Torsion of funiculocele presenting as an incarcerated hernia: A rare case

Abstract

Introduction

Inguinal hernia is common, but the groin area can host various pathologies. Distinguishing clinically between hernias and rare conditions like torsion of funiculocele poses challenges due to similar presentations.

Case presentation

A 50-year-old man, with a 10-year-history of a groin mass, presented with a painful groin mass, initially diagnosed as a strangulated hernia. In surgery, a torsion of a cyst was identified, and it was attached to the spermatic cord. A detorsion of the cyst and an excision were successfully performed. The patient recovered well with no recurrence.

Discussion

The most common causes of acute groin pain are injury, incarcerated hernia, kidney stone and bone fracture. Additionally, funiculocele can cause groin pain or discomfort. Funiculocele, a rare congenital anomaly, typically affects pediatric patients. A torsion of funiculocele is easily confused with an incarcerated hernia. Ultrasonography plays a crucial role in confirmation. Although unusual, a torsion of a cyst can occur, necessitating surgical excision.

Conclusion

Funiculocele in adults, mimicking hernias, is rare but requires timely surgical intervention to prevent complications. Awareness of this anomaly is vital for accurate diagnosis and appropriate management.

Highlights

• •Inguinal hernia is the most common abnormality in the groin area, but this region also hosts various other pathological conditions.
• •We present a case of a torsion of a funiculocele presenting as an incarcerated inguinal hernia in a 50-year-old man.
• •Clinical manifestations of funiculocele in adults are often incidental findings or occur after complications such as torsion.
• •Diagnostic imaging techniques such as ultrasonography play a crucial role in determining the location and characteristics of funiculocele.
• •Funiculocele in adults is rare but requires timely surgical intervention to prevent complications.

1. Introduction

Inguinal hernia stands out as the most common abnormality in the groin area [1]. Nonetheless, this region can also be host to various other pathological conditions such as tumors, hematoma, varicoceles and funiculocele. Distinguishing between these conditions clinically presents a challenge, given the similarities in their clinical presentations.

We describe a very rare case of torsion of funiculocele in a man who presented with clinical manifestations of an incarcerated inguinal hernia.

This work has been reported in line with the SCARE criteria [2].

2. Case report

A 50- year-old man, presenting a groin mass with a 10-year history, who is admitted to hospital with left groin swelling gradually increasing in volume and which has become painful in the last 24 h. There was no history of abdominal pain, vomiting and fever. Clinical examination showed conscious patient with stable hemodynamic and respiratory status but with an irreducible painful left inguinal mass with no cough impulse. The lesion was felt as a separate mass from the testicle. A diagnosis of a strangulated inguinal hernia was established, and we decided to operate the patient. Intra-operatively, a torsion of a cystic structure, measuring up to 7 ∗ 6 ∗ 4 cm, was identified (Fig. 1). It was attached to the spermatic cord filled with fluid and extended through the superficial inguinal ring. A detorsion of the cyst was performed. On gross examination, it had a smooth surface, whereas on cutting, there was a soft amorphous white material. It was carefully dissected from the cord structure and the sac was then completely delivered. Hemostasis was effectively ensured. The postoperative course was uneventful. The patient was discharged with oral analgesics after two days. Suture removal was performed 10 days after the surgery and no recurrence was observed.

Fig. 1.

Shows the funiculocele.

3. Discussion

Acute Groin pain is a prevalent symptom that can affect anyone. While certain causes of groin pain are more frequently encountered than others, it remains a multifaceted condition with various potential triggers. The most common causes are injury, incarcerated hernia, kidney stones and bone fracture. Additionally, round ligament varices, endometriosis, hématoma, orchitis, urinary tract infections and funiculocele can cause groin pain or discomfort.

Funiculocele refers to a localized accumulation of fluid along the spermatic cord, distinctively positioned above the testicle and the epididymis. This uncommon congenital anomaly arises from an aberrant closure of the processus vaginalis [3].

Significantly, the majority of reported cases have primarily centered around pediatric patients, with a limited number of publications focusing on adult cases [4].

The torsion of funiculocele is easily confused with an incarcerated hernia. As in our patient, clinical signs at presentation were indistinguishable from those of an incarcerated hernia for two reasons. First, the cyst was very large that occupied the entire superficial inguinal canal. Second, it was very tender and painful to palpation.

There are two variations of funiculoceles: the encysted hydrocele that does not communicate with the peritoneal cavity and the funicular variety that communicates with the peritoneal cavity [5].

In our case, we found a loculated collection above the testis, with no apparent communication between the cystic mass and the peritoneum.

Although rare, it is crucial to include funiculocele in the list of potential diagnoses when dealing with patients who present a groin mass of a long course.

This benign and uncommon anomaly is typically confirmed through ultrasonographic findings or accidentally intraoperatively as in our case [5].

Given the diverse clinical implications and therapeutic approaches associated with different etiologies, the ability to distinguish them noninvasively is paramount. Despite significant overlap in ultrasonographic findings across groin lesions, certain features, coupled with clinical presentation, may hint at specific diagnoses.

Ultrasonography exhibits high sensitivity in distinguishing between solid and cystic masses. When a fluid-filled mass is identified during the ultrasound examination, the differentiation from an indirect inguinal hernia becomes easy, particularly if a bowel loop or omentum is observed at the cord level [3].

Ultrasound proves particularly adept at determining the location, dimensions, and shape of funiculoceles.

According to Salemis, N. S. et al., the chronic pressure of the groin region maintained by the large cyst can lead to an excessive weakening of the inguinal floor and to the subsequent direct hernia. Despite the absence of reported cases of torsion of cysts in the literature, it does occur.

So, the management of funiculocele typically necessitates surgical excision, a procedure that can be performed under local anesthesia avoiding the morbidity of more aggressive anesthetic techniques.

4. Conclusion

The occurrence of funiculocele in adults is rare, and in certain cases, it can closely mimic an irreducible hernia. Even though it is relatively uncommon, emphasizing the importance of timely and appropriate management is crucial. This is because, like any medical condition, hydrocele requires surgical excision to avert potential complications.

CRediT authorship contribution statement

Atri Souhaib: conceptualization, data curation, redaction.

Zaiem Aida: conceptualization, data curation, redaction.

Sebai Amine: conceptualization, data curation, redaction, project manager.

El Aifia Rany: resources, visualization.

Haddad Anis: Supervision, validation, visualization.

Kacem Montassar: Supervision, validation, visualization.

Sources of funding

Not applicable.

Ethical approval

Our institution (Medicine Faculty of Tunis, Department of surgery la Rabta hospital) require no ethics approval for case reports reporting on a single case.

Registration of research studies

Not applicable. This is not a research study. It is report about one case.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Guarantor

Atri Souhaib.

Zaiem Aida.

Declaration of competing interest

All authors declare that they have no conflicts of interest.