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Labial swelling; anterior perineal herniation of urinary bladder diverticulum

Published:March 28, 2018DOI:https://doi.org/10.1016/j.ajog.2018.03.026
      An 80-year-old multipara presented with a gradually increasing swelling in the perineum. She reported a history of urinary hesitation and incomplete voiding. Examination revealed a large swelling in the right labia majora (Figure 1). The swelling was soft, nonpulsatile, and tender on palpation with a fluid thrill. Pelvic sonography revealed a large cystic lesion with layered echogenic debris with posterior acoustics suggesting calculus, and the adjacent bladder lumen (Figure 2). There was no apparent communication with the bladder. Computed tomographic urography revealed pubic diastasis with a large bladder diverticulum with a hyperdense calculus on noncontrast study (Figure 3, A ). Sagittal delayed (at 20 minutes) computed tomography with contrast showed a narrow neck communication between the contrast-filled bladder and the diverticulum, which herniated through the anterior pelvic floor and extended to the right labia majora region (Figure 3, B). Public diastasis (widened pubic symphysis) was further demonstrated on an anteroposterior radiograph (Figure 4). The diagnosis of anterior perineal hernia of a bladder diverticulum was formulated and patient underwent extraperitoneal repair.
      Figure thumbnail gr1
      Figure 1Clinical image showing the right labial swelling
      Right labial swelling.
      Khan. Anterior perineal herniation. Am J Obstet Gynecol 2018.
      Figure thumbnail gr2
      Figure 2Sonographic image showing the bladder and the diverticulum
      Sonographic image.
      Khan. Anterior perineal herniation. Am J Obstet Gynecol 2018.
      Figure thumbnail gr3
      Figure 3CT images showing the calculus in diverticulum and bladder communication
      A, Noncontrast computed tomography (CT). B, Sagittal delayed CT with contrast.
      Khan. Anterior perineal herniation. Am J Obstet Gynecol 2018.
      Figure thumbnail gr4
      Figure 4AP radiograph of the pelvis showing pubic diastasis
      Anteroposterior radiograph of pelvis.
      Khan. Anterior perineal herniation. Am J Obstet Gynecol 2018.
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