Endometriosis-associated hydrocele of the canal of Nuck with immunohistochemical confirmation: a case report

NON-COMMUNICATING HYDROCOELE OF THE CANAL OF NUCK: A RARE FINDING IN A RURAL-DWELLING NIGERIAN WOMAN

Background

The surgical condition termed hydrocoele of the canal of Nuck is one of the rarest clinical entities in the female group. It occurs due to the failure of obliteration of the derivative of the peritoneum, the processus vaginalis. It usually presents with painless inguinal swellings and is sometimes associated with features of intestinal obstruction if there is hernia coexisting with it that has become obstructed. Abdominopelvic ultrasonography and magnetic resonance imaging provide the basis for diagnosis, where these imaging modalities are available. However, a definite diagnosis may only be made during surgery. Definitive treatment includes groin exploration and excision of the cyst with high ligation of the neck of the sac up to the peritoneal pouch, along with repair of the inguinal hernia, if present.

Case Presentation

We present a rare case of a 34-year-old woman who presented with clinical features of a left inguinolabial swelling post-surgery, and diagnosed as left recurrent irreducible inguinal hernia. Intraoperatively, a cystic swelling with serous collection was observed. She had hydrocoelectomy and repair of the left groin surgical wound.

Conclusion

Hydrocoele of the canal of Nuck may be misdiagnosed as inguinal hernia because of its rarity, lack of adequate knowledge regarding the entity and paucity of literature on the subject matter. This report is to furthermore increase our level of awareness of this condition especially after a previous groin surgery.

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 in a Nulliparous Woman Mimicking an Inguinal Hernia: A Case Report with Literature Review

BACKGROUND Endometriosis is a common gynecological disorder occurring in around 10% of women of reproductive age. Inguinal endometriosis is a rare condition; however, it should be considered in the differential for inguinal masses in women of reproductive age. Usually, it occurs after implantation of endometrial tissue during previous surgical procedures. Patients with inguinal endometriosis are often multiparous women with a history of previous gynecological or obstetric surgery. It represents a diagnostic dilemma, as it is often misdiagnosed as other inguinal pathologies. CASE REPORT Herein, we report a case of a 33-year-old nulliparous woman with left groin pain for 2 years increasing in the severity during menstruation. A physical examination revealed a 1.5-cm left inguinal mass. Ultrasound showed an ill-defined speculated solid hypoechoic left inguinal mass measuring 1.6×1.4 cm. Computed tomography (CT) of the pelvis revealed a left inguinal mass measuring 1.7×1.2 cm, demonstrating central hypo-attenuation with thickening of the round ligament. Exploration of the inguinal region revealed an adherent mass to the round ligament and floor of the canal, which was excised completely with a safety margin. The inguinal canal floor was strengthened using proline mesh. Histopathological examination of the mass confirmed the diagnosis of left inguinal endometriosis. CONCLUSIONS Inguinal endometriosis is a rare clinical entity mimicking other common inguinal conditions. A high index of suspicion is crucial for its preoperative diagnosis, especially in the presence of an inguinal mass associated with cyclic changes in size and pain severity. Its standard management is surgical excision.

A rare case of left Nuck’s canal cystic endometriosis: Computed Tomography findings

Introduction:

Endometriosis is a common and chronic gynaecological condition but the implant in the canal of Nuck constitutes a very unusual state with an estimated prevalence of 0.3%–0.6% of all endometriosis cases. The canal of Nuck is an abnormal patent pouch of parietal peritoneum extending anteriorly from the round ligament of the uterus into the labia majora, thus represents a communication between the peritoneal cavity and the female inguinal canal. This condition may permit the seeding of endometriotic tissue in the inguinal soft tissues, becoming a possible cause of inguinal swelling or pain.

Case description:

A 43-years-old woman presented with painful swelling in her left groin. Ultrasound and a subsequent pelvic computed tomography showed a cystic lesion as for a Nuck’s canal encysted hydrocele. The patient underwent an anterior open surgery and the histologic examination revealed an endometrium-like tissue in the cystic wall.

Conclusion:

In women presenting with painful swelling of the groin, despite its rarity, endometriosis of the Nuck’s canal must be differentiated from other more common pathologies like hernias, varicoceles, neoplasms, and lymphadenopathies. Imaging can aid in differential diagnosis, but the final diagnosis is entrusted to histology, which enable to exclude an underlying malignancy.

Ultrasound Imaging of Abdominal Wall Endometriosis: A Pictorial Review

Endometriosis is a debilitating disease characterized by endometrial glands and stroma outside the endometrial cavity. Abdominal wall endometriosis (AWE) indicates the presence of ectopic endometrium between the peritoneum and the skin, including subcutaneous adipose tissue and muscle layers, often following obstetric and gynecological surgical procedures. AWE is a not infrequent gynecological surgical complication, due to the increasing number of cesarean sections worldwide. In this pictorial review, we discuss the importance of medical history and physical examination, including the main ultrasound features in the diagnosis of AWE.

Endometriosis of the Canal of Nuck: A Systematic Review of the Literature

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue in tissues outside the uterine cavity. Apart from the common sites of endometriosis, rare sites other have also been reported including the liver, the thoracic cavity, the muscles, nerves, and more rarely in a patent Nuck canal. We aim to evaluate the clinical presentation, diagnostic features, and management of the Nuck endometriosis. A meticulous search of three electronic databases was performed until May 2020 for articles reporting cases of Nuck endometriosis. A total of 36 patients from 20 studies were analyzed. Median age of patients was 36 years with 33 women being of reproductive age. A right-sided lesion was identified in 30 cases (83.3%), while all patients suffer from a groin mass with cyclic pain in a proportion of 22%. All the patients finally underwent surgery for investigation of the lesion and fixation of the defect. Five cases of malignancy were detected at final pathology. All of them were alive with a median reported overall survival of 37 months. Nuck endometriosis should be included in the differential diagnosis of female patients with groin swelling. An evaluation by a gynecologist is important when endometriosis is suspected.

Bilateral Hydrocele of the Canal of Nuck: A Rare Presentation in an Adult Female

Hydrocele of the canal of Nuck is one of the rarest clinical entities in the female population. It occurs due to the failure of obliteration of the processus vaginalis, which is the extension of the parietal peritoneum. Hydrocele may be seen, along with associated inguinal hernia. It usually presents with painless inguinal unilateral or bilateral swellings, and is sometimes associated with features of intestinal obstruction if the hernia becomes incarcerated or obstructed. Ultrasonography of the abdomen and pelvis and magnetic resonance imaging provide the diagnosis, if these imaging modalities are available; however, definite diagnosis may only be made during surgery. Definitive treatment includes open/laparoscopic excision of the cyst with high ligation of the neck up to the peritoneal pouch, along with repair of the inguinal hernia, if present. We present a rare case of a 25-year-old woman who presented with bilateral inguinolabial swelling, clinically diagnosed as bilateral irreducible inguinal hernia. Intraoperatively, polycystic swelling with serous content was observed along with associated indirect inguinal hernia containing omentum on the left side. She was treated with removal of the cystic component of the bilateral canal and tissue repair of the left indirect inguinal hernia.

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Laparoscopic total extraperitoneal treatment for a hydrocele of the canal of Nuck located entirely within the inguinal canal: A case report

A 43-year-old woman was diagnosed with a hydrocele of the canal of Nuck, for which laparoscopic total extraperitoneal excision was successfully undertaken. The hydrocele was located entirely within the inguinal canal and was barely visible at the internal inguinal ring, even with strong retraction. The inferior epigastric vessels were at risk of injury secondary to excessive tension when retracting the round ligament. To overcome these problems, the hydrocele was approached from the medial side of the inferior epigastric vessels across the transversalis fascia. This approach allowed us to reach the distal end of the hydrocele and avoid excessive traction on the vessels. Thus, a hydrocele of the canal of Nuck can be addressed successfully with minimally invasive laparoscopic total extraperitoneal excision. Approaching the hydrocele from the medial side of the inferior epigastric vessels across the transversalis fascia may be useful.

Hydrocele of the Canal of Nuck with Endometriosis: Right-Side Dominance Confirmed by Literature Review and Statistical Analysis

Introduction. The canal of Nuck is an embryological remnant of the peritoneal pouch that extends into the labium majus of women. Hydrocele is the most common presentation, but only a small number of cases are reported in association with endometriosis. Case Presentation. The patient is a 45-year-old woman who presented with left inguinal mass with persistent pain. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 30 mm cystic mass, and a hydrocele of the canal of Nuck (HCN) was suspected. The excised mass was a cyst containing yellow-tan serous fluid, and the cyst wall was lined by mesothelium. The morphology was consistent with conventional HCN. However, since several foci of endometrial-like epithelium and stroma were identified beneath the mesothelium, the mass was diagnosed with HCN with endometriosis (EM-HCN). Discussion. Right-side dominance of EM-HCN is suggested by several authors, but a thorough review has never been performed. For the first time, we reviewed the literature and statistically confirmed that EM-HCNs dominantly occur on the right side compared to those without endometriosis. We consider that this supports the theory that endometriosis derives from retrograde menstruation of endometrial tissue through fallopian tubes. When endometriosis is discovered in HCN, the clinician should be aware of the possibility of pelvic endometriosis.

Persistence of the processus vaginalis and its related disorders

The processus vaginalis is a blind-ended evagination of the abdominal wall that develops during fetal life and typically undergoes obliteration in early life. Persistence of the processus vaginalis is associated with a number of pathologies including congenital indirect inguinal hernias, communicating hydroceles, funicular and encysted hydroceles, canal of Nuck cysts, and acquired undescended testis. Whilst all are detectable sonographically, there is little educational material relevant to the field of ultrasound with much of the literature directed at surgical and primary care physicians. Furthermore, within the literature there is a lack of consensus on several areas including the anatomy and embryology of the processus vaginalis and the mechanisms behind its obliteration. As such the objective of this paper is to distil the information regarding the persistent processus vaginalis as it is relevant to ultrasound and in doing so address the literature gap for sonographers and sonologists. The anatomy and embryology of the persistent processus vaginalis will be discussed including causative mechanisms for anomalies with their sonographic appearance highlighted.

Resection of mesothelial cyst of uterine round ligament by laparoscopic transabdominal preperitoneal procedure alone or combined with open surgery

Objective

Surgical treatment of a mesothelial cyst of the uterine round ligament (MCURL), an uncommon entity, has been rarely documented. In this article, we present our experience with excision of MCURLs.

Methods

The records of all female patients undergoing surgical removal of a groin mass in our department from March 2013 to November 2018 were retrospectively reviewed. Demographic information, clinical data, and follow-up outcomes were collected and analyzed.

Results

Among 298 women who underwent groin hernia repair, 17 (5.7%) had MCURLs. Of these 17 patients, 13 were aged 30 to 45 years and 15 had a normal body mass index (18.5–23.9 kg/m²). MCURLs occurred predominantly on the right side (11/17). Approximately half of the patients (9/17) were preoperatively misdiagnosed with inguinal hernias. Approximately 70% (12/17) of the lesions were localized medially to the inner ring of the inguinal canal and excised by a laparoscopic transabdominal preperitoneal (TAPP) procedure alone. Five patients required open surgery following the TAPP procedure because the cyst extended distally beyond the inner ring. No recurrence was noted during the entire follow-up period.

Conclusion

Most MCURLs were localized medially to the inner ring of the inguinal canal and could be excised by a TAPP procedure.