rep. 2012;26:90.
UROLOGY 80 (5), 2012
Figure 1. Videourodynamics revealed right-sided scrotal cystocele. Images show (A) scout and (B) filling phase.
U
rinary bladder involvement within inguinal hernias occurs in ⱕ4% of patients.1 However, massive extension of the bladder into the scrotum, or scrotal cystocele, is very rare, with ⬍30 reported cases. The presenting symptoms vary. Most patients will have some element of voiding dysfunction. However, some patients will present with renal failure, sepsis, or bladder necrosis, although others will remain asymptomatic.1-4 We report a patient who presented with irritative voiding symptoms and a large, right-sided hydrocele. On evaluation of his voiding symptoms, he was found to have a large scrotal cystocele.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Loyola University Medical Center, Maywood, Illinois Reprint requests: Chandy Ellimoottil, M.D., Department of Urology, Loyola University Medical Center, 2160 South First Avenue, Fahey Center, Room 261, Maywood, IL 60153. E-mail: [email protected] Submitted: June 13, 2012, accepted (with revisions): August 6, 2012
Published by Elsevier Inc.
CASE REPORT A 67-year-old man with a history of renal transplantation presented with irritative voiding symptoms and an increasing creatinine of 3.4 mg/dL from a baseline of 2.1-2.9 mg/dL. A renal ultrasound scan showed marked hydroureteronephrosis of his transplanted kidney down to the level of the bladder. The patient was taking both tamsulosin and finasteride. He denied gross hematuria, stones, or urinary tract infections. The physical examination revealed an obese man with a benign 60-g prostate and findings consistent with a large, right-sided hydrocele. Other than the creatinine level, the laboratory findings were normal. His postvoid residual urine volume measured using ultrasonography was ⬎250 mL. The patient started self-catheterization, and a repeat renal ultrasound scan showed decreased hydroureteronephrosis. A scrotal ultrasound scan demonstrated normal bilateral testes and a fluid collection adjacent to, but discrete from, the right testis. Video urodynamic testing was performed. As the bladder filled, the patient’s scrotum enlarged, revealing 0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.08.010
e53
Figure 2. Coronal view of computed tomography cystogram confirming diagnosis of large, right-sided inguinal hernia containing urinary bladder, or scrotal cystocele.
a large scrotal cystocele (Fig. 1). This was confirmed by computed tomography cystography (Fig. 2). Scrotal cystocele is typically managed surgically using an inguinal approach for defect repair and cystocele reduction.1-4 This case demonstrates rare images of a massive scrotal cystocele and reiterates that scrotal cystocele should be considered in the differential diagnosis of scrotal swelling, especially in the context of voiding dysfunction. Acknowledgment. To Audre Stersic, R.N., and Andrea Heinz, R.N.
e54
References 1. Bisharet M, O’Donnell ME, Thompson T, et al. Complications of inguinoscrotal bladder hernias: a case series. Hernia. 2009;13:81-84. 2. Uchio EM, Calderon JS, Hwang JJ. Laparoscopic repair of inguinal cystocele using cystoscopic light test. Urology. 2012;79:725727. 3. Regensburg RG, Klinkhamer S, van Adrichem NP, et al. Micturation related swelling of the scrotum. Hernia. 2012;16:355357. 4. Panagiotakis GI, Spyridakis KG, Chatziioannou MN, et al. Repair of an inguinoscrotal hernia containing the urinary bladder: a case report. J Med Case Rep. 2012;26:90.
UROLOGY 80 (5), 2012