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Unusual presentation of an inguinoscrotal hernia

An 85‐year‐old man presented to the emergency department with a one‐week history of right groin and testicular swelling. He also complained of difficulty urinating. On clinical examination, his scrotum was grossly swollen and tender to palpation. He was also noted to have an acute exacerbation of his chronic renal impairment, where his creatinine levels were increased from his baseline of 180 to 364 μmol/L. A urinary catheter was inserted and a computed tomography (CT) scan of the abdomen and pelvis was arranged. The CT scan (Fig. 1) showed a sliding hernia with the right ureter caught in the hernia sac (marked A) with moderate dilatation of the right ureter and renal pelvis (indicated with arrows). However, no peritoneal sac was identified at the time of surgery. The contents of the hernia were reduced en masse and open hernia mesh repair was done. An interval follow‐up CT showed resolving dilatation of the right renal pelvis and ureter, with return of baseline renal function on blood tests. Inguinoscrotal herniation of the ureter is rare and more commonly occurs with transplanted kidneys due to greater redundancy of the transplanted ureter. In instances that involve native kidneys, two variants have been described: (1) paraperitoneal (80% of cases) – a sliding type hernia, often acquired, where a loop of ureter extends down alongside a peritoneal sac and is adherent to the sac; or (2) extraperitoneal, and thought to be congenital in nature, where the ureteric bud fails to separate from the Wolffian duct and is drawn down into the scrotum (20%). A preoperative CT urogram in suspected cases may help delineate the anatomy of the herniated ureter and prevent ureter injury intraoperatively. Though rare, a herniated ureter can cause obstructive uropathy and a herniorrhaphy is often necessary to relieve the obstruction and allow return of baseline renal function.