A rare presentation of ectopic ovary in a female adolescent and the impact of obesity: a case report
Abstract
Inguinal hernias in women of reproductive age containing the ovary are very rare. When they occur in this age group, they are mostly associated with malformations of the urogenital system. Prompt surgical intervention is the key to ensure survival of the ovary. Here we present a case of an ectopic ovary presenting like an acute appendicitis.
A 16-year-old Cameroonian girl presented at our emergency service with an acute exacerbation of a mild and intermittent right iliac fossa pain of 5 days’ duration. A clinical examination revealed android obesity and signs suggestive of an acute appendicitis. An abdominopelvic ultrasound scan showed an edematous right ovary in the canal of Nuck. A prompt hernia repair was done and her postoperative period was uneventful.
An ectopic inguinal ovary remains a rare occurrence. An urgent and careful exploration of the hernia sac is the standard of care. Careful physical examination of obese girls and women is vital particularly in emergency settings, as obesity in our patient contributed greatly to a missed diagnosis. Clinicians should potentially consider the possibility of an ectopic ovary when faced with girls and women presenting with right iliac fossa pain.
Background
Inguinal hernias occur in less than 5 % of women. These hernias usually contain a variety of viscera, commonly the intestines and omentum. An inguinal hernia containing the ovary is very rare in women of reproductive age. Only 3 % of cases of inguinal hernias contain viscera such as female adnexa [1], 30 % of which occur in adolescents or women of reproductive age [2]. In most cases, the diagnosis of a hernia is clinical; however, an ultrasound scan is helpful in uncertain circumstances. Inguinal hernias can present either as asymptomatic progressive groin swellings or acutely, with associated mild to severe abdominopelvic pain [3]. We report the case of a 16-year-old girl with an incarcerated right ovarian inguinal hernia presenting like acute appendicitis.
Case presentation
一名 16 岁的喀麦隆女孩因急性加重右髂窝 (RIF) 轻度间歇性疼痛（持续 5 天）并伴有厌食和恶心而来我们的急诊室就诊。她最后一次月经是在就诊前 2 周。她的初潮是在 12 岁时，月经量为 3 至 4 天，周期为 28 至 30 天。她既无性生活，也没有痛经史，其余病史均无异常。没有呕吐、便秘、发烧、异常阴道分泌物或泌尿道症状。在临床检查中，她焦虑不安，疼痛程度根据视觉模拟疼痛量表为 6/10，心动过速（脉搏率为每分钟 110 次）和无发热（最高体温为 36.8 °C）。她的体重指数 (BMI) 为 34.2 kg/m2，腰围为 101 cm。麦氏点压痛，彭博征、闭孔征和腰肌征阳性。临床表现提示可能诊断为急性阑尾炎。
全血细胞计数 (CBC) 和分类计数、C 反应蛋白 (CRP) 和尿液分析均正常，妊娠试验为阴性。腹盆腔超声扫描显示 Nuck 管内有一个水肿的右侧卵巢，大小为 5.7×2.1×4.5 厘米（实时运动清晰可见；图 1）。因此，我们诊断为卵巢嵌顿性右腹股沟疝。我们紧急对她进行了妇科检查，并立即为她准备手术。从诊断到手术的时间大约为 2 小时 30 分钟。术中在她的 Nuck 管内发现一个嵌顿、水肿但可存活的右侧卵巢。她的右侧输卵管、子宫和左侧附件在肉眼下正常。她的左侧内腹股沟环完好，阑尾没有发炎。采用 Bassini 技术对患者进行了右腹股沟疝修补术，并对腹股沟深环进行了加固。术后恢复顺利，6 个月的随访中未出现任何新症状。
图 1
盆腔超声检查显示右侧卵巢水肿，纵向（左）和横向（右）视图。左侧，卵巢位于腹膜壁层（橙色箭头）的浅表，位于皮下组织下方。右侧，卵巢位于髂外动脉的浅表（红色箭头）
讨论
在本病例报告中，我们重点介绍了青春期女孩中罕见的异位卵巢表现以及肥胖的不利影响。除了卵巢位于 Nuck 管内以及颇似急性阑尾炎的特征外，最初的误诊部分可能是由于她的腰围增加和男性肥胖。腹股沟疝有两种类型：腹股沟疝约占此类疝的 96% ，股疝仅占腹股沟疝的 4%。男孩患腹股沟疝的几率是女孩的九倍。在世界范围内，腹股沟疝修补术是最常见的外科手术之一 [4]。尽管腹股沟疝相对常见，但只有 3% 的疝气中含有女性附件等内脏，据报道其中 30% 发生在青少年或育龄妇女身上 [2]。
荷兰解剖学家 Nuck 于 1691 年描述的努克管是由异常的开放腹膜囊形成的虚拟空间，是男性鞘突的女性类似物。正常情况下，在胚胎期，壁层腹膜会伴随子宫圆韧带通过腹股沟管外翻，并插入同侧大阴唇根部。腹膜外翻通常在宫内出生后八个月左右消失 [5]。腹股沟内环通常会

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