Pictorial Essay. Imaging of Urinary Bladder Hernias. Genitourinary Imaging Bacigalupo et al. Urinary Bladder Hernias

Transcription

1 Genitourinary Imaging acigalupo et al. Urinary ladder Hernias Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved Pictorial Essay Imaging of Urinary ladder Hernias Lorenzo E. acigalupo 1, Michele ertolotto 2, Filippo arbiera 3, Pietro Pavlica 4, Roberto Lagalla 3, Roberto S. Pozzi Mucelli 2, Lorenzo E. Derchi 1 erniation of the urinary bladder is H not rare. It is usually considered that 1 3% of all inguinal hernias involve the bladder [1], and Iason [2], in 1944, reported an incidence of 10% in men older than 50 years. Most bladder hernias involve the inguinal and femoral canals, with the latter more frequent in women, and a predilection for the right side has been reported. However, herniations through ischiorectal, obturator, and abdominal wall openings have also been described. ny portion of the bladder may herniate, from a small Fig. 1. Excretory urography of 72-year-old woman with femoral hernia., nteroposterior radiograph of pelvis shows protrusion of profile of left wall of bladder that is directed inferiorly., Left anterior oblique view shows lesion extending anteriorly into region of groin. Received pril 20, 2004; accepted after revision July 20, acigalupo LE, ertolotte M, arbiera F, et al. portion or a diverticulum to most of the bladder [1, 3]. The presence of a large bladder hernia with descent into the scrotum was termed by Levine [3] in 1951 scrotal cystocele. In young infants, protrusion of the lateral aspect of the bladder base can be seen as an incidental finding that is normal for their age. These bladder ears are related to the size and position of the bladder in infants and to the persistence of a large inguinal ring [1]. Damage to the herniated bladder during herniorrhaphy has been reported, and in the preantibiotic era, an unrecognized injury to 1 DICMI Radiologia, University of Genova, Largo R. enzi, 8, Genova I-16132, Italy. ddress correspondence to L. E. Derchi. 2 Department of Radiology, University of Trieste, Trieste, Italy. the bladder could lead to infection, sepsis, and even death. To avoid intraoperative complications, it has been suggested that all men older than 50 years who have prostatism associated with a inguinal or femoral hernia should undergo radiographic studies to rule out involvement of the bladder within the hernia before surgical repair. In patients who do not undergo surgery, complications of herniation include possible upper tract obstruction and strangulation, infarction, and perforation of the bladder [1, 3, 4]. Tumors and calculi have been found within the herniated bladder. 3 Department of Radiology, University of Palermo, Palermo, Italy. 4 Department of Radiology, Ospedale Sant Orsola-Malpighi, ologna, Italy. JR 2005;184: X/05/ merican Roentgen Ray Society 546 JR:184, February 2005

2 Urinary ladder Hernias Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved variety of factors can contribute to the development of bladder hernias. mong these are the presence of urinary outlet obstruction causing chronic bladder distention and contact of the bladder wall with the hernia orifices, loss of bladder tone with weakness of supporting structures, pericystitis and perivesical bladder fat protrusion, obesity, and the presence of space-occupying pelvic masses [4, 5]. ladder hernias have been classified into three types according to their relationships with the peritoneum: paraperitoneal hernias, the most frequent type, in which the extraperitoneal portion of the hernia lies along the medial wall of the sac; intraperitoneal hernias, in which the herniated bladder is completely covered by peritoneum; and extraperitoneal hernias, in which the bladder herniates without any relation with the peritoneum [1, 6]. natomically, inguinal bladder hernias may be classified as indirect, entering through the internal inguinal ring and running laterally to the inferior epigastric artery, or direct, protruding through Hesselbach s triangle of the posterior wall of the inguinal canal and running medially to the vessel [1]. Most bladder hernias are asymptomatic and discovered incidentally during surgery or during imaging studies performed for other purposes. Fig. 2. Excretory urography of 45-year-old woman with ischiorectal hernia., Left anterior oblique radiograph of pelvis shows protrusion of bladder wall that extends inferiorly and posteriorly., Lateral radiograph obtained during Valsalva s maneuver clearly shows lesion has posterior extension, and Valsalva s maneuver increases its diameters. Fig. 3. Excretory urography of 65-year-old man with hematuria and left inguinal hernia. and, nteroposterior film () shows filling defect of tumor but does not show any inferior protrusion of bladder wall. Hernia was seen on postvoiding films only, and its inferior and anterior extension was seen on right anterior oblique projection (). Fig. 4. Retrograde cystograms of 67-year-old man with left inguinoscrotal hernia who was referred for suspected bladder outlet obstruction. and, Filling phase of cystogram () does not reveal any involvement of bladder within hernia. Large scrotal bladder hernia is visible on postvoiding films () only. JR:184, February

3 acigalupo et al. Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved Symptoms such as dysuria, frequency, urgency, nocturia, and hematuria have been reported; however, it is difficult to dissociate similar symptoms arising from coexisting conditions such as bladder outlet obstruction or urinary infection. Patients with large hernias may have specific symptoms, such as reduction in size of the hernia mass after micturition and two-stage micturition, a situation in which initially the patient empties the normally located bladder, then voids again after manual compression of the hernia sac [1, 4, 6, 8]. Fig. 5. Retrograde cystograms in 21-year-old man after suprapubic prostatectomy. Filling defect from balloon of Foley catheter can be seen., nteroposterior film shows reflux into left ureter. Small protrusion is visible on right side, near bladder base, that is slightly less dense than bladder itself., Full extent of hernia running anteriorly and inferiorly (arrows) is visible on oblique radiograph. C, Lesion (arrow) is seen to enter muscles of anterior abdominal wall on axial sonogram. Excretory Urography The diagnosis of bladder hernia is made on urographic studies when a wide-mouthed, rounded protrusion of the bladder wall directed downward is noted (Fig. 1). Differentiation between cystocele and bladder hernia is based on location of the protrusion on the bladder wall and on its direction; cystoceles are triangular and along the midline, whereas bladder hernias protrude laterally and inferiorly, and this can be easily seen on oblique projections (Fig. 1). Ischiorectal bladder herniations may be misinterpreted as an inguinal hernia on frontal views, but their posterior position should be evident on oblique or lateral projections (Fig. 2). n anterior herniation occurring on the midline, which can be misinterpreted as a cystocele, or even can be undetectable on anteroposterior films, is easily recognized on oblique or lateral views [1]. significant bladder hernia may be overlooked on excretory urography [1]. One reason is that the customary radiographs may not be centered low enough to include the herni- C Fig. 6. CT scans of 69-year-old man with inguinal hernia who was referred for staging of lung cancer. and, ase of bladder extends inferiorly and toward left side (). More caudal image () shows urinary bladder entering inguinal canal. 548 JR:184, February 2005

4 Urinary ladder Hernias Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved ation. Furthermore, because contrast-enhanced urine is heavier than nonopacified urine and layers on the posterior wall of the bladder, when the patient is supine contrast material does not enter through the neck of the hernia that, in most cases, is located anteriorly. In fact, patient positioning seems crucial. Only 30% of hernias can be detected on supine films, more than half are apparent when the patient is placed prone, and only the erect view allows 100% identification of bladder hernias [1, 4]. Furthermore, the increased intravesical pressure during micturition can force passage of contrast medium into the herniated bladder or cause the hernia to occur only in this phase of the study, thus allowing detection on postvoiding films of lesions that were previously undetected (Fig. 3). Identification of signs such as a small asymmetric bladder, incomplete visualization of the bladder base, or lateral displacement of the lower third of one or both ureters may suggest the diagnosis and lead to the performance of additional studies with proper patient positioning [4, 6]. Retrograde Cystography Retrograde cystography is usually considered the best technique to image a bladder hernia. However, also with this examination the lesion can become visible only during voiding, when increased intravesical pressure allows the contrast medium to enter or, as an alternative explanation, if herniation occurs only during the voiding phase [1] (Fig. 4). Lesions of the anterior abdominal wall can be easily recognized with this technique using oblique or lateral projections (Figs. 5 and 5). CT Pointing of the bladder toward the side of the hernia that is, angulation of the base of the bladder anteriorly and inferiorly is the CT sign of a bladder herniation (Fig. 6) and, especially in patients with large lesions, it is C Fig year-old man referred for sonography of right scrotal mass., On sagittal scan of right inguinal region (), sonogram obtained with 3.5-MHz transducer shows continuity of scrotal mass (arrows) with bladder. and C, MR images were obtained to clarify sonographic findings. xial T1-weighted image () shows extension of bladder base toward right side and inferiorly. Sagittal T1-weighted image (C) clearly reveals bladder herniation into right scrotum. JR:184, February

5 acigalupo et al. Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved possible to follow the bladder down into the inguinal or femoral canal [7] (Fig. 6). Even in the absence of contrast medium in the herniated bladder, identification of its thick wall surrounding unopacified urine can suggest the diagnosis. The use of CT with the patient in the prone position has been shown to ease the passage of contrast medium in the herniated portion of the bladder [4]. Reconstructions along sagittal or coronal planes can be useful [1]. CT also can reveal herniations through other abdominal wall defects. Hernias along the midline after suprapubic prostatectomy, or laterally after traumatic defects in the bone and musculature of the pelvis, have been reported [1, 6]. C Sonography Sonography also can detect hernias of the urinary bladder, although only large scrotal lesions have been reported. In these patients, sonography is usually requested to characterize the nature of a scrotal mass. Diagnostic criteria include the presence of a fluid-filled lesion at the scrotum that can often be followed cranially to join the intraabdominal portion of the bladder [8] (Fig. 7). Continuity can be difficult to show; a beaked appearance of the cranial portion of the scrotal mass, which can be seen entering the inguinal canal, can suggest the correct diagnosis. Changes in volume of the lesion and thickening of its wall after micturition are the diagnostic clues (Figs. 8 and 8). Postoperative hernias can be detected also by sonography by showing extension of the bladder into a defect of the anterior abdominal wall (Fig. 5C). MRI MRI can identify bladder hernias; such lesions can be detected during studies of the abdomen and pelvis performed for unrelated Fig. 8. Morbidly obese 65-year-old man referred for sonography of right scrotal mass. and, Extended-field-of-view sagittal sonogram of right scrotum () shows fluid-filled mass, cranial portion (arrows, ) of which has beaked appearance, entering inguinal canal. Right testis (T) is displaced inferiorly. fter micturition (), sonogram shows that lesion decreases in volume and its wall thickens, thus allowing diagnosis of scrotal herniation of bladder. C and D, Coronal T-2 weighted MR image (C) clearly shows bladder herniation. On axial image (D), pointing of bladder base and relationships of hernia with inferior epigastric vessels (arrow, D) are seen. D 550 JR:184, February 2005

6 Urinary ladder Hernias Downloaded from by on 05/14/18 from IP address Copyright RRS. For personal use only; all rights reserved purposes, or MRI can be used to clarify the findings seen on urography or sonography. The findings observed in axial planes parallel those seen on CT, with pointing of the bladder base inferiorly and laterally toward the side of the hernia (Fig. 7). Sagittal or coronal images can provide better appreciation of the relationships of the herniated bladder, especially in patients with large lesions (Figs. 7C and 8C). The high resolution provided by MRI can allow analysis of the relationship of the hernia to the inferior epigastric vessels, thus classifying the lesion as direct or indirect according to its position (medial or lateral) in relation to the vascular landmarks (Fig. 8D). References 1. Curry NS. Hernias of the urinary tract. In: Pollack HM, McClennan L. Clinical urography, 3rd ed. Philadelphia, P: Saunders, 2000: Iason H. Repair of urinary bladder herniation. m J Surg 1944;63: Levine. Scrotal cystocele. JM 1951;147: Cavallaro G, Cittadini G, Loria G, Onetto F, Cicio G, Saitta S. Su un caso di ernia vescicale associata a mixoma ovarico. Radiol Med (Torino) 1993;85: Liebeskind L, Elkin M, Goldman SH. Herniation of the bladder. Radiology 1973;106: Reardon JV, Lowman RM. Massive herniation of the bladder: the roentgen findings. J Urol 1967;97: Izes, Larsen CR, Izes JK, Malone MJ. Computerized tomographic appearance of hernias of the bladder. J Urol 1993;149: Catalano O. US evaluation of inguinoscrotal bladder hernias: report of three cases. Clin Imaging 1997;21: JR:184, February