An unusual cause of inguinal hernia in a male patient: endometriosis.
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ABSTRACT: A rare case of abdominal pain secondary to endometriosis in a 52-year-old man with cirrhosis is presented. The patient had a repair of recurrent inguinal hernia 7 months prior to presentation. An exploratory laparotomy revealed a 4.5 cm × 2.5 cm cystic mass attached to the urinary bladder and the inguinal area. The mass pathology showed a cystic lumen of diameter of 1.5 cm filled with old blood and surrounded by thick muscular mass. Microscopically, the lesion consisted of thick smooth muscle fibers that concentrically surround a central lumen that is bordered by endometrium such as glands and stroma. Immunostains were positive for estrogen receptors and progesterone receptors in the glandular component and for CD10 in the stroma, which is consistent with endometriosis.Avicenna journal of medicine. 10/2014; 4(4):99-101.
Gut and Liver, Vol. 6, No. 2, April 2012, pp. 284-285
An Unusual Cause of Inguinal Hernia in a Male Patient: Endometriosis
Gulcin Simsek*, Hakan Bulus†, Adnan Tas‡, Seyfettin Koklu§, Suleyman Burhan Yilmaz†, and Ali Coskun†
Departments of *Pathology, †General Surgery, Kecioren Training and Research Hospital, Ankara, ‡Department of Gastroenterology, Osmaniye
Public Hospital, Osmaniye, and §Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey
Endometriosis is an ectopic endometrium, commonplaced in
the female. But its occurence in the man is mysterious. In the
literature two cases of endometriosis in men have occured fol-
lowing surgery.1 The present case is the first reported arising in
the inguinal region, near the ductus deference.
Forty-nine years old man was presented to hospital with left
inguinal hernia. He was operated from that area for 3 times,
before. Furthermore he has unexplained infertility. His physical
examination revealed normal external genitelia. He underwent
surgical operation for hernia. In the operation, a mass was dis-
covered beside the spermatic cord and sent to our laboratory.
Macroscopically the mass was 8×7×6 cm in diameters (Fig. 1).
In dissection cystic cavity was seen and beside it, ductus def-
erens was identified. Cyst wall was containing small lumens
that was thought as small vessels. In microscopic examination,
cyst was lined with columnar epithelial cells and simple tubular
invaginations showing the same type of cell lining, and cellular
stroma, with typical features of endometrial mucosa. In addi-
Correspondence to: Adnan Tas
Department of Gastroenterology, Osmaniye Public Hospital, Raufbey Mah., Atatürk Cad., No: 432 A-Z blok ev no: 14, Osmaniye, Turkey
Tel: +90-328-2617100, Fax: +90-328-8261224, E-mail: firstname.lastname@example.org
Received on September 7, 2011. Accepted on October 10, 2011.
pISSN 1976-2283 eISSN 2005-1212 http://dx.doi.org/10.5009/gnl.2012.6.2.284
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
tion, there was smooth muscle proliferation and some endome-
trial glands and stroma in these areas (Fig. 2). The pathological
diagnosis was endometriosis. Chromosom analysis was normal
(46, XY). The patient had an uneventful postoperative course
and was discharged on the seven postoperative day. The patient
decided on regularly follow-up in the out-patient department.
Three theories of the pathogenesis of endometriosis have been
proposed in the female: transplantation, coelomic metaplasia,
and embryologic cell rests.2,3 Transplantation theory is obviously
impossible in the male because of the absence of a source of
menstruel material.1 The coelomic metaplasia could occur sec-
ondary to inflammatory and hormonal influences. This theory
could explain endometriosis in women with Mullerian agenesis,
who have an absent uterus or the occasional presence of endo-
metriosis in men.4 Third theory, also known as induction theory,
is based on induction of the embryologic cell rests. Between the
utricle and the appendices testes, cell rests may persist. These
mullerian cell rests would be expected to lie along the course
Fig. 1. Uterus-like mass beside the deferent ductus, holded area in the
Fig. 2. High power field of endometriotic area (H&E stain, ×200).
Simsek G, et al: Endometriosis in a Male Patient 285
of the ejaculatory and deferent ducts.1 In this case, endometrio-
sis was diagnosed along the ductus deferens; so this theory is
very likely for this case. This patient has used a drug named of
Fertilin, for sperm maturation and activation. The drug consists
of clomiphen citrate that shows antiestrogenic affect by bind-
ing estrogen receptors in hypothalamus and hypophysis.5 It is
a contrary event for the cases in the literature that were associ-
ated with prolonged estrogen therapy which appearing to be
necessary for the development of endometriosis in the male. But
also it is surprising not to have seen this phenomenon more fre-
quently in men with prostatic carcinoma treated with estrogens.
So, in our case additional factor must have been for the devel-
opment of the lesion.
In conclusion, endometriosis within an inguinal hernia is
an exceptionally rare event; most surgeons are unlikely to see
one. All previously reported elderly cases underwent estrogen
therapy for prostatic carcinoma, contrary, our patient had anti-
estrogenic therapy for infertility.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was
1. Pinkert TC, Catlow CE, Straus R. Endometriosis of the urinary
bladder in a man with prostatic carcinoma. Cancer 1979;43:1562-
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fancies. Obstet Gynecol Surv 1968;23:1-35.
3. Rock JA, Markham SM. Pathogenesis of endometriosis. Lancet
4. Bontis JN, Vavilis DT. Etiopathology of endometriosis. Ann N Y
Acad Sci 1997;816:305-309.
5. Bozkirli I, Sinik Z, Isen K, Biri H. Erkek infertilitesinin ampirik te-
davisinde klomifen sitrat ve L-arginin kombinasyonu. Turk J Fertil