Femoral hernia containing the right fallopian tube: chronic pain with menstruation

Abstract

Femoral hernias represent less than 10% of groin hernias and appear mainly in adult women; incarceration is more usual than in other hernias. Content found within the sac is commonly small bowel or omentum. Other anatomical structures, such as appendix, bladder, Meckel’s diverticulum, ectopic testis, stomach and gynaecological organs are extremely unusual. A 48-year-old woman presented with intense right groin pain over 48 hours. Her past medical history revealed periodical moderate right groin pain coincident with her menstrual cycles, usually self-limited. No abdominal symptoms or fever were present. On physical examination, an incarcerated right femoral hernia was suspected. Subsequently abdominal ultrasound revealed a right femoral hernia containing an echogenic structure with conserved vascularisation. The patient underwent an emergency surgery. During the procedure the right fallopian tube and several small cysts were discovered as the hernia sac contents. As no ischaemic signs were observed, and the sac was sutured and reduced. Femoral hernioplasty was accomplished with polypropylene mesh. The postoperative course was uneventful and the patient was discharged within 24 hours. After an exhaustive literature review, we have found few cases reporting the presence of fallopian tube in adult women with femoral hernia, but none described a recurrent groin pain coinciding with menstruation, as in this case.

Background

Femoral hernias represent less than 10% of groin hernias and appear mainly in adult women. Their small size makes incarceration much more usual than in other hernias. Content found within the sac is frequently small bowel or omentum. Other anatomical structures, such as appendix, bladder, Meckel’s diverticulum, ectopic testis, stomach and gynaecological organs are extremely unusual.¹ We present the case of a woman with recurrent right groin pain coinciding with her menstruation who was diagnosed with an incarcerated right femoral hernia containing the right fallopian tube.

Case history

A 48-year-old woman presented with intense right groin pain over 48 hours. Her past medical history revealed periodic moderate right groin pain coincident with her menstrual cycles, usually self-limited. No abdominal symptoms or fever were present. On physical examination, an incarcerated right femoral hernia was suspected. Subsequently abdominal ultrasound revealed a right femoral hernia containing an echogenic structure with conserved vascularisation (Fig 1 and Fig 2. The patient underwent emergency surgery. During the procedure, the right fallopian tube was discovered as the hernia sac content, together with several small cysts (Fig 3). As no ischaemic signs were observed, the sac was sutured and reduced. Femoral hernioplasty was accomplished with polypropylene mesh. Microbiological and cytological studies showed no relevant findings. The postoperative course was uneventful and the patient was discharged within 24 hours.

Figure 1.

Abdominal ultrasound showing vascularised and echogenic contents in the femoral hernia.

Figure 2.

Abdominal ultrasound visualising intra-arterial vascularisation of the contents in the femoral hernia.

Figure 3.

Right fallopian tube inside the femoral hernia.

Discussion

Femoral hernias represent approximately 10% of groin hernias in adults. They appear below the inguinal ligament, protruding between lacunar ligament and femoral vein. These hernias are more common among women, as their femoral ring is anatomically wider compared with that of men, and pregnancy also contributes to broaden the femoral ring. On physical examination, femoral hernias present as tender, non-reducible and painful swellings below the inguinal ligament. Due to the small defect of the femoral ring and its rigid ligamentous structures, incarceration is observed far more frequently with these hernias rather than with other abdominal hernias.

Incarcerated hernias generally contain small bowel or omentum. Rare contents of incarcerated femoral hernias include vermiform appendix, bladder, Meckel’s diverticulum, ectopic testis, stomach and gynaecological organs. Only 12 cases in the literature report incarcerated femoral hernias containing the fallopian tube (Table 1). Of these 12 cases, isolated fallopian tube alone was present in 10 cases, herniation of the fallopian tube with the ovary was described in 1 case and 1 case contained the uterus, the fallopian tube and the ovary. Ten cases had right-sided presentations and two were left-sided. In three reports, resection of the incarcerated right fallopian tube was necessary. These patients ranged in age from 20 to 84 years. Patients presented to the emergency department with groin pain and the presence of a mass in the inguinal region. None reported a history of groin pain or suffered primary infertility. One case reported a 28-year-old woman with a one-year left groin swelling and absence of menarche; a uterus, left fallopian tube and ovary herniation was observed at surgery.² Although our patient had no fertility problems, she had a history of right groin pain since girlhood, which coincided with some of her menstrual cycles. This is the main difference from other cases of herniation of the fallopian tube, in which this periodic, long-term pain overlapping menstruation is not described.

Table 1.

Cases reported in the literature about femoral hernias in adults containing the right fallopian tube.

Authors	Year	Patient age (years)	Side	Content	Reference
Parkes CH	1910	33	Right	Fallopian tube	Femoral hernia of fallopian tube without ovary. JAMA 1910; 55: 649–650.
Devane JF	1916	Unknown	Right	Fallopian tube	Fallopian tube found in femoral hernia. Lancet 1916; 188(4862): 805.
Kotlinska MA, Ragg JL, Poole DR, Giannopoulos TI	2009	52	Right	Fallopian tube	Groin swelling: unexpected findings. J Obstet Gynaecol 2009; 29(6): 562–563.
Atmatzidis S, Chatzimavroudis G, Dragoumis D, Atmatzidis K	2010	20	Right	Fallopian tube	Incarcerated femoral hernia containing ipsilateral fallopian tube. Case Rep Med 2010; 2010: 741915.
Coyle D	2011	54	Left	Ovary and fallopian tube
Alzaraa A	2011	39	Right	Fallopian tube	Unusual contents of the femoral hernia. ISRN Obstet Gynecol 2011; 2011: 717924.
López C, Durán MC, Tobaruela E et al	2011	47	Right	Fallopian tube	Femoral hernia containing incarcerated fallopian tube. Hernia 2011; 15: 717–718.
Engin O, Cicek E, Oner SR, Yildirim M	2011	39	Right	Fallopian tube	Incarcerated femoral hernia containing the right uterine tube: a pre-operative diagnosis is possible. Ann Ital Chir 2011; 82(5): 409–412.
Oakenful C, Lambrianides AL	2011	46	Right	Fallopian tube	Incarcerated adult femoral hernia containing a fallopian tube. Australas J Ultrasound Med 2011; 14(4): 16–17.
Ambedkar V, Singh A, Bain J et al	2016	28	Left	Uterus, fallopian tube and ovary	A rare case of femoral herniation of female internal genitalia. J Nat Sci Biol Med 2015; 6: 454–456.
Soeta N, Saito T, Nemoto T et al	2016	84	Right	Fallopian tube	Laparoscopic repair of irreducible femoral hernia containing the fallopian tube alone: a case report. Surg Case Rep 2016; 2(1): 57.
Asma H, Youssef N, Ridouan B	2017	58	Right	Fallopian tube	Femoral hernia complications: unusual contents. J US China Med Sci 2017; 14: 45–46.
Present case	2018	48	Right	Fallopian tube

The anatomical location of the ovaries, uterus and fallopian tube below the femoral ring, particularly in adults, makes their herniation unusual.³ Acquired weakness in the pelvic wall, multiparity and elevated intra-abdominal pressure are factors that are thought to play an aetiological role in the development of femoral hernias in adults. Herniation of the fallopian tube is more frequent at paediatric ages, with 70% presenting in children under five years of age.⁴ This is explained due to congenital abnormalities in the femoral region or the proximity of gynaecological structures and the canal of Nuck to the femoral orifice in children. Patients with the fallopian tube inside the hernia sac may present unusual symptoms such as intermittent abdominal pain, incarceration or even symptoms that may mimic ileus or intestinal obstruction. When finding a herniated fallopian tube, it may be reduced it if it is viable or resected if there is any sign of ischaemia.

Our patient presented a recurrent pain in the right groin since adolescence, during menstruation. This led us to suspect the presence of a gynaecological organ within an incarcerated femoral hernia.