Endometriosis of the round ligament: description of a clinical case and review of the literature

Inguinal endometriosis: a case series and review of the literature

BACKGROUND

Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature.

CASE PRESENTATION

8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament.

CONCLUSION

According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery.

Surgical approach to coexistent inguinal endometriosis and inguinal hernial defect: a case report

The presence of ectopic endometrial and myometrial tissue is referred to as endometriosis. The majority of cases of inguinal endometriosis are linked to prior uterine surgery. We present a 39-year-old female presented to the general surgery clinic in June 2013 with mild right inguinal pain and swelling. Enhanced computed tomography scan of the abdominal and pelvis revealed an elongated cystic mass in the right groin region. Diagnostic laparoscopy was performed and the uterus, both ovaries, and pouch of Douglas were examined. Two endometrial deposits were detected: on in the superoposteriar part of the uterus and another below the base of the right fallopian tube. In addition to the right inguinal hernia, a cystic lesion was noted on the surface of the round ligament. The entire round ligament, including the canal of Nuck, and cyst were dissected and excised completely. The right inguinal hernia was repaired.

Primary spontaneous inguinal endometriosis: Two cases with emphasis on the diagnostic approach

OBJECTIVE

While endometriosis is common, inguinal endometriosis with hernia is rarely observed, making its preoperative diagnosis challenging.

CASE REPORT

We report two cases of inguinal endometriosis with different presentations and focus on tailored surgical treatment. The two patients in our series presented with painful swelling in the right groin area. Surgery and pathological examination confirmed the diagnosis of endometriosis in both cases. Herniorrhaphy and excision of the extraperitoneal round ligament were performed in one patient with concomitant inguinal endometriosis and indirect inguinal hernia.

CONCLUSION

We highlight the importance of the preoperative evaluation of concomitant pelvic endometriosis, round ligament involvement, and endometriosis within the inguinal hernia sac. Inguinal endometriosis with or without hernia should be considered even in reproductive-aged women without a previous medical and surgical history. Postoperative hormonal therapy, including dienogest, can be considered to prevent disease recurrence.

The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature

The cyst of the canal of Nuck is an extremely rare female hydrocele, usually occurring in children, but also in adult women. It is caused by pathology of the canal of Nuck, which is the female equivalent to the male processus vaginalis. Due to its rarity and the lack of awareness among physicians, the cyst of the canal of Nuck is a seldom-encountered entity in clinical practice and is commonly misdiagnosed. We report on a case of cyst of the canal of Nuck in a 42-year-old woman, who presented with a painful swelling at her right groin. In addition, we conducted a review of the current available literature. This review gives an overview of the anatomy, pathology, diagnostics, and treatment of the cyst of the canal of Nuck. The aim of this review is not only to give a survey, but also to raise awareness of the cyst of the canal of Nuck and serve as a reference for medical professionals.

Inguinal endometriosis: A systematic review

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

Inguinal endometriosis: Ten case reports and review of literature

BACKGROUND

To describe the characteristics, diagnosis and surgical treatment of inguinal endometriosis (IEM).

CASE SUMMARY

We retrospectively analyzed 10 patients diagnosed with IEM at Beijing Chao-Yang Hospital from 2011 to 2019. Relevant features, symptoms, images, surgical treatment, hormonal therapy and follow-up were collected and discussed. A total of 10 cases of IEM diagnosed by surgery and pathology were characterized by a lesion on the right side (9/11); five patients had symptoms related to the menstrual cycle, and only 3 patients were clearly diagnosed before surgery. Ultrasonography was of little assistance in confirming the diagnosis, but magnetic resonance imaging showed specific, high-intensity patterns. Anatomically, most of the IEM lesions were located in the extraperitoneal ligament (10/11); nine patients had inguinal hernias (IH), five had concurrent or prior pelvic endometriosis, and four had infertility. The clinical results from extensive resection were satisfactory.

CONCLUSION

IEM is an extremely rare condition that can easily be misdiagnosed prior to surgery. A right IH may contribute to the formation of right-sided IEM, and extensive resection involving the round ligament and hernia sac is essential to prevent recurrence.

Clinical aspects and management of inguinal endometriosis: A case series of 20 patients

AIM

This study aimed to describe the clinical presentation, diagnostic evaluation, and operative or medical management of inguinal endometriosis.

METHODS

In this study, we retrospectively reviewed 20 cases of inguinal endometriosis in our facility, particularly on the clinical characteristics, diagnosis, and surgical and medical treatment.

RESULTS

We retrospectively investigated the following items for each patient: age at diagnosis, surgical history, presence of extragenital endometriosis, symptoms, imaging modalities, surgical therapy, hormonal therapy, follow-up period, postoperative recurrence and time to recurrence. We identified 20 cases of inguinal endometriosis in our facility. First, 75% of the patients had right inguinal endometriosis. Second, T1-weighted or fat-saturated T1-weighted images showed hyperintensity in the lesions in 17 patients (17/18 patients, 94.4%). Third, in 5 of 6 patients who underwent surgical therapy, we performed radical surgery to excise the inguinal lesion including the round ligament. One patient had disease relapse. Fourth, in 6 of 7 cases, dienogest effectively improved pain without significant adverse effects, but oral contraceptive was effective in 1 of 4 patients without significant adverse effects.

CONCLUSION

We retrospectively reviewed 20 patients with inguinal endometriosis in our facility. We have shown that magnetic resonance imaging can be a useful imaging modality to obtain a specific diagnosis of this disease. In addition, inguinal endometriosis can be managed with radical surgery to resect lesions including the round ligament and with hormonal treatment. In particular, dienogest ameliorated symptoms, which can be an option for patients who do not want surgery.

Clear Cell Carcinoma Arising in Vulvar Endometriosis

We report a case of vulvar clear cell adenocarcinoma in a woman presenting with a lump and pain in the right side of the labia majora. Three years prior to this visit, she underwent a total abdominal hysterectomy with bilateral salpingooophorectomy and excision of a labial mass. Pathological examination revealed adenomyosis and multiple leiomyomas in the uterus, endometriotic cysts in both ovaries, and foci of atypical endometriosis in the labial mass. The results of an incision biopsy performed before referral indicted only apocrine hidrocystoma. Physical examination revealed a hard mass at the right labia majora extending to the right groin. The mass seemed to be in continuity with the pubic symphysis that would require pubic bone excision and reconstruction with flap surgery to achieve complete resection. However, the patient refused such extensive surgery. Based on previous diagnosis of vulvar endometriosis, she had been treated with GnRH agonists and depot medroxyprogesterone acetate. However, the mass developed into an ulcer and increased in size. A second biopsy of the mass was undertaken, and the pathological diagnosis was clear cell carcinoma with coexisting atypical endometriosis. Computed tomography of the abdominopelvic region showed an ulcerative mass at the right labia majora and nodal metastasis at the external iliac and inguinal regions. Systemic chemotherapy was administered. The growth of the tumors stabilized during the first two cycles of chemotherapy but rapidly progressed thereafter. At 17 months after her initial presentation, the patient passed away due to the progression of the disease.

Laparoscopic excision of round ligament endometrioma

A 14-year-old female patient consulted due to 4 months of recurrent right pelvic pain during her menstrual period. Sonography revealed a 35 mm haemorrhagic right ovarian cyst, initially treated with hormone therapy and oral analgesics with no response. Surgery was indicated due to growth on sonography control and no response to medical treatment. Laparoscopy showed a 7 cm leiomyomatous-like mass arising from the right round ligament that was extracted en bloc without rupture with right salpingectomy and ovarian preservation. The histopathological examination confirmed the diagnosis of round ligament endometrioma with no atypia. The patient presented an uncomplicated postoperative course and was discharged home 48 hours after surgery. Hormonal contraceptives were initiated after the histopathological confirmation; the patient remains asymptomatic at 1-year follow-up.

Spinal versus general anaesthesia in surgery for inguinodynia (SPINASIA trial): study protocol for a randomised controlled trial

Background

Chronic inguinodynia (groin pain) is a common complication following open inguinal hernia repair or a Pfannenstiel incision but may also be experienced after other types of (groin) surgery. If conservative treatments are to no avail, tailored remedial surgery, including a neurectomy and/or a (partial) meshectomy, may be considered. Retrospective studies in patients with chronic inguinodynia suggested that spinal anaesthesia is superior compared to general anaesthesia in terms of pain relief following remedial operations. This randomised controlled trial is designed to study the effect of type of anaesthesia (spinal or general) on pain relief following remedial surgery for inguinodynia.

Methods

A total of 190 adult patients who suffer from unacceptable chronic (more than 3 months) inguinodynia, as subjectively judged by the patients themselves, are included. Only patients scheduled to undergo a neurectomy and/or a meshectomy by an open approach are considered for inclusion and randomised to spinal or general anaesthesia. Patients are excluded if pain is attributable to abdominal causes or if any contraindications for either type of anaesthesia are present. Primary outcome is effect of type of anaesthesia on pain relief. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and (in)direct medical costs. Patient follow-up period is one year.

Discussion

The first patient was included in January 2016. The expected trial deadline is December 2019. Potential effects are deemed related to the entire setting of type of anaesthesia. Since any setting is multifactorial, all of these factors may influence the outcome measures.

This is the first large randomised controlled trial comparing the two most frequently used anaesthetic techniques in remedial surgery for groin pain. There is a definite need for evidence-based strategies to optimise results of these types of surgery. Besides pain relief, other important patient-related outcome measures are assessed to include patient’s perspectives on outcome.

Trial registration

The protocol (protocol number NL54115.015.15) is approved by the Medical Ethics Committee of Máxima Medical Centre, Veldhoven, The Netherlands. The study protocol was registered at www.trialregister.nl (NTR registration number: 5586) on 15 January 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1746-x) contains supplementary material, which is available to authorized users.

Frequently Misdiagnosed Extrapelvic Endometriosis Lesions: Case Reports and Review of the Literature

Extrapelvic endometriosis is a rare condition defined as the presence of endometriotic stroma and glands outside the pelvis and elsewhere in the body. The cervix, vagina, vulva, intestinal tract, urinary tract, diaphragm, abdominal wall, inguinal canal, thoracic cage and lungs, extremities and even the central and peripheral nervous system can be involved. Because extrapelvic endometriosis is located in unusual sites, it is often confused with other pathologic conditions. This can lead to a difficult and challenging diagnosis and management. In the presence of recurrent, cyclical and catamenial symptoms, extragenital endometriotic lesions should be suspected. The aim of our paper is to report 9 cases of rare locations of extrapelvic endometriosis and to provide a literature review.

An unusual presentation of endometriosis

A 25-year-old nulliparous woman attended an orthopaedic clinic with a 12-month history of right hip pain and was found to have a hard tender mass in her right groin. Fine-needle aspiration yielded a diagnosis of endometrial glands. The lesion was excised completely and the final diagnosis was round ligament endometriosis. The patient was pain free 3 months postsurgery.

Endometriosis within a left-sided inguinal hernia sac

Endometriosis is a common gynecologic disorder wherein ectopic endometrial glands and stroma are found at extrauterine sites. Extrapelvic endometriosis is a well-documented, yet rare, disease entity that can affect almost any organ system. Inguinal endometriosis is an extremely rare disease entity characterized by tender inguinal swelling. Here we report a case of a sudden-onset and acutely painful left inguinal hernia with concordant endometriosis. A review of the literature is presented. The presence of isolated endometriosis contained within a left-sided inguinal hernia sac has, to our knowledge, never been reported. Often diagnosed incidentally or on histologic examination, general surgeons should consider inguinal endometriosis in the differential diagnosis of inguinal masses, even in the absence of catamenial symptoms. Surgical excision, with gynecologic follow-up, is locally curative and the treatment of choice for inguinal endometriosis.

Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians

A 49-year-old multiparous woman presented with a swelling in the left groin of 6 months duration. The swelling was associated with a dull aching pain. The patient reported increase in size of the swelling during lifting of heavy weights. Menstrual history was normal and there was no increase in pain over the swelling during menstruation. She underwent a caesarean section 20 years ago and the scar had healed by primary intention. She was provisionally diagnosed to have a left-sided inguinal hernia. Ultrasonography showed a multiloculated cyst measuring 5.3×1.5×5.2 cm within the inguinal canal. The patient had excision of the cyst under spinal anaesthesia. Intraoperatively the cyst was found to arise from the left round ligament. It measured 7×6 cm extending to the left lateral vaginal wall. Histopathology revealed endometriosis of the round ligament. Her gynaecological assessment was normal and they recommended no further treatment. On follow-up the patient was asymptomatic and wound had healed well.

Nuck canal endometriosis: MR imaging findings and clinical features

OBJECTIVE

The purpose of this study was to describe the MR imaging findings of Nuck canal endometriosis (NCE).

MATERIALS AND METHODS

In a 10-year period, 486 out of 612 patients, with laparoscopically and/or surgically proven diagnosis of pelvic endometriosis, underwent MR imaging examination. The examinations were reviewed by two urogenital experienced radiologists working in consensus. Data analysis included: lesions location, size, morphological and signal intensity pattern, involvement of the adjacent muscles, and tendons.

RESULTS

In 372 out of 486 patients an MRI diagnosis of endometriosis was made. NCE was found in eight patients. All the lesions were located on the right side. The mean size of the lesions was 2.5 cm (range 1.5-4.5 cm). Two patterns of NCE were found: type 1, prevalently cystic (n = 2); and type 2, prevalently solid with small scattered cysts within lesion (n = 6). In all the patients, hemorrhagic hyperintense cysts could be seen on T1-weighted images. In four patients, the lesions involved the inguinal canal, and in another four patients, the lesions were only outside the inguinal canal. Involvement of the abdominis rectus muscle was seen in two patients, and of the adductor common tendon in two patients.

CONCLUSION

MR imaging permits the diagnosis of NCE as well as the evaluation of exact extension of the disease.

Inguinal endometriosis: three cases and literature review

Three cases of endometriosis infiltrating the round ligament are presented. The initial diagnosis was irreducible hernia, since this rare nosologic entity often causes unusual preoperative symptoms and diagnostic problems. Diagnosis is frequently made by histologic examination. The rarity of inguinal endometriosis should not exclude it from a possible diagnosis in cases with a painful mass in the inguinal region in a fertile woman, especially if the groin mass is associated in size and tenderness with menstrual variability. Surgery is the treatment of choice and is curative; laparoscopy is suggested during the same operation to evaluate the intraperitoneal conditions.

Radical Excision of Inguinal Endometriosis

BACKGROUND

The diagnosis of inguinal endometriosis can be complex, and patients are often first operated by a general surgeon for a hernia. We present five cases of inguinal endometriosis in which primary surgery resulted in recurrence and a second correct procedure resulted in a cure.

CASES

Five patients with inguinal endometriosis, operated between 1996 and 2002, were seen for the recurrence of symptoms. All underwent excision of the extraperitoneal portion of the round ligament and pelvic exploration. In all cases, both pelvic and round ligament endometriosic lesions were confirmed at histology. No complications or recurrence of inguinal endometriosis occurred.

CONCLUSION

The complete excision of inguinal endometriosis must also include the extraperitoneal portion of the round ligament.