{"paper_id":"06688d07-8ae2-431f-984f-b44f9651a140","body_text":"~ 518 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2026; 10(2): 518-520 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \nIndexing: Embase \nImpact Factor (RJIF): 6.71 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2026; 10(2): 518-520 \nReceived: 21-01-2026 \nAccepted: 25-02-2026 \n \nDr. Indhu Srinivas  \nJunior Resident, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \nDr. Sujata Datti  \nProfessor, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \nDr. Kavya Manivasagham \nJunior Resident, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \nDr. Ravi Sree Shivani  \nAssistant Professor, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \nDr. Rashmi Nayak \nAssistant Professor, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr Kavya Manivasagham \nJunior Resident, Department of \nObstetrics and Gynecology, Vydehi \nInstitute of Medical Sciences and \nResearch Centre, Bangalore, \nKarnataka, India. \n \nUterocutaneous fistula associated with scar \nendometriosis following cesarean section: A rare case \nreport \n \nIndhu Srinivas, Sujata Datti, Kavya Manivasagham, Ravi Sree Shivani and \nRashmi Nayak \n \nDOI: https://www.doi.org/10.33545/gynae.2026.v10.i2g.2085  \n \nAbstract \nScar endometriosis is a rare extrapelvic manifestation of endometriosis that most commonly occurs \nfollowing cesarean section due to iatrogenic implantation of endometrial tissue. Uterocutaneous fistula, an \nabnormal communication between the uterus and the s kin, is an exceptionally uncommon condition and its \ncoexistence with scar endometriosis presents significant diagnostic and surgical challenges. We report a \ncase of a 35 -year-old woman, P1L1, with a history of lower segment cesarean section 12 years ago, \npresented with dysmenorrhea, heavy menstrual bleeding, and cyclical bleeding from a sinus located 3 cm \nbelow the umbilicus since past 3 -4 months. Clinical examination revealed a nodular infraumbilical mass \nwith a sinus tract of approximately 2x2 cm. Ultraso nography suggested scar endometriosis, while magnetic \nresonance imaging demonstrated a well -defined enhancing lesion with a communicating tract to the \nanterior uterine wall of approximately 1.5 cm in length and 5.7 mm width, associated adhesions, and right  \nhaematosalpinx. A provisional diagnosis of scar endometriosis with uterocutaneous fistula was made. The \npatient underwent wide excision of the lesion with fistula tract ablation, right salpingectomy, left ovarian \ncystectomy, and abdominal wall reconstruct ion with mesh reinforcement. Postoperative recovery was \nuneventful. This case highlights the importance of clinical suspicion, advanced imaging for preoperative \nplanning, and complete surgical excision for successful management. \n \nKeywords: Scar endometriosis, uterocutaneous fistula, cesarean section, haematosalpinx, abdominal wall \nreconstruction \n \nIntroduction  \nEndometriosis is defined as the presence of functional endometrial glands and stroma outside the \nuterine cavity [1]. It commonly affects pelvic struc tures such as ovaries, uterosacral ligaments, \nand pouch of Douglas [1]. Extrapelvic endometriosis, though rare, can occur in surgical scars, \nparticularly following obstetric and gynecological procedures [1]. \nScar endometriosis most frequently follows cesar ean section, with reported incidence ranging \nfrom 0.03% to 1% [2]. The most accepted theory for its development is direct mechanical \nimplantation of endometrial tissue during uterine incision and closure [3, 4] . Patients typically \npresent with cyclical pai n and swelling at the scar site, often associated with menstrual \nirregularities [3]. \nUterocutaneous fistula, defined as an abnormal tract between the uterus and skin, is an \nexceptionally rare entity [5]. It may result from postoperative complications, infection, trauma, or \nendometriosis. The coexistence of scar endometriosis with a uterocutaneous communicating \nfistula is extremely uncommon and presents diagnostic and therapeutic challenges [5, 6]. \nWe present a rare case of scar endometriosis with a uterocut aneous communicating fistula \noccurring 12 years after cesarean section, successfully managed surgically. \n \nCase presentation \nA 35 year old woman, P1L1, with a history of lower segment cesarean section 12 years ago, \npresented with dysmenorrhea and heavy mens trual bleeding for three months. She described \ncramping lower abdominal pain beginning with menstruation and reducing by the second day of \nthe cycle. She reported regular menstrual cycles every 28-30 days, lasting 6-7 days, with passage \nof clots and usage of 3-4 pads per day. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 519 ~ \nNotably, she complained of cyclical bleeding through a sinus \nopening of approximately 1.5 cm in length located 3 cm below \nthe umbilicus during menstruation for the past 3 -4 months. The \ndischarge was minimal and did not completely soak  the cloth \nused. There was no history of postcoital bleeding, dyspareunia, \nbowel or bladder disturbances, decreased appetite, or weight \nloss. She had no known history of diabetes mellitus, \nhypertension, tuberculosis, epilepsy, asthma, or cardiac \ndisorders. There was no prior blood transfusion. Family history \nwas non-contributory. She was not tubectomised and reported no \nknown drug allergies. \n \nClinical examination \nOn examination, her general condition was fair. There was no \npallor or pedal edema. Cardiovascu lar and respiratory system \nexaminations were unremarkable. Abdominal examination \nrevealed a soft, non-tender abdomen. \nLocal examination revealed a sinus opening approximately 3 cm \nbelow the umbilicus, between the umbilicus and previous LSCS \nscar. A hard nodular swelling measuring approximately 6 × 5 cm \nwas palpable beneath the sinus opening. \nPer speculum examination revealed a healthy vagina with foul -\nsmelling greenish discharge and minimal bleeding. The cervix \nappeared normal. On per vaginal examination, t he uterus was \nbulky, fixed, and pulled upwards with bilateral fornices free but \nnon-tender. \n \nInvestigations \nRoutine laboratory investigations revealed hemoglobin was 10.8 \ng/dL, total leukocyte count was 7560/mm³, platelet count was \n3.34 lakh/mm³, and renal  function tests were within normal \nlimits. HIV, hepatitis B, and hepatitis C serology were non -\nreactive. Pap smear was Negative for Intraepithelial Lesion or \nMalignancy (NILM). \nUltrasonography of the abdomen and pelvis revealed a fairly \nwell-defined lobulated predominantly hypo echoic lesion in the \ninfraumbilical region suggestive of scar endometriosis. The \nuterus and bilateral ovaries were reported as normal in size, and \nthere was no free fluid in the pouch of Douglas. \nMagnetic Resonance Imaging (MRI) prov ided further \ndelineation. The uterus was bulky and retroflexed. A well -\ndefined enhancing lobulated lesion with irregular margins was \nnoted in the infraumbilical region consistent with scar \nendometriosis. Adhesions were observed between the anterior \nuterine wall and abdominal wall lesion, with obliteration of fat \nplanes. A right -sided haematosalpinx measuring 5 × 3 cm was \nidentified. The right ovary was bulky and displaced anteriorly \nwith altered architecture. These findings raised suspicion of an \ninfiltrative process. \nBased on clinical and radiological findings, a provisional \ndiagnosis of scar endometriosis with uterocutaneous fistula was \nmade. \n \nSurgical management \nAfter informed written consent, the patient underwent scar \nendometriosis excision with fistula  tract ablation, right \nsalpingectomy, and left ovarian cystectomy under combined \nspinal and epidural anesthesia. \nAn elliptical incision encompassing the sinus tract and previous \nLSCS scar was made. Intraoperatively, a mass measuring 12 × 7 \ncm was identifie d on the anterior abdominal wall, 3 cm below \nthe umbilicus. A well -defined fistulous tract communicating \nfrom the anterior uterine wall to the scar endometriotic tissue \nwas noted. The lesion was excised completely with adequate \nmargins, and the fistula tract opening over the uterus was ablated \nusing bipolar cautery. \nThe uterus was normal in size but showed endometriotic spots \nover its surface, which were ablated. The right fallopian tube \nshowed haematosalpinx measuring 5 × 3 cm near the pouch of \nDouglas, an d right salpingectomy was performed. The right \novary was normal in size but densely adherent to the ileocecal \njunction. The left ovary was bulky with cystic areas; accidental \npuncture led to drainage of clear fluid, and cyst wall excision \nwas performed. \nEstimated blood loss was approximately 750 mL. One unit of  \nPacked Red Blood Ce lls (PRBC) was transfused \nintraoperatively, and another unit was administered on \npostoperative day one. \nA significant rectus sheath defect measuring approximately 6 –8 \ncm was noted following excision. Primary closure was difficult; \nhence, flap release was performed, and closure was achieved \nusing modified Smead -Jones technique with polypropylene \nsutures. Mesh reinforcement was performed. A Romovac drain \nwas placed, and layered closure was completed. \n \nPostoperative course \nThe patient remained hemodynamically stable postoperatively. \nIntravenous antibiotics (cefazolin and metronidazole) and \nsupportive medications were administered. The urinary catheter \nwas removed on postoperative day on e. The drain and sutures \nwere removed on postoperative day eleven, with healthy wound \nhealing. \nShe was discharged with advice regarding wound care, protein -\nrich diet, adequate hydration, ambulation, and avoidance of \nheavy lifting. She was advised follow -up for histopathological \nevaluation and to report immediately in case of bleeding, \nabdominal pain, or urinary symptoms. \n \nDiscussion \nScar endometriosis complicated by a uterocutaneous fistula most \ncommonly follows cesarean section and may present years after \nthe surgery; this delayed presentation and variable \nsymptomatology (cyclical pain, swelling, and especially cyclical \nbleeding from a scar) are well described in case series and \nreports. Several case reports corroborate our observation of long \nlatency and c yclical wound bleeding as a red flag for \nuterocutaneous communication [1, 3]. \nImaging-guided preoperative mapping is repeatedly emphasized \nin the literature because it changes operative strategy: ultrasound \noften identifies hypoechoic scar lesions, but MR I more reliably \ndelineates fistulous tracts, adhesions, and associated pelvic \ndisease (haematosalpinx/ovarian involvement) and thus better \ninforms wide excision and reconstruction plans, as highlighted \nin Etrusco et al . and other reports that used MRI to p lan \ndefinitive surgery [4]. \nPathophysiologically cyclical bleeding within implanted \nendometrial tissue produces chronic inflammation, fibrosis and \nadhesion formation that can progress to tract formation and \neventual uterocutaneous communication; this mecha nism is \ndescribed across multiple clinical reports and reviews and was \nimplicated in both Hasan et al . and Gupta P et al . [3, 5]. These \nworks also stress that factors such as incomplete uterine closure, \ninfection, or retained material may act as cofactors,  explaining \nwhy some scar implants evolve into fistulae while others remain \nconfined nodules \nTherapeutically, the consensus from case reports is that \nhormonal suppression can be temporizing but definitive cure \nrequires complete surgical excision of the end ometriotic lesion \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 520 ~ \nwith total resection/closure of the fistulous tract; several reports \ndemonstrate good outcomes with fistulectomy ± uterine repair, \nand when extensive abdominal -wall defects result, \nreconstruction (flap or mesh) is sometimes necessary [5, 6]. Our \noperative approach and need for mesh reinforcement mirror \nthese recommendations and the published outcomes. \n \nConclusion \nScar endometriosis complicated by a uterocutaneous \ncommunicating fistula is an exceptionally rare but significant \ndelayed sequela of cesarean section that should be suspected in \nwomen presenting with cyclical bleeding or discharge from a \nprevious abdominal scar. Early recognition requires a high index \nof clinical suspicion, and advanced imaging, particularly MRI \nplays a crucial rol e in delineating fistulous tracts and associated \npelvic pathology. Definitive management depends on complete \nsurgical excision of the endometriotic tissue with meticulous \nremoval of the fistulous tract and appropriate abdominal wall \nreconstruction when req uired. Timely intervention not only \nprevents recurrence but also alleviates chronic morbidity and \nimproves quality of life. \n \nConflict of interest: None \n \nFunding: None \n \nAcknowledgment: None \n \nReferences \n1. Bhattarai A, Dangal G, Karki A, Bhattachan K, Maharjan S, \nGhimire N. A rare case of scar endometriosis with \nuterocutaneous fistula. J Chitwan Med Coll. \n2023;13(45):95-97. \n2. Poudel D, Acharya K, Dahal S, Adhikari A. A case of scar \nendometriosis in cesarean scar: A rare case report. Int J Surg \nCase Rep. 2023;102:107852. \n3. Gupta P, Gupta S. Scar Endometriosis: a Case Report with \nLiterature Review. Acta Med Iran. 2015 Dec;53(12):793 -\n795. \n4. Etrusco A, Fabio M, Cucinella G, de Tommasi O, Guastella \nE, Buzzaccarini G, Gullo G. Utero -cutaneous fistula after \ncaesarean section delivery: diagnosis and management of a \nrare complication. Prz Menopauzalny. 2022;21(3):214-217. \n5. Hasan JN, Musa DH, Mohammed AA. Uterocutaneous \nfistula after cesarean section; Case report. Int J Surg Case \nRep. 2021;89:106621. \n6. Mahto S, Ghimire R, Kunwar S, Saha R. Successful \nOutcome of Uterocutaneous Fistula: A Case Report. JNMA \nJ Nepal Med Assoc. 2021;59(241):913-915.","source_license":"CC0","license_restricted":false}