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Background: Massive herniation of the bladder presents a rare diagnostic challenge. Rarely, bladder herniation is complicated by the development of bladder calculi. We present a therapeutic approach for this situation. Case presentation: A 90-year-old presented with recurrent urinary tract infections secondary to bladder calculi in the setting of inguinoscrotal bladder herniation. He subsequently underwent successful trans-scrotal percutaneous cystolitholapaxy as a creative approach to an unusual presentation. Conclusion: Massive inguinoscrotal herniation of the bladder is a rare clinical entity with significant morbidity and mortality. Intervention requires a balance of patient health status and anatomy, lending to creative approaches as necessary.