Unlike other inguinal hernias, hernial protrusion of the entire bladder into the scrotum, also known as a scrotal cystocele, is a relatively rare condition that generally requires emergency due to its complications [1–3]. Here, we present two cases of massive bladder herniation into the scrotum with clinical findings, preoperative radiographic images along with intraoperative findings and discuss the management of cytsocele. This study reports management of two cases of massive bladder hernia. Written informed consent was obtained from the patients. Patient identification data were not used in this case presentation. 1.1. Case 1 72-year-old male, who lives in a nursery, admitted to the emergency department with a 6-month history of swelling in the right groin and obstructive urinary tract symptoms. Body-mass index (BMI) of the patient was 34 kg/m2. His past medical record included diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), essential hypertension (HT), and coronary artery disease. He was on medication with anti-diabetics, insulin, acetylsalicylic acid, amlodipine, budenoside and montelucast for his chronic diseases. On physical examination, painful swelling of 10 × 8 cm in size starting proximally and extending along the right inguinal canal was found (Fig. 1). Defective lymphatic drainage of right lower extremity was macroscopically noted as there was a significant circumference difference between lower extremities. Physical examination also approved this difference indicating the impairment of lymphatic drainage of the right lower extremity. Palpation revealed pain in the right inguinal region. The ultrasound of the same region reported as vesicle hernia within the inguinal canal and grade 3-hydronephrosis. Blood urea and creatinine levels were found to be increased. An emergency operation was planned and during the preoperative urology consultation, an urinary catheter was placed into the bladder in order to manage the urinary retention. Retrograde cystography showed a vesicle which is full of contrast material herniated to the right scrotum (Fig. 2). Contrast-enhanced CT scan revealed that the bladder was completely herniated to the right scrotum along with the 1/3 of the distal ureter (Fig. 3). Patient was hospitalized for the operation; however he lost his life due to acute myocardial infarct (AMI) during the preoperative preparations. Written informed consent was obtained from the patient's family for publication of this case report. Fig. 1 A painful inguinal swelling, 10, 8 cm in size, was found on physical examination. Fig. 2 Retrograde cystography showed a complete herniation of bladder into the scrotum along with the 1/3 of the distal ureter. Fig. 3 Contrast-enhanced CT scan revealed that the bladder was completely herniated to the right scrotum along with the 1/3 of the distal ureter. 1.2. Case 2 64-year-old male who admitted to the general surgery clinic with a 4-month history of groin pain was evaluated. BMI of the patient was 37 kg/m2. Physical examination revealed a hernia associated with protrusion of the bladder into the inguinal canal and scrotum. The patient was on medication with amlodipine (5 mg, 1 × 1) because of hypertension. Contrast-enhanced CT scan proved that the urinary bladder was herniated into the scrotum (Fig. 4). Elective operation was planned. Reduction of the protruded bladder was performed following the inguinal exploration by using prolene mesh repair. A drain was placed above prolene mesh and removed when the daily drainage decreased below to 20 cc. Since the patient was doing well without any complaints, he was discharged on the 3rd post-operative day and was invited for follow-up clinic visit after 1 week. The patient experienced no unusual or unexplained symptom, and no recurrence after repair surgery on the routine 1, 3 and 6 months of follow-up visits. Fig. 4 Contrast-enhanced CT scan revealed a complete herniation of urinary bladder into the left scrotum. 2. Discussion Urinary bladder or ureter can protrude into the inguinal canal, femoral ring, scrotum or even through the ischiorectal fossa or obturator foramen [4,5]. Even though, urinary bladder protrusion along the inguinal canal occurs in approximately 1–4% of all cases, the incidence increases to 10% in men over the age of fifty. However, massive scrotal hernias are rare. Besides, complete bladder herniation are very rare compared to incomplete bladder herniation [2,6]. Lower urinary tract obstruction, decreased bladder tone, obesity, weakness of abdominal and pelvic walls with advanced age, benign prostate enlargement and chronically distended urinary bladder may contribute to the pathophysiology of the scrotal cystocele [7,8]. In the present cases, the volume of prostate in both patients was in normal ranges. Thus, the cause of the bladder hernia is assumed to be intraabdominal pressure increase because of obesity and COPD. In general, urinary bladder hernia is classified into three groups according to the relationship between the parietal peritoneum and the protruded portion of the urinary bladder: Paraperitoneal, intraperitoneal and extraperitoneal. Presented cases were described as paraperitoneal hernia, in which extraperitoneal portion of hernia lied along medial wall of sac appeared with the obstructed lower urinary tract symptoms. This type of hernia is reported as the most common type of bladder hernia in the previous studies [9]. Massive scrotal cystocele is usually defined with voiding symptoms, involving manual compression of the hernia. The size of the scrotal mostly depends on urination, as it reduces after voiding. In our cases, both patients described voiding with manual compression of the scrotum in accordance with the previous reports [7,8]. The differential diagnosis of a painless unilateral scrotal swelling includes a hydrocele, spermatocele, varicocele (usually left sided), epididymal cyst, tumor, intestinal or omental hernia [1,2,6]. Scrotal cystocele, which involves only 1–4% of the inguinal hernias, can easily be missed during the clinical evaluation. Thus, radiological imaging plays a crucial role as an accurate diagnostic procedure and it may also help to reduce the risk of structures in the hernia sac [10,11]. CT and ultrasonography are both helpful to diagnose a scrotal cystocele, especially to evaluate the massive inguinoscrotal hernias whereas a retrograde cystogram should be performed to determine the involvement of the bladder properly [10,11]. Both CT scan and cystography were used to identify the anatomical involvement of the bladder in the scrotal hernia in our cases and they revealed a complete urinary bladder hernia fully filled with contrast material in both cases. Ureteral hernia is an uncommon, but an important disorder which causes to serious complications and requires immediate surgical treatment. However, hernia repair surgery can increase the risk of ureter injury which may lead to serious consequences [4]. In massive scrotal hernia cases, bladder can protrude with the ureter causing hydronephrosis on the affected side can herniate with the bladder or independently, and can cause ureterovesicular obstruction with hydronephrosis on the involved side [2]. Thus, grade 3 hydronephrosis in our first case and grade 2 hydronephrosis in the second case due to malposition of ureter were noted. Hydnephrosis is remarkable in our first case. Blood creatine and urea levels were increased and the patient was processing to renal failure. Urinary catheter was placed for to empty the urinary bladder. This provides two important benefits: first, the pain will relieved as the size of the hernia reduces, second, the risk of injury of urinary bladder will decrease as the bladder does not fill the entire hernia sac in the scrotum. Massive hernias are still a dilemma for surgeons since no standard approach for massive inguinoscrotal hernias including bladder was described yet in the literature. Thus, the surgeons are advised to approach carefully to these patients according to their clinical presentation. As a surgical procedure, lichtenstein technique and laparoscopic approach are presented as the most used ones [12]. Our first patient could not be operated since he died in the preparation period for surgery due to acute myocardial infarct. In the surgery of the second patient, we freed bladder from hernial sac and reduced it into the abdominal cavity. Lichtenstein technique was performed for repair of defect following the reduction since the lichtenstein open tension-free hernioplasty technique was already suggested to be the best option in such patients. The mesh is positioned in the pre-peritoneal space. The mesh decreases the tension on the weakened abdominal wall and reduces the risk of hernia recurrence [13]. The repair of an inguinoscrotal hernia including the urinary bladder is a great challenge for surgeons. The correct pre-operative management, the appropriate radiological examinations and the right surgical method chosen by the surgeon can increase the success in surgery. Surgical therapy, although it is usually challenging and demanding, seems to be the best choice for treatment of these patients as increasing their quality of life. Informed consensus is always necessary and ensures that the patient is fully aware of all the pros and cons of the possible postoperative complications [14].