{"paper_id":"381b364e-5b60-4091-aecf-a225a0471fac","body_text":"Introduction \nEndometriosis is defined as the presence of func -\ntioning endometrial cells outside the uterine cavity 1\nwhich affects between 5  to 10%  of women in repro -\nductive age affects with peak incidence in the third \nand fourth decades 2 . \nEndometriosis can be divided into intrapelvical \nand, less common - extrapelvical.  Scar endometriosis \nis a form of extrapelvical endometriosis and is on of \nthe least frequent presentations 3. The incidence has \nbeen estimated to be 0.03%  to 0.40%  of all cases of \nendometriosis 4. We report a case of scar endometrio -\nsis in Pfannesteil scar in a 3 1 year old woman, who \npresented 6 years following an emergency Caesarean \nSection, complaining of tender and palpable lumps \non her incision scar. She underwent laparotomy and \nexcision of scar endometriotic nodules. \nCase presentation \nA 3 1 year old Caucasian woman, gravida 2 , para 2 ,\npresented to our clinic complaining of lumps on her \ncaesarean section scar. She had a spontaneous nor -\nmal delivery followed by an emergency Caesarean \nsection, the latter being 6 years prior to presentation.\nLumps were tender to touch and more protuberant \nwhen she was on a period. Her periods were regular \nand fairly painful and she had no urinary or bowel \nsymptoms. Her past medical history was insignifi -\ncant, including pneumonia recently and asthma. \nExamination revealed soft abdomen, with four \npalpable discrete tender masses on the anterior ab -\nHJOG \nAn Obstetrics and Gynecology \nInternational Journal \nVOLUME 17 ISSUE 1, JANUARY-MARCH 2018 \n19 \nHJOG 2018, 17 (1), 19-21 \nCase report \nA  case report of caesarean scar endom etriosis \nTingi Efterpi \nSpecialty registrar in Obstetrics and Gynaecology, Furness General Hospital, Barrow in Furness, UK \nA bstract \nAlthough it is uncommon, extrapelvic endometriosis can form a discrete mass known as an abdominal wall \nendometrioma. The incidence of abdominal wall endometriomas has been estimated to be 0.03%  to 0.15 % \nof all cases of endometriosis. We report a case of scar endometriosis in Pfannesteil scar in a 31 year old woman,\nwho presented six years following an emergency Caesarean Section, complaining of some lumps on her inci -\nsion scar. The patient underwent laparotomy followed by the excision of five endometriotic nodules. \nKey words: caesarean scar, endometrioma \nCorrespondence \nDr. Efterpi Tingi, Department of Obstetrics and Gynaecology, Furness General Hospital, Dalton Lane, L1 4 4LF, \nBarrow in Furness, UK, E-mail:efterpi.tingi@doctors.org.uk. Tel:0044-7796025836, Fax:0044-1 229 871 047 \nTingi.qxp_Layout 1  20/02/2018  00:31  Page 19\n\ndominal wall; two on the right and two on the left \nand superior to her Caesarean section scar. The \nsmallest nodule measured about 0.5 cm and the \nlargest about 2  cm. Speculum, bimanual and pelvic \nexamination were essentially normal apart from \nvery mild tenderness in the Pouch of Douglas. \nTransabdominal and transvaginal ultrasonogra -\nphy revealed a retroverted uterus measuring 8.2 cm,\na rectovaginal nodule measuring  1.3 cm x 0.9cm and \n6-7  nodules were  seen in the anterior abdominal \nwall, with the largest on the left measuring 3 .0 x \n1.5 cm. These had several cystic areas and features of \nabdominal wall endometriosis. The right ovary \nmeasured 15 cc with heterogenous area of 2 cm \nwhich may represent endometriotic deposits. The \nleft ovary appeared normal measuring 8cc.\nOptions had been discussed with patient and she \nopted for surgical excision. Laparotomy was per -\nformed followed by the excision of five endometriotic \nnodules. Both tubes and ovaries appeared normal.\nThere were no adhesions or rectovaginal nodules,\nbut small area of scarring in the Pouch of Douglas.\nHistopathology report confirmed the findings of \nscar endometriotic nodules. Macroscopic examina -\ntion of the specimen showed five irregular fragments \nof fibrofatty tissue the largest 3.5 cm in maximum ex -\ntent. The cut surfaces show irregular pale fibrosis \nwith microcystic change containing mucinous fluid \nand larger cysts up to 0.6cm which contain black ge -\nlatinous fluid. Microscopic examination showed \npieces of fibrofatty with multifocal endometriosis \nand that the endometriotic foci were surrounded by \nfibroblastic and mature scar tissue and within the \nscar tissue were entrapped degenerating skeletal \nmuscle fibres.\nThe patient presented eight months following her \nprocedure with a further nodule at the right angle of \nthe scar. On examination, it was in the area where the \nlargest endometriotic nodule had been excised. This \ntime patient opted for conservative approach.\nD iscussion \nThe presence of a mass of extra-pelvic endome -\ntrial tissue within the abdominal wall (ie, endometri -\noma) is uncommon and it occurs more frequently in \nwomen who had previous abdominal or pelvic sur -\ngery. Although in most cases occurring in patients \nwith previous caesarean, endometriomas have also \nbeen observed in the surgical incisions following la -\nparoscopic hysterectomy. Differential diagnosis of \npalpable masses close to the surgical scar includes \nincisional hernia, hematoma, granuloma, lipomas,\nhaematomas, sebaceous cysts, cheloid, suture gran -\nulomas, abscess or various soft tissue tumours 4.\nThere are different theories in the literature which \nsupport the mechanism of scar endometriosis devel -\nopment. These include the implantation or retro -\ngrade menstruation theory, the coelomic metaplasia \ntheory and that of direct implantation. The most \npopular theory is that of direct implantation; during \nthe surgical procedure, endometrial tissue is seeded \ninto the wound 5 . \nThe most common symptoms of endometriosis \ninclude cyclical pain, subfertility, dysmenorrhea and \ndyspareunia. Quite often patients present with the \ncombination of these problems. Caesarean scar en -\ndometriomas can cause periodic pain at the incision \nsite at the time of menstruation, incision site can be \ntender to touch and hypertrophic 3.The diagnosis of \nabdominal wall endometriosis could be challenging \nif cyclical pain is not present. The time from CS to the \nonset of symptoms varies considerably and ranges \nfrom months to 17 .5  years, with an average of 3 0 \nmonths 4. The presumptive diagnosis should always \nbe considered when signs and symptoms clearly co -\nincide with the phases of the menstrual period.\nUltrasonography, computed tomography (CT),\nMagnetic resonance imaging (MRI) of the abdomen \nand pelvis are important to define not only the size \nof the lesion, but also the degree of involvement of \nthe abdominal wall. MRI’s sensitivity for the diagno -\nVOLUME 17 ISSUE 1, JANUARY-MARCH 2018 \nVerveridou et al \n20 \nTingi.qxp_Layout 1  20/02/2018  00:31  Page 20\n\nsis of abdominal wall endometriosis is reported up\nto 71% and its specificity as 82%; it has been sug-\ngested that MRI seems to be the best method in pre-\noperative diagnosis as it can be used to evaluate\npelvic and extraperitoneal disease4-6. Fine-needle as-\npiration (FNA) cytology is generally inconclusive, al-\nthough it may be of some value in planning surgical\napproach for the management of cases of scar en-\ndometriomas5.\nFinally, laparoscopy is the gold standard for eval-\nuating and diagnosing pelvic and peritoneal en-\ndometriotic implantations7 . Local excision if the\ntreatment of choice of abdominal wall endometri-\nomas like in our case. It has been reported, that the\nlikelihood of recurrence could be decreased by\nachieving clear margins of at least 1 cm8.  Medical\ntreatment with gonadotropin-releasing hormone\nanalogues could be offered to patients who do not\nwish to undergo any surgical intervention for tran-\nsient relief of symptoms7,8.\nConclusion\nCaesarean section greatly increases the risk of de-\nveloping scar endometriosis. In conclusion, scar en-\ndometriosis is a rare condition and should be\nsuspected when a woman in the reproductive age\npresents with pain and swelling at scar site especially\nfollowing obstetric surgery. Abdominal ultrasound\nand computed tomography or MRI of the abdomen\nand pelvis may help in the differential diagnosis.\nConflict of interest\nThe author declare no conflict of interest.\nInformed Consent \nInformed consent was obtained\nReferences\n1. Kaloo P, Reid G, Wong F. Caesarean section scar\nendometriosis: Two cases of recurrent disease\nand a literature review. Aust NZ J Obstet Gy-\nnaecol 2002;42:218–20.\n2. Danielpour PJ, Layke JC, Durie N, Glickman\nLT.Scar endometriosis - a rare cause for a painful\nscar: A case report and review of the literature.\nCan J Plast Surg 2010 Spring;18(1):19-20.\n3. Francica G, Giardiello C, Angelone G, Cristiano\nS, Finelli R, Tramontano G. Abdominal wall en-\ndometriosis near cesarean delivery scars. J Ul-\ntrasound Med 2003;22:1041–7.\n4. Gupta P, Gupta S. Scar Endometriosis: a Case\nReport with Literature Review. Acta Med Iran\n2015 Dec;53(12):793-5.\n5. Efremidou EI, Kouklakis G, Mitrakas A, Lirat-\nzopoulos N, Polychronidis AC. Primary umbili-\ncal endometrioma: a rare case of spontaneous\nabdominal wall endometriosis. International\nJournal of General Medicine 2012;5:999-1002.\ndoi:10.2147/IJGM.S37302.\n6. Sinha R., Kumar M., Matah M. Abdominal Scar\nEndometriosis after Cesarean Section: A Rare\nEntity. AMJ 2011;4;1:60-62.\n7. Nissotakis C, Zouros E, Revelos K, Sakorafas GH.\nAbdominal wall endometrioma: a case report\nand review of the literature. AORN J 2010\nJun;91(6):730-42\n8. Zhao X, Lang J, Leng J, Liu Z, Sun D, Zhu L. Ab-\ndominalwall endometriomas. Int J Gynaecol\nObstet 2005;90(3):218-222.\nVOLUME 17 ISSUE 1, JANUARY-MARCH 2018\nEffects of oral contraceptives to bone mineral density of young women\n21\nReceived 2-12-2017 \nRevised 22-12-2017 \nAccepted 27-12-2017\nTingi.qxp_Layout 1  20/02/2018  00:31  Page 21","source_license":"CC0","license_restricted":false}