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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 35  |  Issue : 6  |  Page : 264-266

Massive Inguinoscrotal Hernia Associated with Acute Renal Failure Complicated Acute Pyelonephritis


1 Department of Internal Medicine, Division of Nephrology, Taoyuan Armed Forces General Hospital, Taiwan, China
2 Division of Radiology, Taoyuan Armed Forces General Hospital, Taiwan, China

Date of Submission18-Jun-2015
Date of Decision16-Sep-2015
Date of Acceptance25-Oct-2015
Date of Web Publication31-Dec-2015

Correspondence Address:
Po-Jen Hsiao
Department of Internal Medicine, Division of Nephrology, Taoyuan Armed Forces General Hospital, No. 168, Jhongsing Road, Longtan Township, Taoyuan County, 32551, Taiwan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.173007

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  Abstract 

We report a 50-year-old man was brought to our Emergency Department due to fever and dyspnea for 2 days. The patient had difficulty in walking and was bed-ridden in the past 5 days due to massive right inguinoscrotal hernia. He had difficulty in micturition in the past 2 days. He was febrile with a body temperature of 39.5°C, a blood pressure of 82/50 mmHg, a pulse rate of 122 beats/minute, and a respiratory rate of 22 breaths/min. Physical examination showed left-sided costovertebral angle knocking tenderness and a large right-sided irreducible inguinoscrotal hernia. Initial laboratory examination revealed abnormalities as follows : l0 eukocyte counts 28.8 × 10 [3] /μL; procalcitonin >200 ng/mL; blood urea nitrogen 77.7 mg/dL; and creatinine 10.6 mg/dL. Computed tomography (CT) of abdomen displayed a large right inguinal hernia containing small and large intestine with compression on junction of bulbous and pendulous urethra. Coronal view of CT reviewed swelling and fat stranding of left kidney which indicated acute pyelonephritis.

Keywords: Acute pyelonephritis, acute renal failure, inguinoscrotal hernia


How to cite this article:
Lin CC, Chen YL, Chan JS, Hsiao PJ. Massive Inguinoscrotal Hernia Associated with Acute Renal Failure Complicated Acute Pyelonephritis . J Med Sci 2015;35:264-6

How to cite this URL:
Lin CC, Chen YL, Chan JS, Hsiao PJ. Massive Inguinoscrotal Hernia Associated with Acute Renal Failure Complicated Acute Pyelonephritis . J Med Sci [serial online] 2015 [cited 2022 Jan 16];35:264-6. Available from: https://www.jmedscindmc.com/text.asp?2015/35/6/264/173007


  Introduction Top


Giant inguinoscrotal hernias are uncommon because of the availability of early elective repair. [1] As well as the usual complications of inguinoscrotal hernia, patients will encounter difficulty in walking or lying down and inability to perform routine activities of daily life. This condition is thought to be acquired and can cause acute renal failure associated with urological tract outflow obstruction combined urinary tract infection with sepsis, which has been less frequently reported. Massive inguinoscrotal hernias have been reported associated with obstructive nephropathy. [2] Patients who have significant symptoms attributable to a groin hernia should undergo surgical intervention as soon as possible to minimize associated complications.


  Case report Top


A 50-year-old man was brought to our Emergency Department (ED) due to fever and dyspnea for 2 days. He was relative healthy without any medical disease in the past. The patient had difficulty in walking and was bed-ridden in the past 5 days due to massive right inguinoscrotal hernia. He had problems with initiating micturition in the previous 2 days. No obvious symptom including nausea or vomiting was found. Physical examination showed left-sided costovertebral angle knocking tenderness and a large right-sided irreducible inguinoscrotal hernia. He was febrile with a body temperature of 39.5°C, a blood pressure of 82/50 mmHg, a pulse rate of 122 beats per minute, and a respiratory rate of 22 breaths per minute. Initial laboratory examination revealed abnormalities as follows : l0 eukocyte counts 28.8 × 10 [3] /μL; procalcitonin >200 ng/mL; blood urea nitrogen 77.7 mg/dL; and creatinine 10.6 mg/dL. Urinalysis showed : w0 hite blood cells, 66-100 per high power field and leukocyte esterase 2+. Arterial blood gas assessment was reported under nasal cannula 3 L/min; pH 7.26, PaCO 2 37.2 mmHg, PaO 2 114.4 mmHg, and HCO 3 -11.9 mmol/L [Table 1]. At ED, abdominal sonography revealed no evident hydronephrosis but noticeable enlargement with swelling of left kidney. Following computed tomography (CT) of abdomen displayed a large right inguinal hernia containing small and large intestine with compression on junction of bulbous and pendulous urethra [Figure 1]a and b. Coronal view of CT showed obvious swollen and fat stranding of left kidney, which indicated acute pyelonephritis [Figure 2].
Figure 1: (a) Computed tomography of abdomen demonstrated a large right inguinal hernia containing small and large intestine (arrowhead) with indentation on junction of bulbous and pendulous urethra (arrow) (b) Coronal reformatted image revealed significant urethral compression caused by the hernia sac

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Figure 2: Coronal view of computed tomography showed obvious swollen and fat stranding of left kidney, which indicated acute pyelonephritis

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Table 1: Blood biochemistry data at ED upon admission


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An indwelling urinary catheter was inserted which drained a residual volume of urine of 1600 mL at ED. Inotropic agents and broad-spectrum antibiotics were administered under the situation of severe sepsis. After admission, he recovered gradually with progressive improvement of renal function. Initial urine culture at ED grew  Escherichia More Details coli. His blood urea nitrogen and creatinine stabilized at 19.7 mg/dL and 0.88 mg/dL when discharged after 12 days in hospital [Figure 3]. Three weeks after discharge, the large inguinal hernia was reducible via a successful operation.
Figure 3: Series of blood urea nitrogen and creatinine levels during hospitalization

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  Discussion Top


This case is interesting because direct compression of urethra caused by massive inguinal hernia lead to obstructive nephropathy. Inguinal hernias are more often direct and can be limited to the inguinal canal or can reach the scrotum. Most cases are asymptomatic and are usually found incidentally at the time of herniorrhaphy. [3] There are some reports showing that inguinal hernia of the bladder cause torsion of the trigone, besides, inguinal hernia cause obstruction of urethra. Furthermore, inguinal hernias have been reported associated with bladder hernia and obstructive nephropathy. The incidence of bladder involvement in inguinal hernias is <4% and may reach 10% in the elderly patients. [4]

Our present case was without obvious bladder hernia and different from most reported cases. The patient had difficulty in walking and was bed-ridden in the recent 5 days due to massive right inguinoscrotal hernia. Obviously, nondilated obstructive nephropathy with acute renal failure developed, therefore, signs of obstructive nephropathy such as hydronephrosis or hydroureter were not found. The mild or absent uremic symptoms (such as nausea, vomiting) with dissociated high serum creatinine was a characteristic of nondilated obstructive nephropathy, which resulted from volume depletion, low urinary flow, and insignificant time for urinary tract dilatation. Risk factors included the older age, abdominal-pelvic malignancy, carcinomatosis, and retroperitoneal fibrosis. [5],[6] However, our patient demonstrated obvious septic sign at admission. Laboratory data revealed apparent leukocytosis with high procalcitonin and C-reactive protein. Pyelonephritis may develop when pathogens ascend to the kidneys passing through the ureters. Most cases of pyelonephritis start at lower urinary tract infections, especially in the setting of urinary tract obstruction. [7] In our case, obstruction of urethra caused by inguinoscrotal hernia may be associated with acute pyelonephritis. His condition of acute renal failure should also be precipitated by sepsis and volume depletion. The diagnosis of inguinoscrotal hernia associated nondilated obstructive nephropathy combined urinary tract infection with septic shock was made based on clinical presentation and CT findings. Of note, there was an improvement of the total renal function 12 days after the immediate urinary catheter insertion and combined empiric antibiotic therapy with adequate intravenous fluid supplement. In the case of renal deterioration due to obstruction from a large inguinoscrotal hernia, stenting of Foley catheter is of much benefit for the kidney.

If urethra obstruction is present though, patients are not asymptomatic and they mostly complain of their lower urinary track symptoms, rather than the hernia itself. The differential diagnosis of urethra obstruction should include inguinal hernia, benign prostate hyperplasia or some form of prostatitis. With regard to the acute renal failure, the urethral obstruction may have been significant. Surgical hernia repair is the definitive treatment of choice. [8] Management of huge inguinal hernia has existing challenges and careful planning in preoperative preparation, and postoperative monitoring is necessary for its successful repair. [9]


  Conclusion Top


Massive inguinoscrotal hernia can be associated with acute renal failure complicated acute pyelonephritis. It is evident that such serious conditions should be suspected and treated. Detailed physical examination and further image study such as CT scan can make the rapid differential diagnosis, and should be immediately performed when suspicion in clinical scenario. Early diagnosis and appropriate antibiotics therapy can reduce morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
El Saadi AS, Al Wadan AH, Hamerna S. Approach to a giant inguinoscrotal hernia. Hernia 2005;9:277-9.  Back to cited text no. 1
    
2.
Yang JL, Tse V, Cameron-Strange A, Matthews AR. Massive inguinal hernia causing acute renal failure. ANZ J Surg 2003;73:1063-4.  Back to cited text no. 2
    
3.
Wagner AA, Arcand P, Bamberger MH. Acute renal failure resulting from huge inguinal bladder hernia. Urology 2004;64:156-7.  Back to cited text no. 3
    
4.
Vindlacheruvu RR, Zayyan K, Burgess NA, Wharton SB, Dunn DC. Extensive bladder infarction in a strangulated inguinal hernia. Br J Urol 1996;77:926-7.  Back to cited text no. 4
    
5.
Onuigbo MA, Lawrence K, Onuigbo NT. Non-dilated obstructive uropathy-an unrecognized cause of acute renal failure in hospitalized US patients : t0 hree case reports seen over 6 months in a Northwestern Wisconsin nephrology practice. Ren Fail 2010;32:1226-9.  Back to cited text no. 5
    
6.
Canavese C, Mangiarotti G, Pacitti A, Stratta P, Modica A, Moretti F, et al. The patient with acute renal failure and nondilated urinary tract. Nephrol Dial Transplant 1998;13:203-5.  Back to cited text no. 6
    
7.
Piccoli GB, Consiglio V, Deagostini MC, Serra M, Biolcati M, Ragni F, et al. The clinical and imaging presentation of acute "non complicated" pyelonephritis : a0 new profile for an ancient disease. BMC Nephrol 2011;12:68.  Back to cited text no. 7
    
8.
Andreu García A, Navio Perales J, Schiefenbusch Munne E, Brotons Márquez JL, Herrero Polo E, Llamazares Cacha G. Inguinal bladder hernias. A report of 2 cases. Actas Urol Esp 1999;23:625-8.  Back to cited text no. 8
    
9.
El-Dessouki NI. Preperitoneal mesh hernioplasty in giant inguinoscrotal hernias : a0 new technique with dual benefit in repair and abdominal rooming. Hernia 2001;5:177-81.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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