Exploring Hydrocele of the Canal of Nuck in a Mature Woman: Beyond the Norm.

A 45‐year‐old female presented a compelling case of a progressively enlarging swelling in the right inguinal region, prompting a visit to the surgery outpatient department. Her symptoms had been worsening over 6 months, with recent exacerbation marked by intermittent pain lasting 9 days with no relation to menstrual cycle. The physical examination revealed a palpable, tender, cystic, and fluctuant swelling measuring approximately 4 × 2 cm (Figure  1 ). Notably, the swelling was irreducible upon manual pressure and demonstrated positive transillumination, characteristic of fluid‐filled structures. Despite the swelling, the patient denied associated symptoms such as vomiting, bowel or bladder dysfunction, and her vital signs remained stable and within normal limits throughout the examination. These findings suggested a differential diagnosis primarily centered on inguinal hernias, hydroceles, or other cystic formations within the inguinal canal, necessitating further investigative measures for accurate diagnosis and appropriate management. Swelling in the right inguinal region on clinical examination. Based on the patient's history and clinical examination, several potential diagnoses were considered, including inguinal hernia, cystic lymphangioma, and hydrocele of the canal of Nuck. The suspicion for hydrocele of the canal of Nuck was heightened due to the specific characteristics of the swelling noted during the examination, coupled with the absence of associated bowel or bladder symptoms typically seen with other differential diagnoses. To further investigate the inguinal swelling, an MRI of the pelvis was performed. This imaging study revealed a distinct cystic lesion measuring 2.6 × 5 × 4.4 cm in the right inguinal region (Figure  2 ). The findings were consistent with a hydrocele of the canal of Nuck, confirming the initial clinical suspicion. MRI showing well‐defined thin‐walled cystic lesion in the right inguinal region. Subsequently, the patient underwent surgical intervention via laparotomy using a traditional anterior approach under general anesthesia (Figure  3 ). During the operation, intraoperative exploration revealed adhesions between the cystic swelling and adjacent tissues. This necessitated meticulous dissection to carefully separate the hydrocele from surrounding anatomical structures and organs, a critical step in ensuring complete removal and preventing complications. During the procedure, clear serous fluid was aspirated from the hydrocele and sent for cytological examination to exclude the possibility of underlying malignancy, a precautionary measure in such cases. Intraoperative image showing the hydrocele of canal of Nuck. Following aspiration and examination, the base of the hydrocele was ligated and excised with precision to minimize the risk of recurrence. Closure of the surgical defect was achieved using conning and plugging techniques, reinforced with a polypropylene mesh to strengthen the repair and enhance its long‐term durability. The surgical wound was meticulously closed in layers to optimize healing and reduce the likelihood of postoperative complications, ensuring comprehensive care from initial diagnosis through to recovery. Following the patient's surgical intervention for hydrocele of the canal of Nuck, her recovery progressed smoothly without complications. Throughout her hospital stay, vital signs remained stable, and there were no immediate postoperative issues. She was discharged with a prescription for oral antibiotics to prevent infection and NSAIDs for pain relief, standard measures to support recovery after abdominal surgery. A follow‐up appointment was scheduled for 10 days after discharge to assess wound healing and overall recovery. During this visit, the surgical wound was carefully inspected. Encouragingly, the wound exhibited signs of healthy healing, characterized by intact closure and absence of redness, swelling, or discharge indicative of infection. Sutures were removed as planned. On pathocytological assessment, the gross specimen consisted of cystic tissue measuring 8.5 cm × 3.5 cm × 1.5 cm, with attached fat (Figure  4 ). The cut section revealed a cystic cavity measuring 3 cm × 2.5 cm, characterized by a smooth inner wall. The wall thickness ranged from 0.2 to 0.4 cm. Microscopically, the cyst wall was fibrocollagenous, partially lined by benign cuboidal to flattened mesothelium, with areas of denudation. The sub‐epithelium exhibited a loosely collagenous stroma containing mild chronic inflammatory cell infiltrates, including lymphocytes, plasma cells, eosinophils, and lymphoid aggregates. Additionally, adipose tissue, areas of hemorrhage, dilated lymphatics, and congested blood vessels were observed. Importantly, there was no evidence of endometriosis, epithelial atypia, epithelioid cell granulomas, or parasites in the examined sections. Cytological assessment confirmed these findings, showing no evidence of malignancy. Gross specimen consisting of cystic tissue with attached fat. Importantly, the patient reported significant improvement in her condition. The initial inguinal swelling had completely resolved, alleviating the discomfort she had experienced preoperatively. Her overall recovery was progressing satisfactorily, with minimal postoperative pain and restored mobility. Looking ahead, the long‐term prognosis appeared promising. Subsequent follow‐up visits confirmed sustained resolution of symptoms and absence of hydrocele recurrence. The patient regained normal function without any lingering issues related to the surgery.

Saurav Jha: conceptualization, writing – original draft. Sweta Singh: conceptualization, writing – original draft. Sajjad Ahmed Khan: writing – original draft, writing – review and editing. Rajat Kumar Shah: writing – original draft. Pratick Shrestha: writing – original draft. Arjun Kandel: writing – original draft. Barsha Baral: writing – original draft. Pratik Raj Regmi: writing – original draft.

The rarity of hydrocele of the canal of Nuck stems from the normal physiological process of fetal development where the processus vaginalis closes in females. However, in some cases, this canal remains patent, allowing for the accumulation of serous fluid. The condition is estimated to account for less than 1% of all inguinal hernias and is most commonly diagnosed in infants and young girls [ 2 ]. The incidence in adult women is exceptionally low, making up a minute fraction of all inguinal masses encountered in clinical practice [ 3 ]. The clinical presentation of hydrocele of the canal of Nuck varies but typically includes a painless or occasionally painful inguinal swelling that enlarges over time. This swelling is often reducible and may be associated with discomfort or pain exacerbated by physical activities or increased intra‐abdominal pressure. Differential diagnosis includes inguinal hernias, cystic lymphangiomas, and other inguinal canal abnormalities, highlighting the importance of accurate clinical evaluation and imaging studies such as ultrasonography or MRI for definitive diagnosis [ 4 ]. Diagnosis of hydrocele of the canal of Nuck is primarily clinical, supported by imaging studies such as ultrasonography or MRI for confirmation and to rule out other differential diagnoses [ 7 ]. Differentiating it from other inguinal swellings, particularly inguinal hernias or cystic lymphangiomas, is crucial for appropriate management [ 8 ]. Surgical management remains the mainstay of treatment for symptomatic cases and those at risk of complications such as infections [ 9 ]. The surgical approach involves excision of the hydrocele sac with closure of the defect to prevent recurrence and alleviate symptoms [ 10 ]. Despite its relatively low prevalence, hydrocele of the canal of Nuck poses diagnostic challenges due to its rarity and variable presentation [ 11 ]. Awareness among healthcare providers, particularly surgeons and radiologists, is essential for timely diagnosis and appropriate management [ 12 ]. Case reports and series on hydrocele of the canal of Nuck illustrate the variability in presentation and management approaches across different age groups and clinical settings. For instance, Kamat et al. reported a case of hydrocele of the canal of Nuck in an adult female, emphasizing the diagnostic challenge and the need for surgical intervention to alleviate symptoms [ 5 ]. Similarly, Matani et al. documented a case in a 40‐year‐old woman, underscoring the uncommon occurrence of this condition in adults and the successful surgical outcome following excision and repair of the canal [ 6 ]. In contrast, pediatric cases of hydrocele of the canal of Nuck often present earlier in life, with characteristic findings on physical examination and imaging studies confirming the diagnosis. Choh and Jehangir reported on three cases of female children, highlighting the necessity of prompt recognition and surgical correction to prevent complications such as herniation or incarceration [ 7 ]. Surgical intervention remains the mainstay of treatment for symptomatic hydrocele of the canal of Nuck, aiming to excise the cystic sac and close the patent canal to prevent recurrence. Vinayagam et al. discussed the surgical management of a case involving an adolescent female, detailing the use of mesh reinforcement to strengthen the repair and reduce the risk of postoperative complications [ 8 ]. The approach to surgical repair may vary depending on the patient's age, clinical presentation, and the presence of associated anomalies. Long‐term outcomes following surgical treatment of hydrocele of the canal of Nuck are generally favorable, with low rates of recurrence reported in the literature. Regular follow‐up is recommended to monitor for potential complications and ensure optimal healing of the surgical site. Liu and Lau reported on the successful long‐term outcome in an adult female, underscoring the importance of comprehensive postoperative care and patient education regarding signs of recurrence or complications [ 9 ]. Hydrocele of the canal of Nuck remains a rare entity that poses diagnostic challenges due to its low incidence and variable clinical presentation. While predominantly encountered in pediatric populations, particularly young girls, adult cases are exceedingly uncommon and necessitate careful evaluation and management. Surgical intervention, guided by thorough preoperative assessment and meticulous technique, offers effective resolution of symptoms and prevention of complications. Continued reporting and analysis of cases contribute to our understanding of this condition, informing clinical practice and improving outcomes for affected individuals. In summary, while hydrocele of the canal of Nuck presents unique diagnostic and management challenges, advancements in imaging technology and surgical techniques have enhanced our ability to accurately diagnose and effectively treat this rare condition across different age groups and clinical scenarios.

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

The authors declare no conflicts of interest.

Hydrocele of the canal of Nuck is a rare but clinically significant condition primarily affecting young‐aged females [ 1 ]. Named after Anton Nuck, a Dutch anatomist who first described the canal in 1691, the canal of Nuck is a vestigial remnant of the processus vaginalis, which normally obliterates during fetal development in females [ 2 ]. Failure of complete closure can lead to the formation of a hydrocele within this anatomical structure, resulting in a fluid‐filled cystic swelling in the inguinal region [ 3 ]. While hydroceles are more commonly associated with male infants due to persistent processus vaginalis, hydrocele of the canal of Nuck presents a unique challenge in adult females [ 4 ]. It manifests as a painless or occasionally painful swelling in the inguinal area, often mistaken for inguinal hernias or other inguinal pathologies [ 5 ]. The condition typically presents with progressive enlargement of the swelling over time, sometimes exacerbated by activities that increase intra‐abdominal pressure [ 6 ]. This case report aims to explore the clinical presentation, diagnostic challenges, imaging modalities, and surgical management of hydrocele of the canal of Nuck. By summarizing current knowledge and highlighting key aspects of this condition, we aim to provide insights into its management and outcomes in clinical practice.