Successful manual reduction for ureterosciatic hernia: A case report

Highlights • Manual reduction was successfully performed for a patient with sciatic hernia.• There were no report of closed manual reduction previously.• A sciatic hernia in women may be manually reduced without surgery.


Introduction
Sciatic hernia is the rarest type of pelvic floor hernias, which includes obturator, perineal, and sciatic hernias. Sciatic hernias are characterized by the hernia contents entering the greater or lesser sciatic foramen. The greater sciatic foramen is subdivided by the piriformis muscle and atrophy of the piriformis muscle may be one cause of sciatic hernia. Sciatic hernia was first described by Papen in 1750 and observed and recorded by Verdier in 1753 [1].
The purpose of this study was to present a novel technique for manual reduction and to review published reports of sciatic hernias to summarize the experience to date in the management and outcomes of this entity. This work has been reported in line with the SCARE criteria [2].

Presentation of case
An 86-year-old female presented with left-sided lumbar pain. She had a past medical history of rheumatoid arthritis and was treated with prednisolone and methotrexate. On physical examination, her left abdomen and left lumbar area were tender. Laboratory examination showed no abnormalities. An unenhanced abdominal computed tomography (CT) scan revealed invagination of the left ureter into the left sciatic foramen and a dilated left proximal ureter and renal pelvis (Fig. 1). Ultrasonography showed an invaginated left ureter when the probe was placed on the left buttock (Fig. 2). The hernia orifice was 10 mm in diameter. She was diagnosed with a sciatic hernia. On the second hospital day, her symptoms continued and ultrasound-guided manual transvaginal reduction was performed. The patient was placed in the prone position in bed. The entire hand of the examiner was inserted into the vagina. Tension was put on the ureter along with nearby retroperitoneal tissue by the right index and middle finger of the examiner (Fig. 3). The ultrasound probe was placed on the left buttock of the patient. The invaginated ureter was then reduced (Fig. 4). Post-procedure unenhanced abdominal CT scan confirmed reduction of the ureter (Fig. 5)    was discharged one day after the procedure. After 10-months of follow-up, there is no evidence of recurrence.

Discussion
A search of English-language abstracts in PubMed and Igakuchuo-Zasshi through 2017, with keywords of "sciatic hernia" or "ureterosciatic hernia" revealed a total of 71 patients with sciatic hernias [1,. Of 72 patients with a sciatic hernia including the present patient, for whom comprehensive data were found, there were 61 adults (age 29-93 years) ( Table 1) and 11 children (age 2-660 days) ( Table 2).
Of 61 adults including the present patient, 57 (93%) were female. Of the 11 children found in this review, five (45%) were female. This suggests that sciatic hernias tend to occur more frequently in adult females. However, there is no difference in incidence between genders in children. Atrophy of the piriformis muscle has been described as a predisposing factor. Therefore, elderly patients with decreased body mass index tend to have this condition. Common symptoms include unilateral lower abdominal pain, lumbar pain, and bulging of one buttock. In adults, the hernia contents have been reported to include the ureter (N = 26), small bowel (N = 14), tumors (myxoma, lipoma, osteolipoma, liposarcoma, dermoid cyst) (N = 8), colon (N = 2), ovary (N = 2), appendix (N = 1), ascites (N = 1), preperitoneal fat (N = 1), multiple organs (N = 6).
Formerly, the diagnosis of sciatic hernia was made by physical examination (e.g. bulging) or at the time of operation. After the advent of the CT scan, it is the mainstay of diagnostic modalities to     identify a sciatic hernia. Intravenous pyelogram or retrograde pyelogram have been performed for some patients with ureterosciatic hernias. The "curlicue" sign of the ureter was specific for this entity if the hernia contains the ureter [6]. The treatment of a patient with a sciatic hernia depends on the hernia contents and commonly includes surgery (usually, open repair or transgluteal repair) or placement of a ureteral stent if the ureter is involved. Open reduction with laparotomy was performed in 24 patients in the series reviewed. Recently, nine patients were reportedly treated laparoscopically and two by robotic-assisted surgery. Two patients underwent conversion from laparoscopy to laparotomy. There are no reports of successful transvaginal closed manual reduction.
Transvaginal closed manual reduction was used to treat the present patient. With the patient in the prone position, the assistant places the ultrasound probe on the left buttock. The exact location of the hernia was confirmed by the CT scan. After confirming the location of the hernia, the operator inserted the right hand into the vagina, while extending the index and middle fingers (Fig. 3). The entire hand of the examiner should be inserted into the vagina. The index and middle fingers were positioned at the posterior fornix of the vagina, and traction applied with the fingertips in a repetitive manner, reducing the invaginated left ureter. The ureter was reduced along with adjacent connective tissue. After that, the operator and assistant confirmed reduction with ultrasound imaging.
In the combined series of 72 patients, postoperative complications include one death from sepsis, one anastomotic leak, one patient developed heart failure, one patient developed pneumonia, and two recurrences occurred in adults. In children, there was one death from bronchopneumonia. Two recurrences are reported after a repair without using mesh (1/20) and after removal of the ureteral stent (1/3). There are deaths reported after operative repair.
Transvaginal manual reduction is less invasive and easier than other reported approaches. If there are no suspicion of strangulation of the invaginated tissue, it may be considered as the first modality to be used. However, there is a possibility of recurrence because the hernia defect has not been definitively closed. In addition, this maneuver is not applicable to men, children (female children have an intact hymen and small vagina), and possibly, young females whose vagina may not be able to accommodate the examiner's hand.

Conclusion
An incarcerated sciatic hernia in women can be manually reduced. To determine the best management strategy, further studies and collection of data regarding this rare entity, treatment and follow-up are necessary.

Conflicts of interest
All authors have no conflict of interest.

Sources of funding
Authors had no sources of funding.

Ethical approval
IRB/Ethics Committee ruled that approval was not required for this study.

Consent
Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contribution
The work presented was carried out in collaboration between all authors. JK, KY, TS, AKL, and TK defined the research theme, discussed analyses and approved the final version to be published. JK analyzed the data, interpreted the results and wrote the paper.

Registration of research studies
There is no need to register because it is a case report.

Provenance and peer review
Not commissioned, externally peer-reviewed.