Massive inguinal herniation of the bladder with bilateral hydronephrosis, complicated by psychosis

Background

Inguinal herniation of the urinary bladder is uncommon, occurring in <4% of all inguinal hernias. Risk factors for the condition include male gender, >50 years, obesity and right-sided inguinal hernia. However, most cases are of small case, and massive (>50% of the bladder existing outside of the pelvis) inguinal herniation is rare, with <100 reported cases.

Case presentation

A man in his 70s was rescued by the emergency services from his burning home. He was mobile, agitated and initially resistive to paramedic assessment or transport to the hospital. Eventually consenting, he reported chronic painful bilateral lower limb ulcers, and since the fire also dry cough and mild shortness of breath. He denied pain elsewhere, cutaneous burns or any other symptoms.

His medical history included hypertension, open appendicectomy and vitamin D deficiency. Six months previously, the patient had been admitted with renal impairment and rhabdomyolysis, after accidentally locking himself out of the house and laying on the doorstep for over 24 hours. The patient did not see a general practitioner, was non-compliant with all medications, and denied recreational drug use or allergies.

Enquiries into social history revealed the patient lived alone in the property. The patient had no social support or friends, and was not in contact with his ex-wife, children or relatives. Neighbourhood relations were hostile. Although first-person and collateral history were both limited, it was apparent that in the year of presentation, the patient had been functioning increasingly poorly at home. This included difficulty in shopping for groceries and failing to pay for utilities, with both water and electricity disconnected. As such, the patient had been living by candlelight. On the night of presentation, the patient had accidentally knocked over a candle at 4 am, causing a housefire.

On initial examination in the emergency department, the patient was alert, orientated, agitated, speaking coherently in full sentences, obese, unkempt and mobilising unaided. Initial vital signs were heart rate 124 beats/min, blood pressure 185/80 mm Hg, pulse oximetry 98% on room air, temperature 36.3°C and Glasgow Coma Scale 15. The patient provided minimal history, and gave consent to a limited inspection of his head, neck and upper limbs. These were unremarkable, without burns. He repeatedly declined abdominal, genital and lower limb examination, or imaging. Specialist psychiatric assessment occurred and deemed the patient as fit to make his own decisions.

Investigations

Initial serum investigations revealed haemoglobin 78 g/L (normal range (NR) 115–165), white cell count 11.2×10⁶/L (NR 4–11), platelets 387×10⁹/L (NR 150–400), sodium 132 mmol/L (NR 135–145), potassium 2.8 mmol/L (NR 3.5–5.0), creatinine 283 umol/L, ferritin 97 ug/L (NR 30–300), transferrin saturation 6% (NR 20%–50%) and HbA1c 6.4% (NR<6%). Meth-haemoglobin and deoxy-haemoglobin were both elevated, consistent with smoke inhalation. ECG revealed sinus tachycardia rate 125 beats/min, and was otherwise normal. Midstream urine culture returned leucocytes 20×10⁶/L (NR<10), erythrocytes 40×10⁶/L (NR<10) and no growth.

Differential diagnosis

The patient was assessed as having poor social functioning, mild cognitive impairment, smoke inhalation, new diagnosis diabetes and ongoing iron deficiency. His raised serum creatinine was attributed to prerenal dehydration. However, renal and postrenal causes were unable to be excluded, given the limited history, examination and investigations.

Treatment

The patient was admitted for management of smoke inhalation and acute kidney injury. He was commenced on intravenous fluids, daily oral iron supplement, as well as analgesia and supplementary potassium. Over the next 3 days, the patient consistently refused nursing observations, interactions with female medical staff, most medications or thorough clinical examination. Limited examination of the lower limbs below the knees revealed bilateral scattered chronic superficial ulcers superimposed on bilateral chronic oedema. After the patient declined wound swabs or antibiotics, these were managed with regular dressings and leg elevation.

On day 3, the patient finally consented to a limited abdominal examination. Abdominal examination revealed a right iliac fossa appendicectomy scar, a soft and non-tender general abdomen with no palpable organomegaly, and a very large irreducible non-tender right inguino-scrotal hernia. The patient’s penis was not visible, engulfed by the enlarged scrotum, with urine leaking from a median skinfold in the scrotum. This had caused tender excoriation of the left scrotum. The testes were impalpable. The patient declined transillumination.

On day 5, he consented to further investigations. Creatinine had risen to 284 umol/L. Renal tract ultrasound revealed bilateral hydroureteronephrosis, and herniation of almost the entire urinary bladder through the right inguinal canal. These findings were confirmed on non-contrast CT scan of the abdomen and pelvis (figure 1). After verbal consent, with the assistance of a nitinol guidewire, an 18-French urethral catheter was placed, and 2.5 L of yellow urine drained.

After the postobstructive diuresis had resolved, the patient’s serum creatinine on day 8 remained elevated at 198 umol/L, and so bilateral percutaneous nephrostomy tubes and antegrade ureteric stents were placed. On day 10, with a combined urological and general surgical team, the patient underwent open right inguinal hernia repair, Jaboulay repair of a large right hydrocele and reduction of the urinary bladder to its orthotopic pelvic position (figure 2). Two days later, the patient failed trial of void, and a new urethral catheter was placed.

Outcome and follow-up

Serum creatinine settled at 160 umol/L. Further urological care was delayed to allow investigation and treatment of the patient’s mental health and medical conditions. After psychiatric assessment, the patient was diagnosed with schizotypal personality disorder and mild cognitive impairment. The manifestations of this included psychosis, paranoia, refusal to eat and malnutrition, with secondary iron deficiency anaemia, hyponatraemia, hypokalaemia, hypomagnaesaemia and vitamin D deficiency. In consultation with the general medical physicians, psychiatry and dietetics department, the patient accepted lower limb wound dressings, oral daily olanzapine 7.5 mg nocte, supplementary vitamins, subcutaneous weekly erythropoiesis stimulator darbepoetin alfa 40 µg, a short-term nasojejunal tube to allow parental nutrition and physiotherapy rehabilitation. These were successful, with normalisation of the patient’s mental state, mobility, nutritional status and serum haemoglobin. The nasojejunal tube and nephrostomy tubes were removed. During this time (approximately 6 weeks postpresentation), the patient again failed trial of void, and a long-term urethral catheter was reinserted. The patient was educated in its care and discharged to government housing after a 3 month admission.

Four weeks later, the patient underwent rigid cystoscopy, removal of bilateral ureteric stents and transurethral resection of prostate (benign histology) with successful resumption of spontaneous voiding. Twelve months postpresentation, the patient continues to void spontaneously.