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Can a hernia cause blood in urine: Gross hematuria as the presentation of an inguinoscrotal hernia: a case report

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Gross hematuria as the presentation of an inguinoscrotal hernia: a case report

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  • J Med Case Reports
  • v.5; 2011
  • PMC3275640

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J Med Case Reports. 2011; 5: 561.

Published online 2011 Dec 4. doi: 10.1186/1752-1947-5-561

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Introduction

Several complications have been reported with inguinal hernias. Although hematuria and flank pain, either as the presentation or as a complication of inguinal hernia, are infrequent, this condition may lead to the development of obstructive uropathy, which can have diverse manifestations.

Case presentation

A 71-year-old Iranian man with Persian ethnicity presented with new onset episodes of gross hematuria and left-sided flank pain. A physical examination revealed a large and non-tender inguinal hernia on his left side. An initial workup included an abdominal ultrasound, an intravenous pyelogram and cystoscopy, which showed left hydronephrosis and a bulging on the left-side of his bladder wall. On further evaluation, computed tomography confirmed that his sigmoid colon was the source of the pressure effect on his bladder, resulting in hydroureteronephrosis and hematuria. No tumoral lesion was evident. Herniorrhaphy led to the resolution of his signs and symptoms.

Conclusion

Our case illustrates a rare presentation of inguinal hernia responsible for gross hematuria and unilateral hydronephrosis. Urologic signs and symptoms can be caused by the content of inguinal hernias. They can also present as complications of inguinal hernias.

Hematuria may reflect either significant nephrological or urological disease. Hematuria of nephrological origin is frequently associated with casts in the urine and almost always associated with significant proteinuria [1]. Isolated hematuria without proteinuria, other cells or casts is often indicative of bleeding from the urinary tract. Hematuria is defined as two to five red blood cells (RBCs) per high-power field (HPF). Common causes of isolated hematuria include stones, neoplasms, tuberculosis, trauma and prostatitis. Gross hematuria with blood clots almost never has a glomerular basis;rather, it suggests a postrenal source in the urinary collecting system. The likelihood of urogenital neoplasms in patients with isolated painless hematuria (nondysmorphic RBCs) increases with age. Hematuria with pyuria and bacteriuria is a typical presentation for infection. Acute cystitis or urethritis in women can cause gross hematuria. Hypercalciuria and hyperuricosuria are also risk factors for unexplained isolated hematuria in both children and adults [2]. Herein, we present a patient with a left inguinal hernia resulted in flank pain, hydronephrosis and hematuria.

A 71-year-old Iranian man with Persian ethnicity presented to our urology clinic complaining of recurrent episodes of gross hematuria and left-sided flank pain of one week’s duration. He mentioned no history of trauma, prior disease, medication usage or significant family disorder. On physical examination, he was fully conscious with a blood pressure of 110/70 mmHg, pulse rate of 120 beats/min and temperature of 37°C. His bowel sounds were normoactive on auscultation. There were no remarkable findings on abdominal palpation, except for a non-tender, large left inguinal hernia with extension to his scrotum. Other related examinations, including a digital rectal examination, were normal. A urine analysis showed pH 5, with 10 to 15 RBCs per HPF, 10 white blood cells per HPF, with rare bacteria and yeast. A urine culture was negative.

Genitourinary ultrasonography reported a grade 2 hydroureteronephrosis on his left side. An intravenous pyelogram also revealed left hydroureteronephrosis associated with an ill-defined filling defect on the left side of his urinary bladder (Figure ). In order to rule out any intravesical lesion, a cystoscopy was performed that showed a bulging on the left side of his bladder wall due to extravesical pressure. The mucosal lining of his bladder was normal. Intravenous and oral contrast-enhanced abdominal computed tomography (spiral multislice thin section scan) showed an entrapped sigmoid colon that was herniated through his left inguinal canal. Anteromedial displacement of his bladder and left ureter were also evident due to the pressure of his sigmoid colon. His left ureter was dilated due to distal obstruction (Figure ).

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Preoperative intravenous pyelogram showing left hydroureteronephrosis.

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Preoperative abdominopelvic computed tomography scan. Left hydroureteronephrosis (thin arrow). Distal ureteral obstruction and bladder displaced by entrapped herniated sigmoid colon (thick arrow).

A diagnosis was made of a large inguinal hernia with pressure effects on the urinary system, resulting in hematuria and obstructive hydroureteronephrosis;the abdominal wall was thus opened with a classic inguinal incision. The contents of his hernial sac, including his sigmoid colon and its mesentery, were adhered to the surrounding tissues. An attempt to reduce the content of his hernial sac was unsuccessful, so a low midline incision was made for better exposure and reduction. There was no intra-abdominal mass. A redundant sigmoid colon was found fixed at the internal ring due to severe and chronic adhesion. His proximal sigmoid colon had compressed his bladder and distal ureter at the vesicoureteral junction. After reduction of his hernial sac content, our patient underwent a successful hernia repair with mesh, leading to a quick and uneventful postoperative recovery.

Our patient’s signs and symptoms subsided following surgery. On a postoperative cystogram, all signs had disappeared (Figure ). Our patient was initially followed-up with monthly visits for the next six months, and then every six months. He remained symptom free during postoperative follow-up.

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Postoperative cystogram showing reversal of all prior radiological signs.

Although hematuria presents with many urologic diseases, the acute onset of gross hematuria is almost always indicative of a postrenal pathology. This includes stones, infection, trauma and tumor.

Inguinal hernias present along a spectrum of scenarios. These range from incidental findings to surgical emergencies such as incarceration and strangulation of the hernia sac contents. Asymptomatic inguinal hernias are frequently diagnosed incidentally on physical examination or may be brought to the patient’s attention as an abnormal pain-free bulge. In addition, these hernias can be identified intra-abdominally during laparoscopy [3]. Patients who present with a symptomatic inguinal hernia will frequently present with groin pain. Less commonly, patients will present with extra-inguinal symptoms such as a change in bowel habits or urinary symptoms. Regardless of size, an inguinal hernia may impart pressure onto proximal nerves, leading to a range of symptoms. These include generalized pressure, local sharp pains and referred pain. Lastly, neurogenic pains may be referred to the scrotum, testicle or inner thigh. A change in bowel habits or urinary symptoms may indicate a sliding hernia consisting of intestinal contents or involvement of the bladder within the hernia sac [3].

The presence of urological symptoms and signs such as hematuria, flank pain and hydroureteronephrosis may be seen with an inguinal hernia, but they generally occur when there is associated bladder herniation [4-6]. A broad literature search revealed that the presence of the bladder within an inguinal hernia occurs in approximately 1% to 4% of all adult hernia cases. Ureteroinguinal herniation was also reported and seems to be an even more rare entity [7].

Moreover, although urological symptoms and signs are often the predominant clinical symptoms when herniation of urinary organs occurs, our case revealed that urological features could be present even in the absence of urinary organ herniation. We think that, given the resultant urinary retention, high intraluminal pressure and consequent urothelial injury in the ureter and upper urinary system, the hematuria occurred as a rare presentation of an inguinal hernia. So, in this clinical pattern, care must be taken to prevent probable morbidities through either diagnostic or therapeutic procedures.

Ruling out urinary organ herniation during preoperative work-up is helpful to avoid surgical complications, the most common being ureteral injury. Ultrasound may be helpful in diagnosis, with its ability to demonstrate hydronephrosis and, occasionally, the herniated urethra in the inguinoscrotal region, but it has limited value in showing the herniated ureter and a high index of suspicion is required. Nevertheless, in this case, ultrasound could be the first step in diagnostic imaging since urinary symptoms were present. Intravenous pyelography may aid the diagnosis by showing an intact non-herniated ureter. Computed tomography is the preferred imaging modality with high spatial resolution, not only to detect herniation, but also to show associated pathologies.

Our case illustrates a rare presentation of inguinal hernia, responsible for gross hematuria and unilateral hydroureteronephrosis. Urologic signs and symptoms can be induced by the contents of an inguinal hernia. They can also be present as complications of an inguinal hernia.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for Review by the Editor-in-Chief of this journal.

The authors declare that they have no competing interests.

Authors were all involved in the drafting and re-editing of the manuscript. The final manuscript was read and approved by all six authors.

This report involved no sources of funding for any of the authors.

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Articles from Journal of Medical Case Reports are provided here courtesy of BioMed Central

Conditions That Can Cause Blood in Your Urine

Medically Reviewed by Minesh Khatri, MD on November 28, 2022

It sounds strange, but you may not always know that you have blood in your urine. Sometimes, there’s so little that it only shows up under a microscope when your doctor is testing you for something else. When you can see it, it can be alarming. But most of the time, the causes aren’t serious. In some cases, though, the symptom points to a bigger health problem.So you should always let your doctor know about it.

It happens when bacteria infect the parts of your body that make and store urine, such as your bladder or urethra. You may hear it called cystitis. Along with seeing blood, you might feel like you have to go all the time, and it could burn when you do. In serious cases, you may have pain in your belly or groin. But sometimes, especially if you’re older, you may not have any symptoms. UTIs are very common, and antibiotics can usually clear them up.

A UTI can make its way to your kidneys through the connecting tubes of the urinary tract. The symptoms are often similar, but with a kidney infection, you’re more likely to have a fever and pain in your sides. And it can be more serious, especially if it spreads to other parts of your body. So be sure to let your doctor know if you notice the signs. This UTI is called pyelonephritis.

They start to form in your kidneys when your body has built up too much calcium or other minerals. And they can really hurt, especially in your back near your hips and ribs, if they grow big enough. You might see blood or even a piece of a stone in your urine. Smaller ones sometimes “pass” on their own in your pee, but you might need surgery to get rid of larger ones.

Infection, surgery, or a sudden hit to this small gland near a man’s bladder could inflame it. Besides seeing blood, you may find it hard or painful to pee. You also might have pain in your groin and lower belly when you poop or ejaculate. Treatment depends on the cause, but you might need antibiotics or pain medicines.

Also called glomerulonephritis,it can damage the tiny filters in your kidneys. That makes it harder for them to get rid of waste. People usually don’t know they have it until their doctor detects it with a urine test. But your pee may have blood or look foamy and brownish, and you may notice swelling in your face, legs, and belly. The issue may get better on its own, but if it doesn’t, treatment can prevent kidney damage.

Genes from your parents cause small, fluid-filled cysts to grow on your kidneys. They can damage the organs and cause blood in your urine. Most people don’t have symptoms until age 30-40, but the first signs can be a bigger belly, a lot of UTIs, and back and side pain. You’re more likely to have high blood pressure and feel chest fluttering, pounding, or pain when you have PKD. There’s no cure, but your doctor can help manage symptoms.

PKD isn’t the only genetic disease that could put blood in your urine. It’s also a symptom of other conditions like sickle cell anemia, hemophilia, or Alport syndrome, which affects the eyes, ears, and kidneys. And sometimes, the symptom can run in families for no clear reason. If that’s the case for you, you may not need any treatment.

It tends to affect runners more than other athletes. But it’s not that common, and doctors don’t know exactly why it happens. It might be a lack of water, injury to the bladder, or the breakdown of more red blood cells in aerobic exercise.

Some drugs, like the antibiotic penicillin or the cancer drug cyclophosphamide, can cause blood in your urine. It also might happen if you take medications like aspirin or the blood thinner heparin, especially if you already have a condition, like a urinary tract infection, that makes your bladder bleed more easily. Blood thinners by themselves are not the cause of blood in the urine, so the cause still needs to be investigated.
 

A hard hit, typically in your lower back area, can make blood show up in your urine. It might happen in a fall or a car accident or if something heavy hits you. Often it gets better on its own with rest, though a doctor should keep an eye on you to make sure you’re recovering well. If your injury is severe, you may need surgery. 

Blood in the urine is a key sign of bladder cancer. It also may be a sign of kidney or prostate cancer. In some cases, you might not have any other symptoms. That’s one reason why it’s important to let your doctor know when you notice any blood. They can rule out more serious conditions or start any treatment you may need.

To find out why there’s blood in your urine, your doctor will examine you and ask about your health and family history. A lab will test your urine for red blood cells, infection, and other possible problems. In some cases, your doctor may test your blood or take pictures of your kidney or bladder with an ultrasound, a CT scan, MRI, or a special camera called a cystoscope. Sometimes, your doctor may need to test a sample of your urine for cancer cells.

The right one depends on what’s causing the symptom. An infection can be cleared up with antibiotics. Different cancers require different approaches, and genetic diseases may need long-term management. Talk to your doctor about what kind of treatment is likely to help you.

IMAGES PROVIDED BY:

1) angelp / Thinkstock

2) David Mack / Science Source

3) John Bavosi / Science Source

4) Ingram Publishing / Getty Images

5) David Mack / Science Source

6) Eraxion / Thinkstock

7) PDSN / Medical Images

8) LWA / Dann Tardif / Getty Images

9) Jacob Ammentorp Lund / Thinkstock

10) James King-Holmes / Science Source

11) Keith Allison / Wikipedia

12) SEBASTIAN KAULITZKI / Science Source

13) Dr. P. Marazzi / Science Source

14) Fuse / Getty Images

 

SOURCES:

American Cancer Society: “Kidney Cancer Signs and Symptoms,” “Signs and Symptoms of Prostate Cancer.”

American Kidney Fund: “Glomerulonephritis,” “Polycystic kidney disease,” “Kidney infection.”

Cleveland Clinic: “Urinary Tract Infections,” “Bladder Cancer,” “Sickle Cell Anemia,” “Hematuria.”

Mayo Clinic: “Prostatitis,” “Blood in urine (hematuria).”

Merck Manual: “Stones in the Urinary Tract.”

National Institute of Diabetes and Digestive and Kidney Diseases: “Hematuria (Blood in the Urine).”

NIH Genetics Home Reference: “Alport syndrome.”

National Kidney Foundation: “Hematuria in Adults,” “What is Glomerulonephritis?”

Nemours Foundation: “Glomerulonephritis.”

Prostate Cancer Foundation: “Prostate Gland.”

Urology Care Foundation: “What is Kidney (Renal) Trauma?”

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diagnostics and treatment in Anapa

Blood in the urine – hematuria may appear as a result of an injury or be a symptom of a serious illness requiring urgent diagnosis. More than a hundred reasons are known, which are revealed during the examination. To establish a diagnosis, contact the Anapa Medical Center “NeoMed”. It uses modern equipment to identify the causes of hidden bleeding with maximum accuracy and minimal discomfort.

Types and features of hematuria

Blood in the urine – a sign that somewhere in the urinary tract there is bleeding or an inflammatory process that damages the vessels. The source may be in the kidneys, bladder, ureter. The cause is trauma, infection, neoplasm, decreased blood clotting, vascular problems, excessive exercise.

There are two types of hematuria :

  • Gross hematuria, when blood stains the urine or its inclusions are clearly visible.
  • Microhematuria, in which the presence of blood can only be detected by laboratory methods. At the same time, there are acceptable norms for red blood cells in urine.

However, the concentration cannot be used to judge the severity and danger of the provoking factor. In addition, a change in the color of urine does not always indicate the presence of blood. A reddish hue can give high hemoglobin, some foods and medicines.

Which diseases are accompanied by blood in the urine

Signs of gross hematuria visible to the naked eye. The color of urine can be from pale pink to dark brown, or blood clots or inclusions are in it in an undissolved form. This condition causes many reasons:

  • Oncology is the most unpleasant factor. Blood clots in the urine indicate growths in the bladder or urinary tract.
  • Kidney bleeding – red or brown urine with the presence of blood clots.
  • Inflammatory diseases of the kidneys: pyelonephritis and glomerulonephritis – urine red or burgundy.
  • Renal injury – the degree of staining depends on the amount of bleeding.
  • Bladder endometriosis – bloody urine appears during menstruation.
  • Urolithiasis – stones cause injuries of varying intensity. The larger the stone, the higher the number of red blood cells in the urine.

Other diseases also lead to gross hematuria: cystitis, urethritis, prostatitis, prostate adenoma, gynecological problems.

If blood is found in the urine during laboratory tests, the cause may be kidney disease, malignant and benign formations of the genitourinary system, connective tissue pathologies, diabetes mellitus, gout, infections.

It is not worth choosing a diagnosis yourself, only diagnostics can determine the danger and urgency of treatment.

Diagnosis and necessary examinations

If red blood cells are found in urine, you should contact your general practitioner, urologist or gynecologist. The doctor, after a preliminary examination and history taking, in any case, will refer you to a specialist, if necessary. NeoMed conducts comprehensive diagnostics to find the underlying causes of hematuria.

  • Urinalysis and urinary sediment examination.
  • General and biochemical blood tests to detect provoking diseases and anemia.
  • Urography – X-ray examination of the kidneys and urinary tract, a contrast agent is injected for better visualization. Helps to identify neoplasms, stones, foci of inflammation.
  • Cystoscopy – endoscopic examination of the bladder through the urethra. Allows non-surgical way to detect a clear source of bleeding, urolithiasis, neoplasms, polyps, inflammatory processes. If necessary, make a puncture.
  • Computed tomography of the kidneys and urinary tract, other organs, if there is a suspicion of a source of bleeding. Reveals pathological processes, consequences of injuries.
  • MRI of the genitourinary system. Detects neoplasms, stones, advanced forms of STDs, hernias, pathologies of the structure of organs.

Treatment is directed at the cause. In some cases, no therapy is required at all, in others, medications or surgery are indispensable. The medical center “NeoMed” has everything for the diagnosis of hematuria and the treatment of provoking diseases, call, you will be assigned to the right specialist.

causes, symptoms, signs, diagnosis, treatment, clinical recommendations

Causes

Symptoms

Classification

Diagnosis

Treatment

Prognosis and prevention

Hematuria is a pathology in which blood is detected in the urine during a laboratory test or visually. The presence of red blood cells in the urine is not a separate disease or syndrome. This is a symptom that is characteristic of some diseases and can pose a certain threat to human life.

Hematuria in the urine varies in severity and can change its color in different ways. The discharge may be the color of meat slops with heavy bleeding, but usually only a urinalysis can determine the presence of blood cells, even if the color of the liquid looks normal. Normally, there are no red blood cells in the urine, although in some cases there may be one or two in the field of view. Hematuria according to the ICD is coded by different diagnoses. There is no single code for just this laboratory symptom.

Causes and triggers

Hematuria can be physiological and pathological. In the first case, it is a variant of the norm and does not carry any danger. It is detected in healthy people and in children quite often, for example, with the immaturity of the renal filter and its increased permeability, with overheating or hypothermia, high physical exertion, long walks.

In all other cases, various diseases can provoke the appearance of blood in the urine. Among them, the most common are:

  • glomerulonephritis or pyelonephritis;
  • kidney or urinary tract infections caused by E. coli;
  • kidney stones;
  • malignant tumors of the bladder;
  • malignant tumors of the prostate;
  • hemophilia;
  • necrotic damage to the kidneys;
  • Berger’s disease;
  • nocturnal paroxysmal hemoglobinuria;
  • poisoning;
  • cystitis.

Hematuria in women is often explained by the fact that menstrual blood enters the jar, so it is not recommended to conduct a blood test during menstruation. Common causes of hematuria in men are malignant tumors in the prostate and bladder catheterization, which is performed with acute urinary retention in prostatitis and prostate adenoma.

Hematuria in children is quite common, especially in newborns. The main reason here is the incomplete maturation of the kidney filtration system, which is why blood cells enter the urine, but this symptom does not pose any danger to babies.

Symptoms

There are no single symptoms for hematuria, as everything will depend on what caused this disorder.

If the cause is glomerulonephritis, then erythrocytes enter the urine through the capillaries of the renal glomeruli, which are damaged by the inflammatory process. In the acute form of the disease, hematuria will be significant, in the chronic course – insignificant and detected only in the analyzes. Often, protein and white blood cells are also found in the urine.

In pyelonephritis, this symptom occurs in approximately 30% of all patients with acute illness or exacerbation. The content of erythrocytes during microscopic examination is small and does not exceed 20 pieces in the field of view. Also, together with erythrocytes, leukocytes, bacteria, nitrates are found.

Necrotic lesions of the renal tissues are observed in acute thrombosis or embolism of the renal vessels. It can also be a complication of diabetes mellitus with kidney damage. Symptoms include dull, aching pain in the lower back. In the urine, along with erythrocytes, leukocytes are also found.

Urolithiasis is another cause of hematuria, but blood appears only during an attack, when the stone begins to move along the ureter. Other symptoms include severe pain, nausea, and vomiting. In the urine there is a high content of oxalates, phosphates, uric acid.

Signs of hematuria are also possible with cystitis. It is also noted against the background of polyposis, bladder stones or schistosomiasis.

Classification

By severity, renal hematuria is divided into microhematuria and macrohematuria. The first happens more often, while outwardly the color of urine is not changed in any way, and it is possible to determine the presence of red blood cells in it only after a laboratory analysis. The second is less common and differs in that fresh blood gives the secreted fluid a noticeable characteristic color. Gross hematuria can be suspected without laboratory analysis.

Hematuria is divided into several types – they depend on the cause of the symptom:

  • renal appears in diseases of the kidneys;
  • prerenal occurs when there is a violation in the blood system and is diagnosed with coagulopathy of various origins;
  • postrenal manifests itself with damage to the lower urinary system.

Hematuria syndrome can be false positive or false negative. This result is obtained when using test strips, which do not always give the correct result. Laboratory research is much more reliable.

Diagnostics

Therapy and diagnosis of hematuria are carried out by therapists, urologists, nephrologists. When examining and questioning the patient, it is important to determine whether there was an infection, inflammation, exacerbation of chronic diseases before the development of this symptom. The presence of edema is determined, blood pressure, body temperature are measured.

Three cups are tested to determine the source of bleeding. A general urine test is done, in which the presence of other pathological elements is noted. Additional methods include a complete blood count, immunological and microbiological studies with seeding to determine sensitivity to antibiotics.

Obligatory ultrasound of the kidneys and prostate. To determine the blood flow in the kidneys, a Doppler study is performed with ultrasound. Radiography with contrast helps to identify polyps, tumors, stones, anomalies in the structure of organs. For a more accurate result, cystoscopy and histology are performed.

Treatment

Treatment of hematuria is directly dependent on the cause that caused the appearance of this symptom. Conservative therapy may include taking antibiotics, glucocorticosteroids, cytostatics, alpha-blocker, alkaline solutions, cardiac drugs.

Therapy is always selected strictly individually. Its main goal is not to rid the patient of the presence of red blood cells in the urine, but to cure the disease that led to the appearance of this dangerous symptom.

It is often impossible to determine the disease only by external signs or complaints of the patient. At the same time, you should not make a diagnosis of hematuria and try to get rid of this phenomenon on your own. Even in the case of a physiological cause, you need to consult a doctor and make sure that everything is in order with your health.

Surgery may be required in case of urolithiasis. It is also recommended to be performed in the presence of tumors, polyps or other neoplasms in the urinary system. Transplantation is indicated in case of severe chronic damage to kidney tissues on both sides with the development of renal failure.

Prognosis and prevention

If a patient with hematuria follows all the doctor’s recommendations, and also does not self-medicate, then it will be possible to cope with the presence of blood in the urine quite quickly. With minor inflammation and exacerbations of chronic diseases of the urinary system, the prognosis is favorable in most cases.

If the disease occurs due to kidney failure or necrosis of kidney tissue, then the only solution will be transplantation.

There is no specific prevention, as it is only a symptom of many different pathologies. Non-specific measures include the timely treatment of diseases, the passage of an annual medical examination, passing urine for analysis at least once a year, a healthy lifestyle, quitting smoking and drinking alcoholic beverages.

The author of the article:

Zavalishin Evgeniy Vitalievich

urologist, specialist in ultrasound of the genitourinary system

work experience 10 years

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