Abstract

A 72-year-old male patient presented with a protruding mass in the right lower abdomen for one day, without urinary abnormalities, pain, or fever. The mass could not be reduced spontaneously. Physical examination revealed a protruding mass in the right inguinal region, scrotal enlargement, negative transillumination test, no significant mobility upon traction of the right scrotum, firm texture, deep tenderness, and no rebound tenderness or muscle guarding. Abdominal CT showed bilateral inguinal hernias, with herniation of the right bladder wall and a small amount of effusion, as well as thickening of the adjacent bladder wall. After failed manual reduction, laparoscopic exploration was performed. Intraoperatively, the hernia sac contained neither intestine nor omentum; instead, the extraperitoneal portion of the right bladder dome protruded into the abdominal cavity and became incarcerated, with the incarcerated portion showing suppurative inflammation and covered with purulent exudate. The incarcerated bladder wall was resected, and a tension-free mesh was placed to repair the abdominal wall defect. Postoperatively, the patient was monitored in the ICU for two days before being transferred to the general ward. During this period, he experienced one episode of high fever with chills, which resolved with antibiotic therapy. He was discharged on postoperative day 12.

The uniqueness of this case lies in the patient presenting with typical clinical manifestations of an inguinal hernia, while imaging and surgical findings revealed the rare condition of bladder wall incarceration. Unlike common indirect inguinal hernias, which usually contain intestine or omentum[1], this case involved only a portion of the bladder wall with secondary suppurative inflammation, a particularly uncommon scenario in clinical practice. Although the patient did not report typical symptoms of urinary obstruction, his advanced age, male gender, and bladder wall thickening suggested potential underlying factors such as benign prostatic hyperplasia contributing to the formation of the hernia[2].

This case provides important insights into the early recognition and management of inguinal bladder hernias. Despite the absence of typical initial symptoms, CT imaging played a crucial role in the timely diagnosis, highlighting the importance of considering bladder herniation in elderly patients with inguinal hernias and performing appropriate imaging evaluations[3]. The postoperative episode of high fever and chills demonstrated that even in the absence of necrosis, incarcerated bladder hernias still carry a significant risk of severe infection, emphasizing the necessity of perioperative antibiotic therapy for such patients[4].

From an academic perspective, this case offers new considerations for the study of the pathological mechanisms of inguinal bladder hernias. The observed suppurative changes in the bladder wall support the hypothesis of "mechanical compression leading to ischemic infection," providing clinical evidence for understanding the spectrum of complications associated with bladder hernias. Additionally, this case reaffirms the theory of "relaxation of perivesical ligaments" and visually demonstrates the anatomical features of bladder dome protrusion through imaging. Notably, the patient’s postoperative recovery showed that even with suppurative changes, favorable outcomes can still be achieved through proper surgical debridement and antibiotic therapy, adding confidence to the management of similar complex cases.

Furthermore, this case prompts reflection on screening strategies for inguinal hernias in elderly patients. It is recommended to routinely assess lower urinary tract symptoms in elderly male patients with inguinal hernias and perform urological evaluations when necessary, as this may help identify potential risk factors for bladder herniation. The decision-making process in this case—switching to surgical treatment promptly after failed manual reduction—also serves as a practical example for managing irreducible hernias. Future studies with more case accumulations are needed to further clarify the optimal timing and surgical approach for bladder hernias, particularly regarding the safety and efficacy of mesh placement in contaminated conditions. The detailed documentation of this case provides valuable firsthand data for the clinical classification and management of special types of inguinal hernias.