The differential diagnosis of a painless unilateral scrotal swelling includes a hydrocele, spermatocele, varicocele (usually left sided), epididymal cyst, tumour, intestinal or omental hernia. This case report reminds us that if scrotal swelling is not apparent during examination it can be difficult to identify a scrotal cystocele. Although mostly asymptomatic, larger hernias can cause voiding complaints related to bladder outlet obstruction and swelling of one side of the scrotum before micturation [
1]. Patients frequently describe the need to manually compress the scrotum to empty the bladder [
2]. This is an almost pathognomonic sign of a cystocele. Additional diagnostic tools to detect this condition are ultrasound, which features further differential diagnosis from other extratesticular cystic abnormalities [
3,
4]. CT scan is also described as an important aid in diagnosing and outlining the anatomy of the affected area [
5,
6]. Typically this condition affects obese men over 50 years of age. Pathophysiological causes include decreasing bladder tonus or increasing laxity of the surrounding tissue in combination with bladder outlet obstruction. Increased abdominal pressure due to obesity is an important factor [
1,
7,
8]. If there is a true hernia of the bladder, patients can have uni- or bilateral hydronefrosis, and renal failure can even occur [
9‐
13]. Other complications described are the formation of calculi in the herniated part of the bladder [
14‐
16], bladder tumour [
11], urosepsis [
16], vesicocutaneous fistula [
17] and bilateral vesico-ureteral reflux [
12]. There are several treatment options, such as repositioning the protruded part of the bladder into the pelvis, or excising the affected part of the bladder. The latter should be done in case of a diverticula or tumour [
10], but in other cases the best treatment option remains debatable. With a lower abdominal transverse incision, good exposure of the bladder and the inguinal area can be obtained at the same time [
18]. Different methods of repairing the inguinal floor have been described. In this case report we used a Lichtenstein procedure, which has been shown to be effective [
13]. In summary, when confronted with a case of a painless unilateral scrotal swelling, include a scrotal cystocele in the differential diagnosis. To identify this condition at physical examination the patient should be evaluated with and without a full bladder.