Inguinal Hernia Containing the Bladder and Postoperative Appearance: A Multimodality Case Report

Background and Clinical Significance: Many diagnostic radiopharmaceuticals are excreted in the urine. This can pose a diagnostic challenge when urine-containing structures are in atypical locations, particularly in review of planar imaging without anatomical details from cross-sectional imaging. This case highlights a challenging 99mTc-methylene diphosphonate (99mTc-MDP) bone scan in a patient with an inguinal hernia containing a portion of the urinary bladder. Subsequently, we review diagnostic challenges on conventional and molecular imaging following surgical repair of the inguinal hernia. Case Presentation: A 79-year-old man with prostate cancer underwent initial staging prior to prostatectomy with 99mTc-MDP bone scintigraphy. Anterior and posterior images showed focal uptake overlying the pubic symphysis. Lateral views showed that the activity was extraosseous. Follow-up CT urography showed a bladder hernia as the cause of the abnormality on bone scan. Prostatectomy and inguinal hernia repair were performed as a combination case. Four years postoperatively, follow-up 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) showed no recurrence. The CT component of the exam showed an intermediate-density focus at the right inguinal hernia repair site, corresponding to a plugoma related to a polypropylene mesh plug, and a hyperattenuating Gore-Tex mesh repair of the left inguinal hernia. Conclusions: This case highlights the importance of lateral projections in resolving scintigraphic pitfalls and recognizing mesh-related imaging appearances to prevent misinterpretation.