Inguinal hernia containing uterus and one ovary

Clinical History

An otherwise healthy 2-month-old girl was sent to the radiology department for ultrasound evaluation of an asymptomatic left inguinal mass, extending to the left major labium. No groin masses were present at birth.

Imaging Findings

Ultrasound of the left inguinal and labial regions using a high-frequency linear probe revealed a large inguinal hernia. The hernia contained some anechoic fluid, as well as a solid mass and a cystic structure. The morphology of the solid mass resembled that of the uterus, with the typical hyperechoic lining of the endometrium. The cystic structure was suspected of being a follicular cyst arising from the left ovary. The findings were confirmed at surgery.

Discussion

Inguinal hernia is a very common paediatric congenital anomaly, especially in the first year of life. The majority are indirect hernias since they enter the inguinal canal through the internal ring. They are a result of persistent patency of the processus vaginalis, in contrast to weakness of the fascia transversalis in the adult population. The processus vaginalis is a peritoneal extension through the inguinal canal in the fetus, which accompanies the descending testis to the scrotum in boys and the round ligament to the labium majora in girls. In the majority, it closes around the time of birth and ought to before one year of age [1, 2]. Delayed or failed closure leads to a persistent connection with the peritoneal cavity, called the canal of Nuck in girls [2, 3]. Girls are less frequently affected, accounting for 17-23% of cases. There is a right side predominance and bilateral involvement is seen in 10% of all cases. The hernia may contain peritoneal fluid, omentum and/or intestines. A herniated ovary occurs in 15-25% of patients [3-5]. A herniated uterus is very rare and is more commonly reported with disorders of sexual development [1]. To date, there are only a few published case reports documenting a hernia containing both uterus and ovary [1, 3-7]. Some authors suggest this entity is caused by primary weakness of the suspensory uterine and ovarian ligaments [3-5].
Female neonates usually present with an asymptomatic unilateral inguinal or labial swelling or mass. Ovarian torsion resulting in ovarian ischaemia is described in 2-33% of cases; such patients are more likely to present with a painful, irreducible mass, however, others will be asymptomatic. Hence early surgical repair is recommended in irreducible hernias, even in the latter [8].
A labial mass in a prepubertal female has a large differential diagnosis [2]. High-frequency ultrasound is the imaging modality of choice since it is an easy, cheap and readily available tool combining high diagnostic efficacy with the advantage of not using harmful radiation. The goal is trifold: to confirm the inguinal hernia, its content and to detect signs of ischaemia. Inguinal hernia is confirmed by showing a connection between the peritoneal cavity and the inguinal lesion. A cystic structure in an inguinal hernia is highly suggestive of a follicular cyst on a herniated ovary. In cases of associated ovarian ischaemia, decreased or absent vascularity and increased ovarian volume may be seen. Furthermore, ultrasound can be of aid in preoperative evaluation and planning [1].

Differential Diagnosis List

Final Diagnosis

Inguinal hernia containing the uterus and the left ovary

URL:	https://www.eurorad.org/case/12026
DOI:	10.1594/EURORAD/CASE.12026
ISSN:	1563-4086