Two-Stage Micturition as a Clue to Giant Inguinoscrotal Bladder Herniation: A Rare Diagnostic Pitfall

Inguinal bladder herniation is a rare condition and is frequently underdiagnosed because of its nonspecific presentation. We report the case of a 68-year-old man who presented with progressively worsening lower urinary tract symptoms, including frequency, nocturia, weak urinary stream, elevated post-void residual volume, and a slowly enlarging right inguinoscrotal swelling. The coexistence of severe voiding symptoms and obstructive urinary parameters initially suggested benign prostatic obstruction. However, the presence of two-stage micturition requiring manual compression of the scrotal mass to complete bladder emptying (Mery's sign) raised suspicion of bladder involvement. Contrast-enhanced computed tomography with delayed excretory-phase acquisition revealed a giant right inguinoscrotal bladder hernia with marked distortion of the bladder contour, while three-dimensional reconstruction provided precise anatomical characterization and facilitated surgical planning. The patient underwent successful surgical repair with complete resolution of urinary symptoms. This case highlights the diagnostic challenge posed by giant inguinoscrotal bladder hernias, particularly when they mimic common causes of bladder outlet obstruction, and emphasizes the importance of recognizing Mery's sign and performing preoperative cross-sectional imaging to establish the diagnosis, prevent iatrogenic bladder injury, and optimize surgical management.