Acute Renal Failure Secondary to Giant Inguino-Scrotal Hernia with Bladder Herniation

Abstract

1.1.Background: Inguinal hernia is one of the more frequent pathology to be treated by general surgeons. The presentation of urinary bladder herniation is less common, with a reported incidence near 0.36%-1% of cases. Most cases course asymptomatic, but urinary symptoms could be presented and in a few cases acute renal failure have been reported. 1.2.Case:We present the case of a 52-year-old man with a giant left inguino-scrotal incarcerated hernia. He has pathological background including multiple urinary tract infections and 2-years of evolution with a left inguinal hernia. He refers dysuria, urinary frequency, pushing, urgency and voiding in two times, needing partial reduction of inguinal hernia to complete (Mery sign). Previous 12 hours presented acute urine retention, with increasing left inguino-scrotal volume, in duration and severe pain, reason why he looked for hospital attention. At physical exam with analgesic position, glasgow 15, arterial tension 240/140 mmHg, 96 beats per minute, 26 breaths per minute, abdomen without compromise, left inguinal region with inguino-scrotal no-reductible hernia, painful at maneuvers and edematized, without vascular compromise signs. Both legs with edema ++/+++, tendon reflexesand distal perfusion. Acute urine retention was solved by a 18 French foley without complications. Blood chemistry evidence acute kidney injury reporting Creatinine 1.5 mg/dL, Urea 75 mg/dL, and BUN 35 mg/dL. Hematological parameters reports systemic inflammatory response with white blood cells 16200/mm3 without neutrophilia and other parameters within normal values as hemoglobine 13.8 g/dL, hematocrit 43% and platelets 448000. Urine general exam with infection data including leucocites >10μL, Nitrites+, Proteins 4g. Prostate Specific Antigen <2.5 ng/mL.Renal, bladder, inguinal and testicular ultrasounds were practiced and reported: Bleeder displacement by left inguinal canal and scrotum. Both kidneys, ureters and testis with normal characteristics. For the high suspect of urinary bladder herniation as the acute renal failure origin a retrograde cystogram was scheduled, finding in filling platecontrast material in urine bladder with 90% displacement to the scrotum by left inguinal canal. In post voiding projection residual urine is observed in left scrotum. During hospitalization the emergency hypertensive crisis was solved during first 24 hours and Lichtenstein hernioplasty was scheduled. A giant paraperitoneal scrotum cystocele was found, without ischemic signs. After three days renal function was normal with creatinine reduction to 0.8mg/dL, and antihypertensive medication were diminished progressively until day 15 when was suspended and foley removed. At six months follow up he remains asymptomatic. 1.3.Conclusion: In big inguino-scrotal hernias with urinary symptoms, bladder herniation must be suspected for the high rate of complications associated ranging from repetitive urinary tract infection to acute or chronic renal failure. Diagnosis confirmation allows surgery planning and diminishes associated morbidity.