What is the treatment for a hernia that partially contains the urinary bladder?

Management of Urinary Bladder Herniation

Surgical repair is required for hernias containing the urinary bladder, with the approach depending on whether the herniation is intraperitoneal or extraperitoneal. 1

Diagnostic Evaluation

• Voiding Cystourethrography (VCUG) is recommended as the initial imaging test for evaluation of bladder herniation 2
• CT Urography provides comprehensive evaluation and can identify the extent of bladder involvement in the hernia 2, 3
• Ultrasound may identify bladder herniation but can sometimes misdiagnose the contents as bowel 3

Treatment Approach Based on Hernia Type

Intraperitoneal Bladder Herniation

• Surgical exploration and primary repair is mandatory for intraperitoneal bladder herniation 1
• Open surgical repair is the standard approach, though laparoscopic repair may be considered in hemodynamically stable patients with isolated injuries 1
• Repair should be performed in a double-layer fashion using monofilament absorbable suture for open approaches 1
• Single-layer repair is common during laparoscopic approaches 1

Extraperitoneal Bladder Herniation

• Uncomplicated extraperitoneal bladder herniation may be managed non-operatively with urinary drainage via urethral or suprapubic catheter if there are no other indications for surgery 1
• Surgical repair is indicated for complex extraperitoneal hernias, including those with: 1
  • Bladder neck involvement
  • Associated pelvic fractures
  • Concurrent rectal or vaginal injuries
  • Exposed bone spicules in the bladder lumen
  • Non-resolution of urine extravasation after 4 weeks of conservative management

Surgical Considerations

• The transabdominal preperitoneal (TAPP) approach can be effective for inguinal bladder hernias 4
• During repair, careful dissection of adhesions is necessary to reduce the bladder back into the abdomen 4
• Mesh repair can be completed provided there is no evidence of urinary tract infection 5
• Indigo carmine injection through a urinary catheter can confirm bladder integrity during surgery 4

Post-Operative Management

• Urinary drainage with a urethral catheter (without suprapubic catheter) is recommended for adults following surgical repair 1
• For pediatric patients, suprapubic cystostomy is recommended 1, 2
• Follow-up cystography should be performed to confirm bladder healing in complex repairs 1
• Catheter drainage should be maintained for 2-3 weeks in standard cases 1

Complications and Pitfalls

• Bladder injuries during hernia repair occur in approximately 0.5-2% of laparoscopic surgeries 5
• Prior lower abdominal surgery is a relative contraindication to extraperitoneal laparoscopic hernia repair due to increased risk of bladder injury 5
• Signs of gas in the Foley bag or hematuria should alert the surgeon to a bladder injury 5
• Elderly males more frequently present with inguinal bladder hernias and may require evaluation for urological pathology 3

Special Considerations

• In cases of hemodynamic instability, temporary urinary drainage may be established and definitive repair postponed 1
• Patients with small, asymptomatic inguinal bladder hernias might be candidates for conservative management with close monitoring 3