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Inguinal hernia: Always a benign condition?
Low, SBL; Boctor, DSZM; Suliman, IGI
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74 ♂ ED c/o pleuritic chest pain and hip pain
CTPA = bilateral consolidations
Hip XR = residual contrast in the bladder which had herniated into his right scrotum
Mr JH
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2 yr hx of intermittent groin swelling, LUTS and compressing his scrotum for complete bladder emptying
CT = bladder hernia, sclerotic bony metastases and a caecal tumour
Treatment = right hemicolectomy + hormonal therapy
Mr JH
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Herniation: Protrusion of part of bladder through abdominal wall or pelvic floor
Important to diagnose as:◦ Increase risk of intra- and post-operative
complications (if diagnosis not made pre-operatively)
◦ Association with underlying malignancy
Introduction
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Prevalence 0.3 – 3%; 1 – 4% of inguinal hernia cases
50 – 70 years old ♂
Right-sided◦ Inguinal canal (70%); Femoral canal (27%); Obturator
foramen; Ischiorectal fossa; Abdo wall
Varying sizes but usually small ‘knuckle’ of herniated bladder
Epidemiology
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Abdominal/ pelvic wall weakness
Abnormal width of the inguinal canal
Abnormal bladder wall 2° bladder outlet obstruction
Peritoneal fibrosis/ adhesions
Obesity
Aetiology
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Paraperitoneal (most common)◦ Portion of parietal peritoneum herniates along
with bladder
Extraperitoneal◦ Peritoneum is intact and in place
Intraperitoneal◦ Herniated part is surrounded completely by
peritoneum
Classification I
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Indirect (via patent processus vaginalis)◦ Protrude lateral to inferior epigastric vessels
Direct (through Hesselbach triangle)◦ Protrude medial to inferior epigastric vessels
Classification II
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Most asymptomatic
LUTS◦ Dysuria, ↑ frequency, urgency, difficulty in
voiding, nocturia, hematuria
Severe◦ 2-stage micturition (Mery’s sign)
Clinical features
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Associated pathologies
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CT Best diagnostic clue◦Demonstration of protrusion through hernia
Cystography (IVU/IVP) is traditional◦ Voiding in an upright position
US◦ Other causes of groin swelling◦Presence of hydronephrosis
Diagnostic Imaging
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Take Home Messages
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Enquire about LUTS in patients with hernia
Take Home Message 1
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If POSITIVE LUTS:
Further imaging needed
Take Home Message 2
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If POSITIVE imaging,
?Investigate for malignancy?
Take Home Message 3
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Thank youAny questions?