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.

Following a first male urinary tract infection (mUTI), systematic investigation for predisposing factors is called for, as mUTIs frequently arise secondarily to anatomical or functional urinary tract abnormalities. Although no international consensus defines a minimal etiological work-up, guidelines from the French (AFU) and European (EAU) Associations of Urology provide a clinical framework. First-line assessment comprises a targeted history (laying emphasis on macroscopic hematuria and lower urinary tract symptoms, LUTS), digital rectal examination (DRE), the International Prostate Symptom Score (IPSS), and urinary tract ultrasonography with post-void residual (PVR) measurement. LUTS, classified as storage (urgency, frequency), voiding (weak stream, straining), or post-micturition (incomplete emptying) may indicate benign prostatic hyperplasia (BPH), the leading aetiology in men over 50. Ultrasound evaluates prostate volume, bladder morphology, and PVR; voiding diaries complement assessment when storage LUTS predominate. Alpha-blockers represent first-line therapy for BPH-related LUTS. Routine PSA testing following mUTI is not recommended, as elevations are non-specific: prostatitis may raise PSA independently of malignancy, and levels can remain elevated up to three months post-infection. No association exists between a first mUTI and prostate cancer, nor between PSA and UTI recurrence. Second-line referral is indicated for pyelonephritis, urinary retention, macroscopic hematuria, IPSS >7, PVR >100 mL, recurrent UTI, age under 40, or imaging abnormalities. Cross-sectional imaging (CT or MRI) is reserved for suspected obstruction, severe presentations, or treatment failure. This stratified approach optimizes cost-effectiveness, ensuring identification of underlying pathology (BPH, urolithiasis, or malignancy) while avoiding unnecessary investigations.

Straining to void is widely regarded as a clinical indicator of bladder outlet obstruction (BOO) in men with lower urinary tract symptoms (LUTS). However, the physiological significance of this behaviour remains poorly understood. This review examines the role of straining during the voiding cycle and evaluates current evidence regarding its relationship with BOO. Straining represents a voluntary increase in intra-abdominal pressure that may occur at different stages of micturition. Studies comparing patient-reported straining with urodynamic findings demonstrate poor correlation, and the prevalence of the symptom does not differ significantly between obstructed and unobstructed individuals. Furthermore, straining may persist after surgical relief of obstruction, suggesting that it may represent behavioural or compensatory mechanisms rather than mechanical obstruction. Overall, available evidence indicates that straining is a non-specific finding with limited diagnostic value for BOO and should be interpreted alongside objective urodynamic assessment. PATIENT SUMMARY: We reviewed research on why some people strain when passing urine. Straining can occur in people with and without bladder outlet blockage and may simply reflect a habit or a way of to help the bladder empty. This means that straining alone is not a reliable sign of obstruction.