Paroxysmally Painful Right Inguinal Mass

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Paroxysmally Painful Right Inguinal Mass

• Andrew H. Kerstein, BS, M3
• October 30, 2006

2
Case History

• 43 year old obese Hispanic female presented to
  the medical clinic with a one year history of
  pain in the right groin area.
• Pt states that the pain is more pronounced during
  her menstruations. It is associated with a waxing
  and waning lump in the same area.
• Past History C-sections at age 26 and 28.
  History of GERD and arhtlagias.
• Meds NSAIDs on a prn basis.
• No history of allergies.

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Physical Examination

• Middle age woman, somewhat obese, in no distress.
• Neck, no adenopathy or thyromnegaly.
• Breasts, without masses or tenderness.
• Chest, clear to auscultation.
• Heart, no murmur or gallop.
• Abdomen, obese. Transverse C-section scar.
• Inguinal area, suggestion of a mass in the right
  inguinal region, ? 8 cm.

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Labs

• HGB 12.9 g/dl
• HCT 38.8
• WBC 8,400 µ/L
• PLT 261,000 µ/L
• HCG 0
• Na 138 mEq/L
• K 4.2 mEq/L
• Cl 104 mEq/L
• HCO3 27.7 mEq/L
• BUN 14 mg/dl
• Cr 0.8 mg/dl
• Glu 98 mg/dl
• Ca 8.1 mg/dl
• Urine analysis Spec. gravity 1.015. Negative
  otherwise.

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Differental Diagnosis

• Right Indirect Inguinal Hernia
• Right Direct Inguinal Hernia
• Lipoma
• Endometrioma
• Metastatic tumor

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Operative Procedure

• Operative findings An incision was made above
  and parallel to the inguinal ligament to the
  right end of previous abdominal incision for
  C-section.
• Dissection was carried out through the external
  oblique muscle.
• A thick dark brownish mass was found in the
  operative field adhered to the surrounding
  adipose tissue.
• Excision of the mass was performed with sharp
  dissection.
• Anesthesiologist gave positive pressure to
  uncover a possible hernia defect. However, none
  was observed.
• At this point wound was irrigated and closed in
  usual manner.
• Patient tolerated the procedure well.

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Pathology

• Frozen section performed- Dx- endometriosis
• Report Specimen consists of two irregularly
  shaped soft tissue masses aggregating in totto 5
  x 4 x1 cm. Focal areas of slightly firm
  hemorrhage are present on sectioning of both
  fragments.
• Histology Fibroconnective tissue with
  endometriosis and focal chronic inflammation.

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Fibroconnective Tissue containing islands of
glandular tissue. Glands and Stroma key to
diagnosis. Morphology consistent with
endometrium.
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Enmetrial glands in ectopic mass found in right
inguinal region.
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Endometriosis
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Discussion

• What is endometriosis?- Essentially, it is an
  abnormal growths of tissue, histologicallly
  resembling the endometrium, present in locations
  other than the uterine lining.
• Exact prevalence is not known due to surgery
  being required for diagnosis. It is estimated to
  be present in 3-10 of women in the reproductive
  age group and 25-35 of infertile women.
• Endometriosis is the single most common
  gynecologic dx responsible for hospitalization of
  women age 15-44.

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Etiology

• The most perplexing question- How does it get
  there?
• Retrograde menstruation? Fist proposed in the
  1920s
• Coelomic Metaplasia? by lymphatic or
  hemotagonous spread of irritant.
• Immune? The activity of peritoneal natural
  killer and T lymphocytes is suppressed in women
  with endometriosis.- unclear whether cause or
  effect of endometriosis
• Surgical Implantation? Previous abdominal and
  Pelvic Surgeries, especially gynecologic.

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Review of the Literature

• Endometriosis consists of the presence of
  extrauterine endometrial tissue. It is usually
  localized in the pelvis, although it can also be
  found in other sites.
• Cutaneous localization is unusual and the most
  frequent form appears on scars from obstetric or
  gynecological interventions. It can, however,
  develop spontaneously, especially in umbilical or
  inguinal areas and can be confused with
  irreducible hernias or granulomas.
• We present the cases of three patients with
  spontaneous endometriotic nodules of the
  abdominal wall. The lesions were located in the
  umbilical region in two patients and in the
  suprapubic area in one.
• In two patients clinical suspicion led to
  preoperative diagnosis, although diagnosis is
  usually established after histopathological
  analysis of the surgical specimen.

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Review of the Literature

• Inguinal endometriosis is a relatively rare
  clinical condition, accounting for 1 of
  extra-uterine locations. Owing to the particular
  anatomical area affected, the diagnosis in the
  asymptomatic forms proves difficult. Imaging
  fails to yield a reliable diagnosis, which is
  only possible on the basis of histological
  findings.
• Rare cases of neoplastic transformation have been
  reported. The case described here may be
  emblematic in terms of the migratory pathogenesis
  of the lesion. Endometriosis is seldom of
  interest to the general surgeon, since it is
  generally an exclusively gynecological condition.
  Atypical locations, however, do fall within the
  domain of general surgery, which is what prompted
  us to review the relevant literature.

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Clinical Manegement of Endometriosis

• The clinical manifestations, the radiologic
  appearance and the treatment of four women with
  extragenital endometriosis of the abdominal wall
  are presented.
• In two patients endometriosis was found adherent
  with the structures of the inguinal canal and in
  the other two the tumors infiltrated structures
  of the abdominal wall.
• Symptoms included cyclical pain and palpable
  subcutaneous masses fixed to the surrounding
  tissues.
• Computed tomography and magnetic resonance
  imaging failed to differentiate the lesions from
  other soft tissue tumors.
• Resection to healthy tissue margins is the
  treatment of choice, in order to avoid local
  recurrence.

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Is Scar Endometriosis Associated with Previous
History of C-Section?

• Surgical scar endometriosis following caesarean
  section has an incidence of 0.03 to 0.4.
• A retrospective study reviewed all the cases of
  parietal endometriosis seen during a 7-year
  period in the department of visceral surgery of
  the Armentiere's hospital center.
• 15 women were treated during this period. The
  mean age is 32 years. All the women have one or
  two antecedents of caesarean with Pfannenstiel's
  laparotomy (transvere type of scar in lower
  abdominal wall).
• The interval between the caesarean and the
  appearance of the first symptoms is on average of
  5 years and 11 months.
• Only 66.6 of cases presented the classical
  symptoms with cyclic pain. For 66.6 of patients,
  the diagnosis of parietal endometriosis was
  suspected before the treatment.

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Is Scar Endometriosis Associated with Previous
History of C-Section?

• The treatment is a surgical.
• In 13.3 of the cases, the lesion is pre
  aponeurotic. In 46.6 of the cases, it overgrows
  the rectus abdominis muscle, in 33.3 of the
  cases the external abdominal oblique and at last
  a lesion overgrows the transversus abdominis and
  one is in an inguinal localization.
• The mean size of lesions is 2.48 cm.
• We have not notified complications and no
  recurrence was noted.
• The local endometrial cell transplant is the most
  likely mechanism to explain the physiopathology
  of parietal endometriosis. The surgical treatment
  has to be sufficiently wide to avoid all
  recurrence. No means of prevention has proved its
  efficiency.
• In 26.6 of cases the parietal endometriosis is
  associated to pelvic endometriosis. This
  localization is more often asymptomatic.
  Laparoscopic exploration is not indicated
  immediately.

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Treatments

• Hormonal- OCPs, Progestional Agents
  (medroxyprogesterone acetate), Danazol,
  Gestrinone (supresses secretion of FSH and LH),
  GnRH agonists
• Surgery is the most definitive treatment.

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References

• Memarzadeh, Sanaz MD Muse Jr., Kenneth N. MD ,
  and Fox, Michael D. MD 40. Endometriosis. Current
  Obstetric Gynecologic Diagnosis and Treatment-
  9th Ed. (2003)
• Inguinal endometriosis a case report and review
  of the literature
• Bronzetti B,
• Cucinotta A,
• Lucibello L,
• Napoli P,
• Celi D.
• S. C. di Chirurgia Generale, Azienda Ospedaliera
  Piemonte, Messina.

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• Endometriosis mimicking soft tissue tumors
  diagnosis and treatment.
• Marinis A,
• Vassiliou J,
• Kannas D,
• Theodosopoulos TK,
• Kondi-Pafiti A,
• Kairi E,
• Smyrniotis V.
• Second Department of Surgery, Areteion University
  Hospital, Athens Medical School, Athens, Greece.

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• Primary endometriosis of the abdominal wall an
  entity to be included in the differential
  diagnosis of abdominal wall masses
• Parra PA,
• Caro J,
• Torres G,
• Malagon FJ,
• Tomas F.
• Servicio de Cirugia General y Aparato Digestivo,
  Fundacion Hospital de Cieza, Cieza, Murcia,
  Spain. pedroapb_at_yahoo.es

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• Abdominal wall endometriosis after caesarean
  section report of fifteen cases
• Picod G,
• Boulanger L,
• Bounoua F,
• Leduc F,
• Duval G.
• Service de chirurgie gynecologique, hopital
  Jeanne-de-Flandre, CHRU de Lille, avenue Avinee,
  59037 Lille cedex, France. g.picod_at_caramail.com

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Special Thanks

• Ignacio Fleites, M.D. F.A.C.S.
• Hector Colom, M.D. F.A.C.P.
• Antonio M. Gordon, Jr., M.D., Ph.D. F.A.C.P.