Groin mass in a young woman: expanding the differential

Daniel Guy MD, Joseph Hardman MD

Oregon Health & Science University, Portland, Oregon
Introduction
Inguinal region swelling and palpable masses are frequently
encountered in the clinical setting. They present a diagnostic
challenge as they encompass a wide variety of disorders. We
present a case of an unusual cause of an inguinal mass in a
young female. It is so unusual that many providers are
unaware of its existence.
Case Description
• A 29 year old healthy woman presented with a tender
right groin mass the size of a grape. The mass had been
present for three weeks causing pain with walking.
• She had no surrounding erythema, swelling, fever, chills,
weight loss, or night sweats. There was no preceding
trauma to the area.
Clinical Course Discussion
• With a possible diagnosis of hematoma, the patient was • Incomplete proximal obliteration of the canal of Nuck (the
discharged home with a follow-up plan. female counterpart of the processus vaginalis in males) leads
to a congenital patent pouch of peritoneum between the
• As symptoms persisted, a repeat US was obtained a
round ligament of the uterus and the labia majora.
month later and revealed an enlarging complex cystic
structure. • This may result in the development of a cystic swelling,
which is not reducible and does not worsen with Valsalva
• A subsequent contrast enhanced CT scan demonstrated maneuver. This can happen at any age!
thickening within the right inguinal canal along the round
• Hydrocele ≠ Inguinal hernia, as no omentum or intestine are
ligament. There was a fluid density compatible with a
present within the sac.
hydrocele of the canal of Nuck.
• The patient was referred for surgical consultation and Differential Diagnosis of Inguinal Swelling/Mass
decided to proceed with laparoscopic resection of the Trauma (hematoma, soft tissue injury) Anatomic (inguinal hernia, femoral
lesion. hernia, Bartholin’s cyst)
Infectious (abscess, lymphangitis) Vascular (femoral aneurysm, DVT)
Benign neoplasms (lipoma, Malignant neoplasms (lymphoma,
neurofibroma) sarcoma, metastasic disease)

• Physical exam revealed normal vital signs, a medial

inguinal nodule approximately 2 cm in size, which was
slightly tender to the touch. There was no change with
Valsalva maneuver. There was no palpable
lymphadenopathy.
Inguinal US showing a hypoechoic nodule
• Labs with normal CBC.
• Inguinal US demonstrated a 2.2x0.8x2.5 cm non-
compressible hypoechoic nodule just to the right of the
midline and medial to the femoral vessels. There was no
vascularity on Doppler and no change with Valsalva
maneuver.
CT showing thickening within the right inguinal canal
in the subcutaneous tissue
CT Abdomen/Pelvis showing a fluid density within the right inguinal canal,
consistent with a hydrocele of the canal of Nuck
Take Home Points
• The differential diagnosis for an inguinal mass in a young
woman is broad and encompasses pathologies from multiple
systems.
• Female hydrocele, also known as a cyst of the canal of Nuck,
is an unusual diagnosis that ought to remain on the
differential.
• US is invaluable in evaluation of inguinal masses.
References:
1. Stickel WH, Manner M. Female hydrocele (cyst of the canal of Nuck): sonographic
appearance of a rare and little-known disorder. J Ultrasound Med 2004; 23(3):429-32.
2. Bunni J, Gillam M, Pope IM. Hydrocele of the canal of Nuck—an old problem revisited.
Front Med 2013; 7(4):517-9.
3. Ozel A, Kirdar O, Halefoglu AM et al. Cysts of the canal of Nuck: ultrasound and magnetic
resonance imaging findings. J Ultrasound 2009; 12(3):125-7.
4. Bagley JE, Davis MB. Cyst of Canal of Nuck. Journal of Diagnostic Medical Sonography
2015; 3(2):111-114.