“Locus minoris resistentiae” and connective tissue weakness in older women: a case report and literature review on pelvic organ prolapse with inguinal bladder hernia

Background Conditions such as genital prolapse and hernia are known to be related to connective tissue dysfunction. In this report on cases of the rare simultaneous finding of large genital prolapse and post-prolapse repair female inguinal bladder hernia, we aim to contribute to the discussion of a possible clinical definition of connective tissue weakness, for its clinical assessment and preoperative patient counselling. Case presentation Three cases of medial third-grade (MIII, Aachen classification) inguinal bladder hernia developing or enlarging after successful stage-IV pelvic organ prolapse (POP) repair at a university pelvic floor centre are presented. All patients were aged ≥ 80 years with long-standing postmenopausal status. One patient was followed for 5 years and two patients were followed for 6 months. In all patients, ultrasound revealed that the hernia sac contained the urinary bladder, which had herniated through the inguinal hernia orifice. A literature search revealed only one case report of direct female inguinal bladder hernia and few investigations of the simultaneous occurrence of POP and hernia in general. Conclusion The simultaneous occurrence of inguinal hernia and female POP can lead to bladder herniation following prolapse surgery in the sense of a “locus minoris resistentiae”. Clinical examination for simultaneous signs of connective tissue weakness and counselling prior to pelvic reconstructive surgery could help to increase patients’ compliance with further surgical treatment for hernia.

Ultrasound imaging for bladder hernia: a rare cause of female inguinal hernia

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154 Complete Inguinal Bladder Hernia Causing Acute Obstruction of Right Upper Urinary Tract

Case Summary An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. CT scan demonstrated acute acalculous cholecystitis and complete inguinal bladder hernia with compression of right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous cholecystostomy and percutaneous nephrostomy were attempted but were not possible due to patient non-compliance. Patient improved with conservative management. Discussion Bladder involvement in inguinal herniae is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. Clinicians should aim to make the diagnosis of inguinal bladder hernia pre-operatively to reduce risk of intra-operative bladder injury during hernia repair. Acute acalculous cholecystitis tends to occur in critically ill patients and is a marker of poor prognosis.