Answer for BIR CoW 13 Oct 2024
Left Inguinal Hernia with Bladder and Benign Prostatic Hyperplasia (BPH)
Findings
Hernia: A defect measuring 3.5 cm in the left inguinal region, with herniation of the bladder as the content. This suggests a left direct inguinal hernia.
Prostate: Median lobe hypertrophy with intravesical protrusion noted.
Prostate Size: Diffuse enlargement of the transitional zone of the prostate with multiple circumscribed T2 isointense to hypointense nodules, with no diffusion restriction or low ADC, indicating BPH with PIRADS III nodules.
Discussion
Bladder Herniation
- Overview: Bladder herniation, though uncommon, can occur when the bladder or ureter herniates into the inguinal canal, scrotal sac, or femoral canal. It may also happen through other openings, such as the ischiorectal, obturator, or abdominal wall.
- Clinical Presentation: Most cases are asymptomatic and discovered incidentally during radiological evaluations of inguinal hernias. However, some patients may experience dysuria, frequency, urgency, nocturia, and hematuria. A reduction in hernia size after urination and the ability to pass urine by pressing on the hernia sac is characteristic.
- Etiology: Common causes include chronic bladder distension (such as from prostatism), loss of bladder tone, pericystitis, and perivesical fat protrusion.
Types of Bladder Hernia
1. Paraperitoneal Hernia: The extraperitoneal portion of the hernia lies along the medial wall of the sac (most common).
2. Intraperitoneal Hernia: The herniated bladder is completely covered by peritoneum.
3. Extraperitoneal Hernia: The bladder is not covered by peritoneum at all.
Radiographic Features
- Excretory Urography: A wide-mouthed protrusion of the bladder wall directed downward, with indirect signs like a small asymmetric bladder and lateral displacement of the lower ureter.
- Ultrasound: A fluid-filled sac in continuity with the bladder; can show a beaked appearance of the fluid-filled scrotal sac.
- CT and MRI: Useful for diagnosing bladder herniation, particularly in males ≥50 years with inguinal swelling and lower urinary tract symptoms. CT shows angulation of the bladder base towards the hernia, while MRI provides superior anatomical detail, particularly in relation to adjacent vascular landmarks.
Benign Prostatic Hyperplasia (BPH)
- Pathology: BPH is characterized by glandular and stromal hyperplasia, presenting as expansile nodules. T2-weighted MRI shows cystic ectasia and hyperplastic glandular components in hyperintense nodules, while fibromuscular components appear hypointense.
MRI Classification of BPH
- Type 0: Prostate volume ≤25 cm³ with minimal enlargement.
- Type 1: Bilateral transitional zone (TZ) enlargement (35%).
- Type 2: Retrourethral enlargement (10%).
- Type 3: Bilateral TZ and retrourethral enlargement (46%).
- Type 4: Solitary or multiple pedunculated enlargement.
- Type 5: Pedunculated with bilateral TZ and/or retrourethral enlargement.
- Type 6: Subtrigonal or ectopic enlargement.
- Type 7: Other combinations of enlargements.
References
1. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132:474–479.
2. Roehrborn CG, McConnell JD. Etiology, pathophysiology, epidemiology, and natural history of benign prostatic hyperplasia. Campbell’s Urology. 8th ed. WB Saunders Co; 2002.
Findings
Hernia: A defect measuring 3.5 cm in the left inguinal region, with herniation of the bladder as the content. This suggests a left direct inguinal hernia.
Prostate: Median lobe hypertrophy with intravesical protrusion noted.
Prostate Size: Diffuse enlargement of the transitional zone of the prostate with multiple circumscribed T2 isointense to hypointense nodules, with no diffusion restriction or low ADC, indicating BPH with PIRADS III nodules.
Discussion
Bladder Herniation
- Overview: Bladder herniation, though uncommon, can occur when the bladder or ureter herniates into the inguinal canal, scrotal sac, or femoral canal. It may also happen through other openings, such as the ischiorectal, obturator, or abdominal wall.
- Clinical Presentation: Most cases are asymptomatic and discovered incidentally during radiological evaluations of inguinal hernias. However, some patients may experience dysuria, frequency, urgency, nocturia, and hematuria. A reduction in hernia size after urination and the ability to pass urine by pressing on the hernia sac is characteristic.
- Etiology: Common causes include chronic bladder distension (such as from prostatism), loss of bladder tone, pericystitis, and perivesical fat protrusion.
Types of Bladder Hernia
1. Paraperitoneal Hernia: The extraperitoneal portion of the hernia lies along the medial wall of the sac (most common).
2. Intraperitoneal Hernia: The herniated bladder is completely covered by peritoneum.
3. Extraperitoneal Hernia: The bladder is not covered by peritoneum at all.
Radiographic Features
- Excretory Urography: A wide-mouthed protrusion of the bladder wall directed downward, with indirect signs like a small asymmetric bladder and lateral displacement of the lower ureter.
- Ultrasound: A fluid-filled sac in continuity with the bladder; can show a beaked appearance of the fluid-filled scrotal sac.
- CT and MRI: Useful for diagnosing bladder herniation, particularly in males ≥50 years with inguinal swelling and lower urinary tract symptoms. CT shows angulation of the bladder base towards the hernia, while MRI provides superior anatomical detail, particularly in relation to adjacent vascular landmarks.
Benign Prostatic Hyperplasia (BPH)
- Pathology: BPH is characterized by glandular and stromal hyperplasia, presenting as expansile nodules. T2-weighted MRI shows cystic ectasia and hyperplastic glandular components in hyperintense nodules, while fibromuscular components appear hypointense.
MRI Classification of BPH
- Type 0: Prostate volume ≤25 cm³ with minimal enlargement.
- Type 1: Bilateral transitional zone (TZ) enlargement (35%).
- Type 2: Retrourethral enlargement (10%).
- Type 3: Bilateral TZ and retrourethral enlargement (46%).
- Type 4: Solitary or multiple pedunculated enlargement.
- Type 5: Pedunculated with bilateral TZ and/or retrourethral enlargement.
- Type 6: Subtrigonal or ectopic enlargement.
- Type 7: Other combinations of enlargements.
References
1. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132:474–479.
2. Roehrborn CG, McConnell JD. Etiology, pathophysiology, epidemiology, and natural history of benign prostatic hyperplasia. Campbell’s Urology. 8th ed. WB Saunders Co; 2002.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!