Inguinal endometriosis: Ten case reports and review of literature

Table 1 Clinical data of patients with inguinal endometriosis in this study

Index	Cases, n (%)	Percentage, n (%)
Age at diagnosis (yr)	38 (32-53)
Age distribution	Total: 10
30–39 yr	5	50
40–49 yr	3	30
50 yr and older	2	20
Parity
Nulliparous	4	40
Dysmenorrhea
Yes	7	70
No	3	30
Surgical history	6	60
Cesarean section	1	10
Pelvic endometriosis	4	40
Inguinal hernia	1	10
No surgical history	4	40
Department of admission
Gynecology	2	20
General surgery	8	80
Laterality of inguinal endometriosis
Right	8	80
Left	1	10
Right and left	1	10
Lesion size (cm)	3.2 ± 1.2
Symptoms
Presenting symptoms	10	100
Symptoms related to menstruation	5	50
Symptoms not related to menstruation	5	50
No symptoms (incidental findings)	0	0
Swelling
Yes	10	100
No	0	0
Block size varies with body position
Yes	9	90
No	1	10
Pain
Yes	10	100
No	0	0

Table 2 Characteristics of patients who underwent surgery for inguinal endometriosis

Case	Age (yr)	EM history	Parity	Surgery year	Laterality	ICS	Preoperative diagnosis	US/MRI	Site of EM	Surgery	Postoperative diagnosis	Follow-up (mo)
1	47	-	P	2018	R	-	IH/cyst of Nuck’s canal?	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	24
2	52	+	P	2016	R	-	IH/IEM?	US: Low echo with cluster; Cysts (IEM); MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	41
3	33	-	P	2017	R	+	IH/cyst of Nuck’s canal?	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	24
4	53	-	P	2018	R	+	IH	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	12
5	35	+	N	2018	R	-	IH	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	19
6	36	+	N	2019	R	-	IH	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	13
7	42	-	P	2015	R	+	IH	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (R); IH (R)	60
8	40	+	N	2012	L	-	IH	US: Hetero-geneous echo; MRI:/	Extraperitoneal round ligament	Wide excision of the lesion; Hernia repair	IEM (L); IH (L)	70
9	32	-	N	2014	R	+	IEM; Pelvic EM	US: Hetero-geneous echo; MRI: IEM (R)	Extraperitoneal round ligament	Wide excision of the lesion	IEM (R); Pelvic EM	88
10	36	-	P	2011	B	+	Bilateral IEM; IH (R)	US: Hetero-geneous echo (L) + cyst (R); MRI: IEM (bi)	Extraperitoneal round ligament (L); Hernial sac (R)	Wide excision of the lesion (L + R); Hernia repair (R)	IEM + IH (R); IEM (L)	97

ICS: Inguinal catamenial symptom; IH: Inguinal hernia; IEM: Inguinal endometriosis; N: Nulliparous; P: Parous; US: Ultrasonography; MRI: Magnetic resonance imaging; EM: Endometriosis.

Table 3 Literature reviewed of this study

Ref.	Case number	Age (yr)	Side	Size (cm)	EM history, n (%)	Reproductive history	Presenting symptoms	Imaging	Preoperative diagnosis	Site of lesion	Operation	Recurrence
Kapan et al[14], 2005	3	39-51	R: 2; L: 1	2-4	/	/	Groin lump (100%)	/	0	Type I (1); Type II (2)	Wide excision of lesion (3); Hernia repair (3)	/
Gaeta et al[22], 2010	8	30 (22-46)	R: 8	1.5-4.5	/	/	Groin lump (100%); Pain (50%); Catamenial symptom (25%)	MRI: Type I: Prevalently cystic (2/8); type II: Prevalently solid with small scattered cysts (6/8)	100%	Type I (8)	Wide excision of lesion (8)	/
Sun et al[9], 2010	9		R: 8; L: 1	/	/	/	Catamenial symptom (66%)	/	33%		Excision of inguinal lesion (8/9); Extra round ligament (1/9); Laparo-scopy (4 pelvic EMs)	0%
Wong et al[39], 2011	1	48	R	4 × 5	No	Gravida 3, para 3	Period pain at the groin during menses	US: A slightly bulky uterus	Fineneedle aspiration biopsy of the mass revealed EM	Proliferative endometrium	Solid, fibroid-like tumor was removed from the right groin	Remained asymptomatic and underwent a second exploratio: Revealed a multinodular subinguinal endometriotic lesion
Rajendran et al[15], 2012	1	36	L	2 × 2		Crampy lower abdominal pain and a lump in her left groin. The lump present for 3 yr		CT: Mass adjacent to the rectus femoris muscle. US: A 2 × 2 cm solid mass with evidence of blood flow at the posterior aspect		Biopsy of the lesion revealed endometrial tissue
Albutt et al[44], 2014	1	23	L	2.1	No	No	A new-onset tender bulge with subjective fevers and chills	US: Avascular complex cystic lesion measuring 2.1 cm in the left groin. CT: A tubular cystic structure along left inguinal canal, round ligament	Inguinal hernia	Fpathology: A hydrocele with concordant EM	The cystic structure was dissected away from the round ligament	no
Mourra et al[17], 2015	42	35 (20-53)	R: 29; L: 11; Unk: 2	3.36 (1-5)	5	/	Groin lump (100%)	/	31%	/	Wide excision of lesion (42); Hernia repair (8); Laparo-scopy (4)	1 (2.38%)
Çayır et al[37], 2018	1	35	R	2.5 × 1.5				US: Hypoechoic solid mass of 2.5 cm × 1.5 cm
Wolfhagen et al[13], 2018	9	32.5 (27-43)	R: 7; L: 2	/	0	P: 4; N: 5; S: 2	Groin lump (100%); Catamenial symptom (44%)	US: 1/7 suggestive for IEM; MRI: 0/4 suggestive for IEM; Image: 3/7 suggestive for hernia; Fin: 1/2 suggestive for IEM; 1/2 inconclusive	33%	Type I (7); No mention (2)	Wide excision of lesion (9); Laparo-scopy (1 pelvic EM)	0%
Niitsu et al[10], 2019	28	20-50	R: 25; L: 3	1-3.3	4	/	Groin lump (100%); Catamenial symptom (57.1%)	US: Low or with cyst (28/28); CT: Soft tissue density (18/18); MRI: T1 low/T2 low (3/3)	71.4%	Type I (15); Type II (10); Type Ⅲ (3)	Wide excision of lesion (28)	2 (7.1%)
Arakawa et al[18], 2019	20	37.2 ± 6.7	R: 13; L: 5; R and L: 2	2.4 ± 1.1	11	P: 3; N: 17	Groin lump (100%); Pain (100%); Swelling (70%); Catamenial symptom (80%)	US: Solid mass (15/20), cystic mass (2/20), mixed (1/20), no record (2/20); CT: Inguinal mass (13/13); MRI: Solid (9/18), cystic + solid (8/18), cystic (1/18)	5/6	No mention	Operation: Radical excision of lesion (5/6), Wide excision of lesion (1/6); Hormone: OC (4/8), DNG (4/8); Chinese medicine (1); No treatment (5)	1 (5%)
Jena et al[4], 2020	1	25	r	3 × 2	No		2-yr history of painful persistent mass in the right groin and her symptoms fluctuated with the menstrual cycle	MRI: 2.7 cm × 1.7 cm × 1.6 cm heterogeneous nodular lesion in the right inguinal subcutaneous plane superficial to the adductor muscles and at the lower edge of the rectus abdominis muscle	Inguinal hernia	Mass showed the possibility of intramuscular endometriosis	Excision of the lesion and the	Patient was symptom free on subsequent follow-up
Zihni İ et al[25], 2020	1	31	r	2.1 × 1.2		The patient had given birth by caesarean section 2 yr previously	Pain and swelling in the right inguinal area. The complaints had been ongoing for approximately 1 yr, and the pain and swelling increased undertaking strenuous labour	US: A cystic structure, 21 mm × 12 mm in size, was seen within the hernia pouch in the right inguinal canal
Basnayake et al[23], 2020	1	27	r	4 cm × 4 cm	No	No	Enlarging, painless, right inguinal swelling of 4 mo duration	US: Multiloculated, thin septated, anechoic cystic swelling without increased internal vascularity at the right inguinal region	There was no demonstrable hernia	The histology: Type I endometriosis	A complete excision of the cyst was performed	Follow-up after 1 yr showed no evidence of recurrence
This study	10	38 (32-53)	R: 8; L: 1; B: 1	3.2 ± 1.2	4	P: 6; N: 4	Groin lump (100%); Pain (100%); Swelling (100%); Catamenial symptom (50%)	US: Low echo with cluster cysts (1/10); heterogeneous mass (8/10); heterogeneous low echo lesion (L) + cyst echo (R) (1/10); MRI: T1 +c high (2/2)	30%	Type II (9); Type I + II (1)	Wide excision of lesion (10); Hernia repair + mesh (9)	0%

EM: Endometriosis; MRI: Magnetic resonance imaging; N: Nulliparous; P: Parous; S: Subfertile; US: Ultrasonography.