Not just a simple inguinal hernia. A rare case of an inguino-scrotal ureter!

Inguinal hernias involving the ureter or inguino-scrotal ureters are a rare and infrequently described finding with both clinical and surgical consequence. While the majority are asymptomatic and rarely cause obstructive uropathy our case aptly highlights the risk to a general surgeon prior to an elective hernia repair. A review of the literature outlines a systematic approach of investigation if clinical suspicion of an inguino-scrotal ureter is raised, with careful operative planning and a multidiscipline approach for repair recommended.

Introduction

This case report is based upon a 75 year-old gentleman who was referred to a General Surgeon by his GP for management of a reducible inguino-scrotal hernia progressing over one year. This is on a background of morbid obesity, hiatus hernia and alcohol-induced hepatitis.

Case presentation

Prior to the surgeons review an ultrasound was performed which showed an elongated simple fluid filled “structure” in the right groin, which was thought to be a patent processus vaginalis with no herniation.

Clinically he had an inguinoscrotal ‘hernia’ in the right groin with reducibility from the scrotum proximally. Further investigations were arranged including a CT abdomen, which revealed the right hernia sac, contained the right ureter and consequent right hydroureter and hydronephrosis.

He was then referred to the supervising author Urologist who ordered an urgent CT Urogram, which revealed the rare diagnosis of a right-sided uretero-inguinal hernia (Fig. 1, Fig. 2, Fig. 3).

Fig. 1

Coronal CT Urogram images demonstrating the course of the right ureter retro-peritoneal (A) crossing the inguinal ligament in the second image (B) and looping within the right hemi-scrotum (C).

Fig. 2

Axial CT Urogram images in the prone position demonstrating the right sided hydronephrosis, hydroureter and cholelithiasis in first image (A), the vesicoureteric junction with the ureter coursing from the inguinal region in the second image (B) and the looped dilated ureter in the right hemi-scrotum (C).

Fig. 3

Sagital CT Urogram images demonstrating the right sided hydronephrosis in the first image (A), the right ureter crossing the inguinal ligagment junction in the second image (B) and the impressive and rare looped dilated ureter in the right hemi-scrotum (C).

Discussion

While uretero-inguinal hernias are not uncommon, herniation of the ureter and other urological organs is incredibly rare, further more they are commonly asymptomatic and often found incidentally during the work up for other abdominal pathology.

On review of the literature there are under 140 cases of ureteral herniation and only half of these describe herniation into the scrotum. Fewer than 10 of these cases of ureteral inguinal hernias have involved native kidneys.

It is unclear how and why the ureter was dragged towards the internal ring, through the inguinal canal, into the hemiscrotum and then to course back to the retroperitoneal to drain into the bladder. Could have it occurred early in development or acquired? The most common cohort of this pathology is older obese males. The clear majority of these patients have a history of kidney transplant, which places them at a far greater risk due to the anterior mobilization of the ureter placing it at a far closer proximity to the abdominal wall. Signs and symptoms that an uretero-inguinal hernia may include lower urinary tract symptoms (LUTS), unexplained unilateral hydronephrosis on imaging and unexplained renal failure.

Uretero-inguinal hernias can be separated anatomically as paraperitoneal (80%) or extraperitoneal (20%). Paraperitoneal can also be described as the acquired variant which is thought to be caused by the traction of other abdominal organs surrounding the hernia causing the ureter to be delivered into the scrotum. Extraperitoneal conversely can be described as congenital due to the malformation of ureter to the genitofemoral ligaments causing the pathology. Unlike extraperitoneal which usually cause urinary symptoms, paraperitoneal are nearly always asymptomatic due to large size of the hernia and fatty constituent.,

With many cases being found intra-operatively during hernia repair, it's vital the clinician thoroughly works up a patient with any clinical suspicion to prevent ureteral damage. In patients with an inguinal hernia the routine pre-operative assessment should at least include a urine MCS plus UECs with baseline and trend comparison, however this might not be performed in the routine hernia repair. We suggest that any patient with an abnormality from the above investigations should undergo an ultrasound of the renal tract as the first line modality as it can reliably without radiation identify abnormalities such as hydronephrosis or hydroureter., From here a CT intravenous pyelogram/urogram can be used to accurately assess the patient and should include a urology referral.

Beyond a troublesome symptomatic inguinal hernia, from a urological perspective repair is indicated to prevent obstructive uropathy and its associated sequelae. Temporary management can include nephrostomy tube placement for operative planning in uropathic patients, or regular clinical review with renal function results for patients without biochemical obstruction.

Optimum definitive management includes an open hernia repair with mesh with pre-operative ureteric stents to aid careful dissection and prevent iatrogenic injury. From a urological perspective surgical techniques involve an open approach, attempting to retract the ureters to cut abundant distal ureter and careful re-implantation with great caution due to risk of ureteric ischemia. We also recommend all cases are conducted as a multidisciplinary approach between Urology and General Surgery departments. It is important to remember as shown in the case presented, consideration of a patient's co-morbidities and risk of complications should be reflected prior to intervention.

Conclusion

In conclusion our case shows the need for an elevated index of suspicion in the ‘high risk patients’ who may have a ureter containing hernia despite its rarity. This illustrates the importance of preoperative assessment based on basic screening, multidisciplinary management and never assuming each presentation will be a ‘textbook’ case.

Disclosure statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

There are no conflicts of interests to declare.