Kotekar O**, Prasad R***.
Obstetrician and Gynecologist , Deenanath
** Consultant Obstetrician and
Gynaecologist, Dr. Saroj Tamboli Memorial Hospital, Alibaug; *** Clinical
attache to Dr. Mahindra Borse; India
Hydrocele of canal of Nuck
in an adult female is a rare entity
arising from a persistent fold of peritoneum. Here we describe a case of an
hour-glass shaped hydrocele in a 32 year old multiparous lady with a 20-week
size fibroid uterus. Following laparoscopic myomectomy the hydrocele was
excised and the deep inguinal ring was repaired with purse-string polypropylene
Hydrocele of canal of Nuck
is a rare entity. It arises from a
persistent fold of peritoneum (canal
), analogous to
the processus vaginalis in the male that failed to fuse and involute in early
extra – uterine life. Though the condition is most often seen in young girls with
an incidence of 1%
, it has been reported in older women. The
hydrocele can be small and asymptomatic, or grow to form a large multiloculated
or could be associated with an indirect inguinal
hernia. Here, we report a case of a
large fibroid uterus with an associated hydrocele.
A 32 year old
woman, para 2 living 2, presented with complaints of menorrhagia since 6 months
and a gradually increasing lump in the lower abdomen and left groin since one
year. Her menstrual cycles had increased in duration from 3 to 10-12 days over
the last 6 months, with heavy flow and passage of clots. She began to feel a
firm lump in her lower abdomen one year ago, which had gradually increased in
size and was presently as big as a fist. At about the same time, she felt an
additional mass in her left groin, which also increased in size over the period
of a year. On examination, her general condition was fair except for mild
pallor. On local examination, a 4*4 cm flocculant, nontender, irreducible
swelling was noted in the left inguinal region.
Inguinal component of the hydrocele (arrows).
There was no impulse
generated over the mass when the patient was asked to cough. The contralateral
inguinal region was normal. Per abdomen, a 20-week size firm, immobile mass was
palpable arising from the pelvis. On per speculum examination, the cervix and
vagina were found to be healthy. The vaginal examination confirmed the presence
of a 20-week size uterus with normal adnexae. A provisional diagnosis of
fibroid uterus with left sided hydrocele of canal of Nuck
was made. On ultrasonography a 12x10x10 cm anterior wall fibroid was
visualized. However, the inguinal area had not been imaged. After correction of
anemia, she underwent a laparoscopic myomectomy with high ligation of the canal of Nuck
on the left side and tubal ligation.
Intraoperatively, the uterus was enlarged with an anterior wall fibroid of
about 10x10x10 cm and a 2x3 cm cyst was seen stretching the left deep inguinal
ring. This was the intra–abdominal portion of the hydrocele. The trans -
illumination test was positive. The fallopian tubes and ovaries on both sides
Figure 2 – Intraabdominal portion of the hydrocele (black arrow), enucleated leiomyoma (yellow arrow)..
over the cyst was incised and drained to permit visualization of the canal. The
cyst wall was dissected off the round ligament and surrounding connective
tissue and sent for histopathological examination.
Figure 3 –
Opening of the overlying peritoneum
deep inguinal ring was then repaired using a 1-0 polypropylene suture taken in
a purse string fashion, incorporating the round ligament into the stich, and
thus obliterating the opening. At this
point, the bulge above the labia majora disappeared, even when the
pneumoperitoneal pressure was raised to 25 mm of Hg. A second stitch was taken to ensure adequate
closure. The overlying peritoneum was closed. The right deep inguinal ring was
found to be normal.
Figure 4: Purse-string suture obliterating the deep
inguinal ring (arrow).
report of the cyst wall showed a mesothelial cell lining along with fibrocollagenous and fibrofatty tissue. She made an uneventful recovery and at her
3-month follow up visit the she was cured.
The canal of Nuck
is a fold of peritoneum that
traverses the inguinal canal and ends at the labium majus which begins to fuse during
month of fetal life and occludes completely to form a
fibrous cord by the 1st
year of extra-uterine life. If the fold
remains patent, it can form a hydrocele (due to accumulation of fluid) or a
hernia (due to abnormal protrusion of viscous). There is a 1% incidence of hydrocele
of canal of Nuck
in children, but its incidence in the adult female is unclear
because of its rarity.
The mesothelial cells that line the canal secrete
fluid that is reabsorbed through venous channels or the lymphatics.
Inflammation, trauma or blockage of lymphatic channels could lead to an
imbalance in the rate of secretion and absorption, resulting in a hydrocele,
though in most cases the occurrence is idiopathic.
In our case, the
probable etiology could be blockage of lymphatic channels due to pressure from
the large fibroid as the hydrocele first manifested when the fibroid began to
grow. Hydrocele of canal
could be encysted
(present along the track of descent), have a persistent communication with the
peritoneal cavity or be shaped like an hourglass. In our case it was the third
type with both abdominal and inguinal components constricting at the deep
differential diagnoses for inguinal masses in women of reproductive age include
hernia, lymphadenopathy, haematoma.[3,5,6]
inclusion cyst, round ligament cyst, ganglionic cyst, abscess, varicosity of
the round ligament
and rarely endometriosis.
presence of an irreducible, flocculant, transilluminant mass without a cough
impulse or tenderness or signs of inflammation on it points to the diagnosis of
a hydrocele. It can be confirmed on ultrasound which often shows a well-defined
hypoechoic or anechoic mass in the inguinal region with posterior enhancement.[6,9]
The most common complication is an associated hernia. Rare ones include
hydrocele/ hernia of the contralateral side and infection.
A report by
Counsellor and Black on the histology of the hydrocele cyst wall in 17 cases showed
flattened mesothelial cells and fibrous tissue along with occasional smooth
muscle cells and blood vessels. 
Our report was congruent with
these findings. The standard recommended treatment for this condition is
excision of the hydrocele sac and high ligation of the canal of Nuck.
This can be done through a groin incision or laparoscopically
the latter has the advantages of a shorter operating lime, less post–operative
pain and minimal scarring. If there is an associated hernia, a Trans–abdominal
pre–peritoneal (TAPP) or Total extra–peritoneal procedure (TEP) may be
However, for an isolated hydrocele, a TAPP or TEP is
not justified due to complications of the mesh like adhesions, peritoneal
migration of the mesh, infection, bowel obstruction and scarring.
Women, who in addition to their benign
gynaecological condition, have a hydrocele of canal of Nuck, can be adequately
treated by laparoscopic excision, high ligation of canal, and repair of the
deep inguinal ring in the same sitting.
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Borse M, Kotekar
O, Prasad R. Laparoscopic Repair of Hydrocele of Canal of Nuck
JPGO 2015. Volume 2 No. 5.
Available from: http://www.jpgo.org/2015/05/concurrent-laparoscopic-myomectomy-and.html