Keywords
complex hernia - urethral obstruction - urethral deviation
Abdominal wall hernias seldom cause obstruction of the urinary tract at the level
of ureters and the bladder outlet.[1]
[2] We are reporting a case of a complex abdominal wall hernia, causing urethral path
distortion leading to outflow obstruction in a patient having an old standing urethral
stricture.
Case Report
The patient was a 48-year-old male who had been undergoing regular dilatations for
the last 8 years for sustaining relief from his urethral stricture. He had a history
of having undergone open suprapubic cystostomy (SPC) 8 years ago for acute urinary
retention secondary to recurrent urinary tract infection (UTI). He developed surgical
site infection (SSI) postoperatively which was managed conservatively. The stricture
had been managed with internal optic urethrotomy (IOU) and serial dilatations, following
which the patient started doing well with 6 monthly dilatations.
Since last 2 years, he developed a swelling in the right inguinoscrotal region associated
with repeated thinning of urinary stream and recurrent episodes of burning micturition.
The swelling became static and persistent in the last 2 months.
On examination, there was a 5-cm long vertical midline scar in the suprapubic region.
An irreducible soft swelling of 8 cm × 6 cm was present in the right inguinal region
which extended up to the base of scrotum. Cough impulse was present, and we could
not get above the swelling. The defect could not be localized. There was also a gradual
growing difficulty in negotiating urethral dilators due to the path distortion by
the contents of the hernia. Cystoscopy revealed narrowing in bulbar urethra with deviations
in the proximal anterior urethra and the scope needed to be negotiated to reach the
urinary bladder. Ultrasound showed findings consistent with right inguinal omentocele
and a scarred suprapubic region. Defect could not be localized.
The patient had been coaxed for surgery multiple times but he did not agree due to
poor past surgical experience. He eventually landed with difficulty in micturition
and inability to get dilators passed. A preoperative diagnosis of right sided, complete,
irreducible, inguinal omentocele with urethral stricture was made, and the patient
was planned for right open hernioplasty with cystourethroscopy along with IOU.
Intraoperatively, a right indirect hernial sac with omentum as content was found;
the sac was opened, omentum resected, and sac was transfixed at its neck followed
by posterior wall strengthening. Another hernial sac with omentum as content was found
in midline beneath the scar of old SPC which was densely adherent to the surrounding
fibrotic tissue ([Fig. 1A]). This sac was dissected out, opened, content resected, and sac was closed. For
the right inguinal hernia, a mesh hernioplasty was done. After the closure of the
external oblique aponeurosis, anatomical repair of midline defect was achieved and
strengthening was done with overlay mesh covering the midline defect. On cystourethroscopy,
a stricture was present from posterior part of penile urethra to bulbar urethra. IOU
was done and 18-Fr Foley's catheter left in situ.
Fig. 1 (A) Intraoperative image showing the right indirect inguinal hernial sac and the contents
of the suprapubic incisional hernia. (B) Postoperative image showing the visible surface markings of pouches of inguinal
and incisional hernial sacs.
A postoperative diagnosis of right-sided, complete, irreducible, indirect inguinal
hernia, and incisional hernia with omentum as contents with urethral stricture was
made. The patient developed SSI on post operative day (POD)-2 which was managed by
wound irrigation and oral antibiotics.
At follow-up after 1 month, a repeat cystourethroscopy was performed which showed
fibrosis and narrowing at the site of IOU. A repeat IOU was done. The anterior urethra
had straightened out and dilatation was simple and smooth. The patient now has a good
urinary stream, no complaint of restriction in passage and dilatations have become
a smooth affair. The patient has been on 4 monthly dilatation for the past year which
have all been smooth and has now been called after 6 months for next follow-up.
Discussion
This was a case of an inguinal, as well as incisional, hernia secondary to lower urinary
tract obstruction, the contents of which led to further penile urethral passage distortion
due to external compression. This led to repeated difficult traumatic dilatations
till the dilators could no longer be passed.
Inguinal and incisional hernias have been known to cause obstruction to the urinary
tract. Reported causes have been extrinsic compression of ureters by the hernial contents,
involvement of ureters in the hernial sac, or the presence of the urinary bladder,
or its diverticula as contents of the hernial sac causing bladder outlet obstruction.[1]
[2]
[3] The present case highlights the importance of lower urinary tract obstruction as
a cause for hernia and also points toward the deviation and further obstruction of
urethra due to the direct mass effect of the omentum lying in the hernial sacs. Such
an effect seems to have occurred by descent of the hernial contents under the Colles'
fascia.
The deviation of the urethra was accompanied by lower urinary tract symptoms. Dilatations
were attempted to relieve the patient's urinary symptoms. The patient's initial unwillingness
for surgery probably led to the formation of a complex hernia secondary to the stricture
which might have been prevented, had the patient undergone a timely urethroplasty.
The patient's further unwillingness for a hernia repair caused increasing difficulty
in urethral dilatations. While urethral dilatations can cause urethral trauma and
recurrent strictures,[4] the appearance of lower urinary tract symptoms (LUTS) with hernia, the patient's
previous 6 years of uneventful dilatations, and cystoscopy showing urethral deviation
indicate that the path distortion was responsible for repeated trauma during dilatations
that led to an increase in the severity of stricture and was managed by IOU. An earlier
hernia repair before significant path deviation of urethra could have prevented the
need for repeat IOU, while a further delay could have led to obstructive uropathy,
the need for an emergency SPC, and a need of future urethroplasty to manage the stricture.
This case also highlights the impact of surgeries and their postoperative events on
the psychology of patients impeding patient compliance, leading to a higher morbidity
associated with a complicated illness and its complex management.
Conclusion
Lower urinary tract obstruction may lead to hernias and all hernia patients must be
evaluated for the same. In complex hernias, to prevent urethral deviation and obstruction
by external pressure of hernial contents which can cause added complications, an early
hernia repair should be undertaken to provide relief.
