This report describes a rare case of immunohistochemically confirmed endometriosis-associated hydrocele of the canal of Nuck in a 44-year-old Japanese woman. Endometriosis is a chronic estrogen-dependent condition that affects 6 to 10% of reproductive-aged females . While ectopic endometrial tissue may appear anywhere in the body, implants tend to be located in the pelvic region. As a result, extrapelvic endometriosis is relatively rare. Scott and Te Linde  conducted an analysis of 516 endometriosis cases that included only four cases (0.8%) of inguinal endometriosis; among these, three cases involved the inguinal portion of the round ligament and one case involved the canal of Nuck. In addition, Jimenez and Miles  reported the incidence of endometriosis in the extraperitoneal portion of the round ligament to be 0.42%. Some researchers have described the diagnostic difficulty of inguinal endometriosis, and the most common preoperative diagnosis is inguinal hernia [11, 12].
To the best of our knowledge, few reports have conducted an immunohistochemical confirmation of endometriosis-associated hydroceles of the canal of Nuck. Usuki et al.  reported that the cyst-lining cells of such hydroceles were positive for calretinin and podoplanin, and that the subepithelial stromal cells were positive for CD10. In our patient, the cyst-lining cells were positive for podoplanin and the stromal cells were positive for estrogen receptors. These findings verified that the hydrocele was associated with endometriosis.
Previous studies have reported the identification of hydroceles of the canal of Nuck through ultrasound [2, 3] and MR imaging [3, 14]. Ozel et al.  reported that sonography showed a tubular cystic structure with internal septae in the inguinal canal of a female with inguinal swelling, and MR imaging found that the mass was hypointense in T1-weighted imaging and hyperintense in T2-weighted imaging.
Because our patient had previously undergone laparoscopic surgery for intrapelvic endometriosis, we were able to consider the possibility that the inguinal swelling was due to recurrent endometriosis. However, she did not notice that the inguinal swelling was related to her menstrual cycle, and had requested surgical excision for pain relief.
Treatments for a hydrocele of the canal of Nuck include surgical excision of the cyst with closure of the inguinal internal ring defect  and simultaneous inguinal hernia repair if required . Surgical excision is effective as it is both therapeutic and diagnostic . When possible, a laparoscopic approach may be considered because of the advantage of a shorter recovery period . In addition, a laparoscopic approach enables an examination for any associated intra-abdominal endometriosis. However, further studies and longer follow-up periods are needed to verify the superiority and cost-effectiveness of the laparoscopic approach over anterior open procedures.
Patients with inguinal endometriosis often undergo initial surgery by a general surgeon under a diagnosis of hernia . General surgeons therefore need to be more aware that inguinal masses in females may not only be due to hernia, but also due to endometriosis-associated hydroceles of the canal of Nuck.
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