Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

17 December 2021: Articles  Saudi Arabia

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

Challenging differential diagnosis, Rare disease, Clinical situation which can not be reproduced for ethical reasons

Fatima M. AlSinan1BDEF, Abdulelah S. Alsakran2BDEF, Mohammed S. Foula ORCID logo2ADE*, Tahseen M. Al Omoush3D, Hassan Al-Bisher2ACDE

DOI: 10.12659/AJCR.934564

Am J Case Rep 2021; 22:e934564

0 Comments

Abstract

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.

Keywords: chronic pain, Endometriosis, Hernia, Inguinal, Menstruation, Parity

Background

Endometriosis is a common gynecological disorder, with an estimated incidence of 10% in women of reproductive age [1]. It typically involves intra-pelvic organs and peritoneum, but can also affect any extra-pelvic organs [2]. It commonly occurs after implantation of endometrial tissue during previous pelvic surgical procedures [3].

Inguinal endometriosis is a rare clinical entity that was first reported in 1896 by Cullen. Its incidence is not estimated, as there are only around 50 cases reported in the literature. It represents a diagnostic dilemma as it is often misdiagnosed as other inguinal pathologies such as inguinal hernia, soft tissue tumors, and inguinal lymphadenopathy [3–5]. Most of the reported cases are managed surgically without preoperative imaging or biopsy [6]. Herein, we report a case of left inguinal endometriosis in a virgin nulliparous middle-age woman with no previous gynecological procedures, mimicking an inguinal hernia.

Case Report

A 33-year-old nulliparous woman reported having left groin pain radiating to the left thigh and aggravated by menstruation that lasted for 2 years prior to her presentation. She had regular menstrual cycles and denied any gynecological symptoms suggestive of endometriosis such as dysmenorrhea or dyspareunia. She was otherwise healthy with no previous abdominal or pelvic surgeries or any gynecological interventions. She never received hormonal therapy or contraception and she was not on any regular medications. Upon physical examination, she had a 1.5-cm left inguinal mass, tender on palpation and adherent to the underlying tissue. Ultrasonography of the abdomen and pelvis showed an ill-defined speculated solid hypoechoic left inguinal mass measuring 1.6×1.4 cm in diameter. The uterus and ovaries were within normal limits. Computed tomography (CT) of the pelvis revealed a central hypo-attenuation left inguinal mass measuring 1.7×1.2 cm in diameter and thickening of the left round ligament (Figure 1). There were no other identified lesions, or suspicion for endometriosis, malignancy, or inguinal lymphadenopathy. Based on the presentation, examination, and imaging, left inguinal hernia was one of our differential diagnoses.

The patient underwent left inguinal canal exploration that revealed a 1.5-cm mass adherent to the round ligament and floor of the canal. The mass was excised completely with a 0.5-cm safety margin. The inguinal canal floor was repaired and strengthened with proline mesh. The patient tolerated the procedure well and was discharged in good condition.

The mass was sent for histopathological examination. Macroscopically, the excised mass was 3.5×3×1.5 cm in size, and consisted of fibrous tissue, with a cut section showing hemorrhagic areas. Histopathological examination showed multiple foci of endometrial glands surrounded by endome-trial stroma embedded within the fibrous tissue (Figure 2). Postoperatively, the patient was followed up in surgery and gynecology out-patient clinics. She had no recurrences. There was no need for further imaging or postoperative hormonal therapy according to the consultant gynecologist.

Discussion

Endometriosis is characterized by the presence of normal endometrial tissue including glands and stroma at sites other than the uterine cavity. The ovaries are the most commonly affected organ, accounting for 96% of cases. Extra-pelvic endometriosis is much less commonly seen but can involve any organ [2].

Patients with inguinal endometriosis are often multiparous women with a history of previous gynecological or obstetric surgery [7,8]. We performed an extensive review of the English literature using the search terms “inguinal endometriosis”, “groin endometriosis” and/or “extra-pelvic endometriosis” in the title, abstract, and/or keywords of articles indexed in the Medline, Scopus, and Google Scholar databases, which is summarized in Table 1. Only 29 cases of inguinal endometriosis have been reported in nulliparous women similar to our case [3–49].

Patients usually present with a palpable inguinal swelling that is often associated with cyclic pain and change in size. Cyclic exacerbation of symptoms is a typical feature for endometriosis that is often missed during the initial assessment [9,10]. A history of dysmenorrhea, dyspareunia, and infertility may also be present, indicating concomitant pelvic endometriosis [10–14]. However, most patients, including this case, have regular menstrual cycles, which can be a misleading point in the clinical assessment [8,9]. Inguinal endometriosis is more common on the right side. This is believed to be associated with the presence of the sigmoid, which places pressure on the left inguinal area, acting as a preventive measure [8]. Our patient had left-sided inguinal endometriosis, which is less common, as only 13 cases in the literature review were reported on the left side [3–49].

Inguinal endometriosis mimics a wide variety of inguinal conditions such as inguinal hernia, hemangioma, lymphadenopathy, and hydrocele of canal of Nuck [3–5]. The preoperative diagnosis of inguinal endometriosis is difficult owing to its rarity and inconclusive imaging findings. In the literature, there is no comparative study assessing the efficacy of different imaging modalities in such cases. On ultrasonography, inguinal endometriosis often shows a hypoechoic unilocular or multilocular cyst that is difficult to distinguish from other inguinal region pathologies such as lymph nodes and simple cysts [5,11,16,50].

CT may not be helpful in confirming the diagnosis of inguinal endometriosis, but it can be used to exclude other possible differentials diagnoses [14,17]. However, it did not confirm the diagnosis of -inguinal endometriosis in this case. Magnetic resonance imaging (MRI) is the most specific and sensitive imaging modality for the diagnosis of endometriosis in general. MRI can detect iron particles in the hemosiderin present in the endometrioma, making it a better tool for diagnosing endometriosis than the other modalities [10,16]. The typical appearance of inguinal endometriosis is similar to pelvic endometriosis on MRI, showing high intensity on T1-weighted images and hypointensity on T2-weighted images [17,51]. However, the majority of reported cases in the literature have reported inconclusive MRI results for diagnosing inguinal endometriosis. The MRI findings were commonly atypical and non-specific for endometriosis; therefore, the diagnosis of inguinal endometriosis cannot be established [11]. A case series involving 20 patients diagnosed with inguinal endometriosis showed that the majority of patients have a mixed hyper- and hypointensity of both T1- and T2-weighted images (61.1% and 50%, respectively) [18].

Preoperative fine-needle aspiration cytology (FNAC) is diagnostic for endometriosis [19,20]. However, it is rarely performed, as most patients are treated surgically with a preoperative diagnosis of incarcerated inguinal hernia or other inguinal pathologies. The final diagnosis is confirmed by histopathological examination of the excised mass showing endometrial glands and stroma [8,19]. In our patient, CT findings did not suggest endometriosis, and an inguinal hernia was still one of the differential diagnoses. Therefore, preoperative FNAC was not done, as it could have injured the contents of the hernial sac.

It is common for patients with inguinal endometriosis to have co-existing inguinal hernia or hydrocele of canal of Nuck. The management of both conditions is surgical [5,21,22,52]. The surgical management for inguinal endometriosis requires radical excision to decrease the rate of recurrence [52]. However, most patients are managed surgically before being diagnosed with endometriosis; therefore, the radical surgical resection is not done in most cases without evidence of recurrence on follow-up [3,12,23].

Patients with inguinal endometriosis often have concomitant pelvic endometriosis. It is recommended to refer patients for complete gynecological assessment postoperatively [16,21,22]. Laparoscopic evaluation of pelvic endometriosis in patients with inguinal endometriosis is recommended if there is clinical evidence of pelvic endometriosis such as dysmenorrhea, dyspareunia, or infertility [10,11,19,21]. The use of hormonal therapy for inguinal endometriosis is controversial. Its role is more prominent in patients with concomitant pelvic endometriosis. It is sometimes recommended in patients with inguinal endometriosis as an adjuvant therapy after surgical intervention to decrease the risk of reoccurrence [7,18,19,21]. In our case, the patient did not have any clinical evidence of pelvic endometriosis, so she was only given follow-ups with gynecology without the need for diagnostic laparoscopy and hormonal therapy.

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. FNAC is diagnostic but rarely performed. FNAC for a patient in whom there is a high suspicion of inguinal hernia can injure the contents of the hernia sac. Its standard management is surgical excision. Gynecological assessment is needed pre- and postoperatively to exclude the presence of pelvic endometriosis.

References:

1.. Zondervan KT, Becker CM, Missmer SA, Endometriosis: N Engl J Med, 2020; 382(13); 1244-56

2.. Lee HJ, Park YM, Jee BC, Various anatomic locations of surgically proven endometriosis: A single-center experience: Obstet Gynecol Sci, 2015; 58(1); 53

3.. Basnayake O, Jayarajah U, Seneviratne SA, Endometriosis of the inguinal canal mimicking a hydrocele of the canal of nuck: Case Rep Surg, 2020; 2020; 8849317

4.. Fujikawa H, Uehara Y, Inguinal endometriosis: Unusual cause of groin pain: Balkan Med J, 2020; 37(5); 291-92

5.. Albutt K, Glass C, Odom S, Endometriosis within a left-sided inguinal hernia sac: J Surg Case Rep, 2014; 2014(5); rju046

6.. Stojanovic M, Brasanac D, Stojicic M, Cutaneous inguinal scar endosalpingiosis and endometriosis: Am J Dermatopathol, 2013; 35(2); 254-60

7.. Husain F, Siddiqui ZA, Siddiqui M, A case of endometriosis presenting as an inguinal hernia: BMJ Case Rep, 2015; 2015; bcr2014208099

8.. Prabhu R, Krishna S, Shenoy R, Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians: BMJ Case Rep, 2013; 2013; bcr2013200465

9.. Pandey D, Coondoo A, Shetty J, Jack in the box: Inguinal endometriosis: BMJ Case Rep, 2015; 2015; bcr2014207988

10.. Hagiwara Y, Hatori M, Moriya T, Inguinal endometriosis attaching to the round ligament: Australas Radiol, 2007; 51(1); 91-94

11.. Wolfhagen N, Simons NE, de Jong KH, Inguinal endometriosis, a rare entity of which surgeons should be aware: Clinical aspects and long-term follow-up of nine cases: Hernia, 2018; 22(5); 881-86

12.. Okoshi K, Mizumoto M, Kinoshita K, Endometriosis-associated hydrocele of the canal of Nuck with immunohistochemical confirmation: A case report: J Med Case Rep, 2017; 11(1); 354

13.. Kim DH, Kim MJ, Kim M-L, Inguinal endometriosis in a patient without a previous history of gynecologic surgery: Obstet Gynecol Sci, 2014; 57(2); 172

14.. Wang C-J, Chao A-S, Wang T-H, Challenge in the management of endometriosis in the canal of Nuck: Fertil Steril, 2009; 91(3); 936.e9-e11

15.. Dormandy T, Inguinal endometriosis: Lancet, 1956; 267(6927); 832-35

16.. Licheri S, Pisano G, Erdas E, Endometriosis of the round ligament: Description of a clinical case and review of the literature: Hernia, 2005; 9(3); 294-97

17.. Hagiwara Y, Hatori M, Katoh H, A case of inguinal endometriosis with difficulty in preoperative diagnosis: Ups J Med Sci, 2002; 107(3); 159-64

18.. Arakawa T, Hirata T, Koga K, Clinical aspects and management of inguinal endometriosis: A case series of 20 patients: J Obstet Gynaecol Res, 2019; 45(10); 2029-36

19.. Wong WSF, Lim CED, Luo X, Inguinal endometriosis: An uncommon differential diagnosis as an inguinal tumour: ISRN Obstet Gynecol, 2011; 2011; 272159

20.. Fong KNY, Lau TWS, Mak CCC, Inguinal endometriosis: A differential diagnosis of right groin swelling in women of reproductive age: BMJ Case Rep, 2019; 12(8); e229864

21.. Mashfiqul MAS, Tan YM, Chintana CW, Endometriosis of the inguinal canal mimicking a hernia: Singapore Med J, 2007; 48(6); e157-59

22.. Ducarme G, Uzan M, Poncelet C, Endometriosis mimicking hernia recurrence: Hernia, 2007; 11(2); 175-77

23.. Freed KS, Granke DS, Tyre LL, Endometriosis of the extraperitoneal portion of the round ligament: US and CT findings: J Clin Ultrasound, 1996; 24(9); 540-42

24.. Swatesutipun V, Srikuea K, Wakhanrittee J, Endometriosis in the canal of Nuck presenting with suprapubic pain: A case report and literature review: Urol Case Rep, 2021; 34; 101497

25.. Skarpas A, Kondyli P, Zoikas A, Rare findings in the groin mimicking hernia in a woman: World J Med Surg Case Rep, 2021; 10; 1

26.. Nigam V, Nigam S, Endometriosis in a right inguinal hernia sac: Int J Abdom Wall Hernia Surg, 2020; 3(1); 41

27.. Zihni İ, Karaköse O, Özçelik KÇ, Endometriosis within the inguinal hernia sac: Turkish J Surg, 2020; 36(1); 113-16

28.. Thomas JA, Kuruvilla R, Ramakrishnan KG, Endometriosis of the canal of Nuck – an unusual case of inguinal swelling: Indian J Surg, 2020; 82(4); 737-38

29.. Azhar E, Mohammadi SM, Ahmed FM, Extrapelvic endometrioma presenting as acute incarcerated right inguinal hernia in a postpartum patient: BMJ Case Rep, 2019; 12(9); e231213

30.. Nagama T, Kakudo N, Fukui M, Heterotopic endometriosis in the inguinal region: A case report and literature review: Eplasty, 2019; 19; ic19

31.. Raviraj S, Priatharshan M, A rare case of endometriosis in the canal of Nuck: J Postgrad Inst Med, 2019; 6(2); 95

32.. Ion D, Bolocan A, Piţuru S, Concomitant inguinal endometriosis and groin hernia – case report: Arch Balk Med Union, 2017; 52(4); 462-66

33.. Kiliç M, Dener C, Terzioğlu S, Inguinal endometriosis mimicking incarcerated groin hernia: J Gynecol-Obstet Neonatol, 2016; 13(1); 41-42

34.. Tsuchie H, Tomite T, Okada K, Endometriosis of right inguinal subcutaneous tissue: J Med Cases, 2016; 7(3); 98-101

35.. Borghans RA, Scheeren CI, Dunselman GA, Endometriosis of the groin: The additional value of Magnetic Resonance Imaging (MRI): J Belgian Soc Radiol, 2014; 97(2); 94

36.. Al-Ibrahim N, Endometriosis presenting as inguinal mass attached to the extra pelvic part of round ligament: Pak J Med Res, 2013; 52; 53-55

37.. Rajendran S, Khan A, O’Hanlon D, Endometriosis: Unusual cause of groin swelling: BMJ Case Rep, 2012; 2012; bcr2012007526

38.. Apostolidis S, Michalopoulos A, Papavramidis TS, Inguinal endometriosis: Three cases and literature review: South Med J, 2009; 102(2); 206-7

39.. Kaushik R, Gulati A, Inguinal endometriosis: A case report: J Cytol, 2008; 25(2); 73

40.. Ku J, Marfan M, Shea M, Differential diagnosis of an incarcerated inguinal hernia: Extraperitoneal endometrioma of the round ligament: Grand Rounds, 2006; 6; 18-21

41.. Kapan M, Kapan S, Durgun AV, Inguinal endometriosis: Arch Gynecol Obstet, 2005; 271(1); 76-78

42.. Boggi U, del Chiaro M, Pietrabissa A, Extrapelvic endometriosis associated with occult groin hernias: Can J Surg, 2001; 44(3); 224

43.. Ling CM, Lefebvre G, Extrapelvic endometriosis: A case report and review of the literature: J SOGC, 2000; 22(2); 97-100

44.. Goh JT, Flynn V, Inguinal endometriosis: Aust New Zeal J Obstet Gynaecol, 1994; 34(1); 121

45.. Imai A, Iida K, Tamaya T, Detection of inguinal endometriosis by magnetic resonance imaging (MRI): Int J Gynecol Obstet, 1994; 47(3); 297-98

46.. Mitchell AO, Hoffman AP, Swartz SE, An unusual occurrence of endometriosis in the right groin: a case report and review of the literature: Mil Med, 1991; 156(11); 633-34

47.. Quagliarello J, Coppa G, Bigelow B, Isolated endometriosis in an inguinal hernia: Am J Obstet Gynecol, 1985; 152(6); 688-89

48.. Brzezinski A, Durst AL, Endometriosis presenting as an inguinal hernia: Am J Obstet Gynecol, 1983; 146(8); 982-83

49.. Clausen I, Nielsen KT, Endometriosis in the groin: Int J Gynaecol Obstet, 1987; 25(6); 469-71

50.. Yang DM, Kim HC, Ryu JK, Sonographic findings of inguinal endometriosis: J Ultrasound Med, 2010; 29(1); 105-10

51.. Siegelman ES, Oliver ER, MR Imaging of endometriosis: Ten imaging pearls: RadioGraphics, 2012; 32(6); 1675-91

52.. Niitsu H, Tsumura H, Kanehiro T, Clinical characteristics and surgical treatment for inguinal endometriosis in young women of reproductive age: Dig Surg, 2019; 36(2); 166-72

SARS-CoV-2/COVID-19

11 August 2022 : Case report  Japan

A 32-Year-Old Man with Persistent Olfactory Dysfunction Following COVID-19 Whose Recovery Was Evaluated by ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936496  

09 August 2022 : Case report  Japan

A Case of Segmental Arterial Mediolysis of Multiple Visceral Arteries Following Anti-COVID-19 Vaccination: ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.937505  

29 July 2022 : Case report  Indonesia

Posterior Myocardial Infarction in a 45-Year-Old Javanese Woman with a 1-Month History of COVID-19-Related ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.937105  

08 July 2022 : Case report  Australia

Unusual Case of Painful Glossitis and Xerostomia Following Vaccination with Pfizer-BioNTech SARS-CoV-2 (BNT...

Am J Case Rep In Press; DOI: 10.12659/AJCR.937212  

In Press

12 Aug 2022 : Case report  Indonesia

A 30-Day-Old Infant with Necrotizing Fasciitis of the Perineal Region Involving the Scrotum Due to Methicil...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936915  

11 Aug 2022 : Case report  Japan

A Challenging Case of Streptococcus pneumoniae Meningitis in a 64-Year-Old Woman Who Presented with Symptom...

Am J Case Rep In Press; DOI: 10.12659/AJCR.937139  

11 Aug 2022 : Case report  Japan

A 32-Year-Old Man with Persistent Olfactory Dysfunction Following COVID-19 Whose Recovery Was Evaluated by ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936496  

11 Aug 2022 : Case report  Italy

A Rare Case of Negative Serum Calcitonin in Metastatic Medullary Thyroid Carcinoma: Diagnosis, Treatment, a...

Am J Case Rep In Press; DOI: 10.12659/AJCR.935207  

Most Viewed Current Articles

13 Jul 2022 : Case report  USA

Whistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound

DOI :10.12659/AJCR.936441

Am J Case Rep 2022; 23:e936441

23 Feb 2022 : Case report  USA

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

06 Dec 2021 : Case report  Brazil

Lipedema Can Be Treated Non-Surgically: A Report of 5 Cases

DOI :10.12659/AJCR.934406

Am J Case Rep 2021; 22:e934406

17 Feb 2022 : Case report  Oman

Myocarditis, Pulmonary Hemorrhage, and Extensive Myositis with Rhabdomyolysis 12 Days After First Dose of P...

DOI :10.12659/AJCR.934399

Am J Case Rep 2022; 23:e934399

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923