An unusual scrotal swelling: JAMA case report
A 56-year-old white man presented to the surgical outpatient clinic with swelling of the right scrotum, which started approximately 6 months prior. Swelling was intermittent and sore. The patient noted that tumefaction was more prominent in the morning on waking, and he denied any associated fever, weight loss, or other symptoms.

The patient had no significant medical story. Physical examination showed a painless but tender right scrotal tumefaction in an apparently healthy obese man. No inguinal lymphadenopathy was observed. Swelling was not reducible, the right testicle was not palpable, and the transillumination test was nondiagnostic. Laboratory evaluation demonstrated a hemoglobin level of 13.5 g/dL, leukocyte or white blood cell count of 11 350/μL , and lactate dehydrogenase level of 240 U/L.

Unenhanced computed tomography of the abdomen and pelvis was performed. Computed tomography showed the bladder herniating in the right scrotum. The patient was diagnosed with scrotal cystocele.

Endoscopic exploration confirmed the patient had a large sliding indirect hernia, without sac, involving the urinary bladder. During surgery, the bladder was released from adhesions and reduced in physiological position while the inguinal defect was repaired with a macroporous, partially absorbable mesh. The patient was discharged on the first postoperative day. He had no recurrence at the 11-month follow-up.

Scrotal cystocele is classified according to the relationship between the herniated bladder and the peritoneum: (1) paraperitoneal, when a portion of the peritoneum herniates into the bladder; (2) intraperitoneal, in case the bladder is completely surrounded by a herniated peritoneal sac; and (3) extraperitoneal, when the herniated bladder has no peritoneal sac.

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