NON-COMMUNICATING HYDROCOELE OF THE CANAL OF NUCK: A RARE FINDING IN A RURAL-DWELLING NIGERIAN WOMAN

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K.I Egbuchulem¹, B.A. Akinboyewa², C.O Onwurah³

1. Division of Paediatric Surgery, Department of Surgery, University College Hospital, Ibadan.
2. Department of Anaesthesia, University College Hospital, Ibadan.
3. Final Year Medical Student, Faculty of Clinical Sciences, University of Ibadan, Ibadan.

Abstract

Background: The surgical condition termed hydrocoele of the canal of Nuck is one of the rarest clinical entities in the female group. It occurs due to the failure of obliteration of the derivative of the peritoneum, the processus vaginalis. It usually presents with painless inguinal swellings and is sometimes associated with features of intestinal obstruction if there is hernia coexisting with it that has become obstructed. Abdominopelvic ultrasonography and magnetic resonance imaging provide the basis for diagnosis, where these imaging modalities are available. However, a definite diagnosis may only be made during surgery. Definitive treatment includes groin exploration and excision of the cyst with high ligation of the neck of the sac up to the peritoneal pouch, along with repair of the inguinal hernia, if present.

Case Presentation: We present a rare case of a 34-year-old woman who presented with clinical features of a left inguinolabial swelling post-surgery, and diagnosed as left recurrent irreducible inguinal hernia. Intraoperatively, a cystic swelling with serous collection was observed. She had hydrocoelectomy and repair of the left groin surgical wound.

Conclusion: Hydrocoele of the canal of Nuck may be misdiagnosed as inguinal hernia because of its rarity, lack of adequate knowledge regarding the entity and paucity of literature on the subject matter. This report is to furthermore increase our level of awareness of this condition especially after a previous groin surgery.

Keywords: Canal of Nuck, Hydrocoele, Rural Nigerian woman.

Introduction

Hydrocele of the canal of Nuck is an uncommon condition seen in the female adult population. It is an anatomical extension of the parietal peritoneum that has developed into an analogous entity, and when it fails to obliterate, hydrocele could develop.^1-3.

Hydrocele of the canal of Nuck was first described by Anton Nuck in the seventeenth century, and the fluid filled processus vaginalis (Hydrocoele) within the inguinal canal of the female is named after him.⁴. The incidence of a patent processus vaginalis decreases with age. In newborns, 80-94% have patent processus vaginalis.⁵As many as 30% of adults are discovered to have a patent processus vaginalis at autopsy. Why all patient with patent processus vaginalis do not develop into hydrocoele is not well understood. Hydrocoele of the canal of Nuck occurs more in adult females and less in infants and girls.⁶

We report a case of an adult female who initially was thought to have a left recurrent irreducible Inguinolabial Hernia status post a previous left groin hernia repair. She had groin exploration with finding of a left cystic swelling within the canal of Nuck. The aim of this report is to draw the attention of practitioners to the occurrence of this rare finding, and to make them raise their index of suspicion and consider this as a possible differential diagnosis in young females who present to them with inguinolabial swelling especially after previous groin surgery.

CASE PRESENTATION
She is a 34-year-old woman, trader and farmer who lives in Ago-are area of Oyo State in western Nigeria. She presented to a surgical outreach with complaints of progressive painless swelling in the left groin. Symptoms were said to have been noticed after a left inguinal repair which she had three months earlier at a secondary health facility for an inguinal hernia. The procedure was said to be largely uneventful. There was no family history suggestive connective tissue disorder and she neither takes alcohol nor smoke cigarette. There is no history of chronic cough,constipation, or abdominal swelling. There were no features suggestive of intestinal obstruction.

On general examination, she was not found to be obese, no swelling on the right groin region, the left groin revealed a previous well-healed scar, no positive cough impulse, an irreducible left Inguinolabial swelling, with soft consistency and non-tender, measuring approximately 10 × 4 centimeters. Transillumination was unremarkable and vital signs were within normal limits.

A preoperative clinical diagnosis of Left Recurrent Irreducible Inguinolabial hernia was made. (Figure 1).
Laboratory investigations done were within normal limits. The patient was prepared for surgery as per the routine for groin swellings and consents were obtained.

A left groin exploration was done under a subArachnoid block type of anaesthesia. The findings of dilated left canal of Nuck with a cystic swelling containing serous fluids (Figures 2) were in keeping with a left non-communicating hydrocele of the canal of Nuck (Type 3).⁷

This cystic lesion extended up to the deep ring, (Figure 3) and this was excised after high ligation of the sac with Vicryl 2/0 suture and the external oblique aponeurosis, subcutaneous layer of the surgically created groin wound were repaired with nonabsorbable suture. The immediate post-operative period was uneventful.

The patient was discharged on the second postoperative day. A follow-up visits to the clinic in the second and sixth post operative weeks showed satisfactory wound healing.