A soft tissue groin mass

Abstract

Groin lump in a pregnant womanDiagnosisVaricosities of the round ligamentDiscussionRound ligament varicosities are engorged pelvic veins, thathave extended into the inguinal canal around the roundligament. These typically occur during and after the secondtrimester of pregnancy and present as soft and non-tendermasses in the inguinal region.The most common differential diagnosis of a groin lumpwith this presentation is an inguinal hernia [1–4]. Althoughinguinal hernias are uncommon in women, increased intra-abdominal pressure during pregnancy can lead to thiscondition. Its incidence in pregnancy has been reported tobe 1 in 1,000–3,000 [5]. Distinguishing round ligamentvaricosities from inguinal hernia on clinical grounds can bedifficult and is often not possible as both have a similarlocation, can be reducible or irreducible and can transmitcough impulses [1–4]. Other possible causes of an inguinalmass include femoral hernia, persistent embryonic remnants(cyst of the canal of Nuck), lymphadenopathy, soft tissuetumour and abscess formation.In this case the history of sudden onset in the thirdtrimester of pregnancy suggested the diagnosis, but thecorrect diagnosis was confirmed by the typical appearanceson Doppler ultrasound [6]. Many of the other possiblediagnoses, such as lymphadenopathy, hernias, cysts andabscess, also have characteristic ultrasound appearances,while the absence of a solid component to the mass wouldmake soft tissue tumour unlikely. Round ligament varicos-ities appear as large dilated spaces on ultrasound, locatedwithin the inguinal canal and passing through the deepinguinal ring (lateral to the inferior epigastric vessels). Inour case the varicosities also passed through the superficialring. Colour or power Doppler confirms the presence ofblood flow within the veins comprising the varicocoele,and this characteristically augments with the Valsalvamanoeuvre [7]. The inferior epigastric vessels are easily seenon ultrasound and lie immediately medial to the deepinguinal ring. As with investigation of inguinal hernia, theyprovide a landmark for the sonographer. The superficialinguinal ring lies immediately lateral to the pubic tubercle,which provides a useful bony landmark. Although the veinsare associated with the round ligament of the uterus, theligament itself was not visualised. In the normal femaleinguinal canal, the veins and artery characteristically markthe course of the round ligament on ultrasound.Round ligament varicosities are an accentuation of aphysiological process and correct diagnosis is imperative toavoid unnecessary surgery. They are managed conserva-tively and resolve in the post-partum period. The resolutionpost-partum helps to exclude other causes of vascular mass,such as an arterial-venous malformation, although the