{"paper_id":"4391278a-9111-4c0c-b822-7dc306f8593d","body_text":"Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.\nJ Case Rep Images Obstet Gynecol 2018;4:100036Z08AO2018. \nwww.edoriumjournals.com/case-reports/jcrog\nOmar et al. 1\ncase report opeN access \nMenstruation from the pfannenstial scar: A case of rare \npresentation of atypical endometriosis\nAhmad Akram Omar, Mohd Shukri Othman, Pek Sung Hoo,  \nErinna Mohamad Zon, Ahmad Amir Ismail, Rahimah Abdul Rahim,  \nNik Rafiza Afendi, Adibah Ibrahim\nAbstrAct\nIntroduction: Endometriosis is the presence of \nfunctioning endometrium (gland and stroma) \nin sites other than uterine mucosa, usually in \nthe pelvis, causing dysmenorrhea, dyspareunia, \nmenstrual irregularities, and infertility. case \nreport: A 27-year-old, had caesarean section \n11 months ago  presented to Obstetrics and \nGynaecology clinic with cyclical bleeding \nfrom her surgical scar from ten months. she \nnoted bleeding from the small nodule over \nthe healed pfannenstial scar on day of her \nmenses. Examination revealed a small reddish \nnodule 0.5 cmx0.5 cm, non-tender, with two \nblackish dots on it. transabdominal ultrasound \nexamination revealed that  the nodule confined \nat the subcutaneous tissue, above the rectus. \nAhmad Akram Omar 1, Mohd Shukri Othman 2, Pek Sung \nHoo3,  Erinna Mohamad Zon 4, Ahmad Amir Ismail 1, Rahi-\nmah Abdul Rahim 1, Nik Rafiza Afendi 1, Adibah Ibrahim 5\nAffiliations: 1Senior lecturer, Obstetrics and Gynaecology \nDepartment, School of Medical Science, University Sains \nMalaysia, Kota Bharu, Kelantan, Malaysia; \n2Professor, Ob-\nstetrics and Gynaecology Department, School of Medical \nScience, University Sains Malaysia, Kota Bharu, Kelantan, \nMalaysia; \n3Clinical lecturer, Obstetrics and Gynaecology \nDepartment, School of Medical Science, University Sains \nMalaysia, Kota Bharu, Kelantan, Malaysia; \n4Specialist \ntrainee, Obstetrics and Gynaecology Department, School \nof Medical Science, University Sains Malaysia, Kota Bharu, \nKelantan, Malaysia; \n5Associate Professor, Obstetrics and \nGynaecology Department, School of Medical Science, Uni-\nversity Sains Malaysia, Kota Bharu, Kelantan.\nCorresponding Author: Pek Sung Hoo, Clinical lecturer, Ob-\nstetrics and Gynaecology Department, School of Medical \nScience, University Sains Malaysia, Kota Bharu, Kelantan, \nMalaysia.\nReceived: 20 August 2017\nAccepted: 26 December 2017\nPublished: 11 April 2018\nDiagnosis of scar endometriosis was made. she \nhad wide local excision and recovered well. \nthe histological examination was consistent \nwith scar endometriosis. conclusion: scar \nendometriosis is a very rare condition. Women \nin the reproductive age with swelling, pain and \ndischarge at the scar following surgery should \nbe suspected for scar endometriosis.\nKeywords: caesarean section, Endometriosis, \nPfannenstial scar, scar endometriosis\nHow to cite this article\nOmar AA, Othman MS, Hoo PS, Zon EM, Ismail \nAA, Rahim RA, Afendi NR. Menstruation from the \npfannenstial scar: A case of rare presentation of \natypical endometriosis. J Case Rep Images Obstet \nGynecol 2018;4:100036Z08AO2018.\nArticle ID: 100036Z08AO2018\n*********\ndoi: 10.5348/100036Z08AO2018CR\nINtrODUctION\nEndometriosis is the presence of functioning \nendometrium (gland and stroma) in sites other \nthan uterine mucosa, usually in the pelvis, causing \ndysmenorrhea, dyspareunia, menstrual irregularities, \nand infertility [1]. It is not a neoplastic condition, although \nmalignant transformation is possible. Endometriosis is \na disease of contrast. It is a benign but locally invasive, \ndisseminates widely. Cyclic hormones stimulate growth \nbut continuous hormones suppress it. Scar endometriosis \nis rare with incidence of 0.3–1% [2]. It usually manifest \ncase report peer reviewed | opeN access   \n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.\nJ Case Rep Images Obstet Gynecol 2018;4:100036Z08AO2018. \nwww.edoriumjournals.com/case-reports/jcrog\nOmar et al. 2\nas discrete mass near surgical or procedural scars such \nas caesarean section, hysterectomy and episiotomy. \n[3]. A palpable subcutaneous mass near surgical scars \nassociated with cyclic pain and swelling during menses \nis the most frequent clinical presentation [4]. Some even \nmanifest as cyclical bleeding during menses. Hereby \nwe report a case of cyclical bleeding scar endometriosis \nfollowing caesarean section.\ncAsE rEPOrt\nA 27-year-old Malay lady, whose last child birth was \n11 months ago  presented to Obstetrics and Gynaecology \nclinic with cyclical bleeding from her surgical scar for ten \nmonths. She had emergency lower segment caesarean \nsection (EMLSCS) for poor progress of labour and the \nsurgery was uncomplicated. She regained her menses after \ntwo months and noted bleeding from the small nodule on \nday one menses. On subsequent months bleeding became \nlonger till day three menses. She denied dysmenorrhea, \ndyspareunia, and intermenstrual bleeding. Examination \nof the abdomen revealed a small reddish nodule 0.5cm \nx0.5cm, non-tender, with two blackish dots on it, well \ndefined lesion and non-mobile (Figure 1).\nTransabdominal ultrasound examination revealed \nthat the nodule was confined at the subcutaneous tissue, \nabove the rectus. Diagnosis of scar endometriosis was \nmade based on the clinical presentation and ultrasound \nexamination. Subsequently, the patient underwent \nexcision of scar endometriosis. The excision was made \naround the mass with a margin of 1cm circumferential \nand 2cm depth (Figure 2).\nThe histological finding was consistent with scar \nendometriosis. Postoperative recovery was uneventful \nand patient was discharged without medication. At three \nmonths follow-up, the patient was asymptomatic.\nDIscUssION\nEndometriosis is the presence of functioning \nendometrium (gland and stroma) in sites other \nthan uterine mucosa, usually in the pelvis, causing \ndysmenorrhea, dyspareunia, menstrual irregularities, \nand infertility [1]. This is the first occurrence of scar \nendometriosis at our center [4, 5]. Scar endometriosis \nis rare with incidence of 0.3–1% [2]. It was postulated \nto occur as the result of mechanical transplant of the \nendometrium or placenta cell at the incision site during \nthe operation [4]. Endometrial cells in early stage of \nwound healing might benefit with protective barrier and \nnutrition source provided by clot formation. With the \neffect of angiogenesis and stimulation of oestrogen, the \ndisease might  progress further.\nCareful history and physical examination are \nimportant to diagnose the disease. Symptoms varies \nsuch as cyclical change in swelling size, bleeding or \ndischarge from the scar and abdominal wall pain and is \nalways misdiagnosed as the incidence is extremely low, \nand symptoms may be easily dismissed by the patient. In \none case, series of six cases by Poonam Goel at el, none \nof the patient had symptoms of pelvic endometriosis [9]. \nThe incidence of concomitant pelvic endometriosis with \nscar endometriosis has been reported to be from 14.3% \nto 26% [2]. Ideally, all patients should be examined \nfor concomitant pelvic endometriosis. When a proper \ndiagnosis cannot be achieved, scar endometriosis can \nbe easily mixed with other surgical conditions like \nhematoma, neuroma, hernia, granuloma, abscess, scar \ntissue, neoplastic tissue, or even metastatic carcinoma, \nwhich is a simple excuse to refer the patient to the general \nsurgeon [8, 9]. Often, the diagnosis of endometriosis is not \nsuggested until after a biopsy and histology examination \nhas been performed. Correct preoperative diagnosis is \nachieved in 20% to 50% of these patients [ 2, 3, 4].\nImaging procedures help, rather than confirm, in \nobtaining a differential diagnosis. Ultrasonography is \nthe best and most commonly used investigation tool for \nabdominal masses, given its practicality and lower cost. \nFrancica et al showed diagnostic USG features of scar \nendometriosis as (i) a hypoechoic echoes, (ii) regular \nmargin, often speculated, infiltrating the adjacent \ntissue and (iii) a hypoechoic ring of variable width and \ncontinuity [6]. Fine-needle aspiration cytology (FNAC) \nFigure 1: Small nodule at the region of caesarean section scar.\nFigure 2: Tissue removed after excision. \n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.\nJ Case Rep Images Obstet Gynecol 2018;4:100036Z08AO2018. \nwww.edoriumjournals.com/case-reports/jcrog\nOmar et al. 3\nwas reported in some studies for confirming the diagnosis \nHowever, FNAC is not a liable method to make the \ndiagnosis of scars, and surgeons must be aware of some \ndiagnosis such as inguinal hernia and re-implantation of \npotential malignancies during process. Theoretically, this \nprocedure has the potential to seed the needle tract with \ncell and cause recurrence, especially within concomitant \nintra-pelvic endometriosis [3, 5, 6]. It might be benefit \nin the   cases of large masses, doubtful diagnosis, and \natypical clinical presentations.\nLocal wide excision, with at least a 1 cm margin, is an \naccurate treatment choice of scar endometriosis and also \nfor recurrent lesions [2–4, 10, 11]. It is often misdiagnosed \nentity and commonly occurs after caesarean delivery, \nhysterostomy, hysterectomy and laparotomy [4, 5, 12]. \nRecurrence of scar endometriosis seldom happens \nwith only a few cases reported. As expected, the larger \nand deeper lesions to the muscle or the fascia are more \ndifficult to excise completely. In large lesions, complete \nexcision of the lesion may entail a synthetic mesh \nplacement or tissue transfer for closure after resection \n[2, 3, 11]. Medical therapy with danazol, progesterone, \nand GnRH produces only partial recovery, and mostly \nrecurrence occurs after cessation of the treatment with \nextreme side effects [7]. The cause of recurrence might be \nincomplete initial incision or spreading of endometriosis \nduring manipulation.\nHistology is the hallmark of diagnosis. It is confirmed \nby presence of endometrial glands, stroma, and \nhemosiderin pigment [1].\nNumerous measures have been proposed to prevent \nscar endometriosis. Wasfie et al suggested a method to \nprevent such iatrogenic implants by careful cleaning and \nvigorous irrigation of the abdominal wall wound with a \nhigh-jet saline solution before closure [13].\ncONcLUsION\nIn conclusion, scar endometriosis is a rare condition \nbut with significant quality of life disturbance. Therefore, \nany women in the reproductive age presented with painful \nswelling and discharge from the scar following obstetric \nsurgery, scar endometriosis should be suspected. \nWide local excision is the procedure of choice for both \ndiagnostic and therapeutic purposes. \nrEFErENcEs\n1. Pauerstein CJ. Clinical presentation and diagnosis. In: \nSchenken RS, editor. Endometriosis: Contemporary \nConcepts in Clinical Management. Philadelphia, PA: \nJB Lippincott; 1989. p. 127–44.\n2. Bergqvist A. Different types of extragenital \nendometriosis: A review. Gynecol Endocrinol 1993 \nSep;7(3):207–21.\n3. Steck WD, Helwig EB. Cutaneous endometriosis. Clin \nObstet Gynecol 1966 Jun;9(2):373–83.\n4. Koger KE, Shatney CH, Hodge K, McClenathan JH. \nSurgical scar endometrioma. Surg Gynecol Obstet \n1993 Sep;177(3):243–6.\n5. Patterson GK, Winburn GB. Abdominal wall \nendometriomas: Report of eight cases. Am Surg 1999 \nJan;65(1):36–9.\n6. Francica G, Giardiello C, Angelone G, Cristiano \nS, Finelli R, Tramontano G. Abdominal wall \nendometriomas near cesarean delivery scars: \nSonographic and color doppler findings in a series of \n12 patients. J Ultrasound Med 2003 Oct;22(10):1041–\n7.\n7. Rivlin ME, Das SK, Patel RB, Meeks GR. Leuprolide \nacetate in the management of cesarean scar \nendometriosis. Obstet Gynecol 1995 May;85(5 Pt \n2):838–9. \n8. Rani PR, Soundararaghavan S, Rajaram P. \nEndometriosis in abdominal scars: Review of 27 \ncases. Int J Gynaecol Obstet 1991 Nov;36(3):215–8.\n9. Goel P, Devi L, Tandon R, Saha PK, Dalal A. Scar \nendometriosis - a series of six patients. Int J Surg \n2011;9(1):39–40.\n10. Ding DC, Hsu S. Scar endometriosis at the site of \ncesarean section. Taiwan J Obstet Gynecol 2006 \nSep;45(3):247–9.\n11. Marsden NJ, Wilson-Jones N. Scar endometriosis: A \nrare skin lesion presenting to the plastic surgeon. J \nPlast Reconstr Aesthet Surg 2013 Apr;66(4):e111–3.\n12.\t Uzunçakmak\t C,\t Güldaş\t A,\t Ozçam\t H,\t Dinç\t K.\t Scar\t\nendometriosis: A case report of this uncommon entity \nand review of the literature. Case Rep Obstet Gynecol \n2013;2013:386783.\n13. Wasfie T, Gomez E, Seon S, Zado B. Abdominal wall \nendometrioma after cesarean section: A preventable \ncomplication. Int Surg 2002 Jul–Sep;87(3):175–7.\n*********\nAuthor contributions\nAhmad Akram Omar – Substantial contributions to \nconception and design, Acquisition of data, Drafting the \narticle, Revising it critically for important intellectual \ncontent, Final approval of the version to be published\nMohd Shukri Othman – Substantial contributions to \nconception and design, Acquisition of data, Drafting the \narticle, Final approval of the version to be published\nPek Sung Hoo – Substantial contributions to conception \nand design, Acquisition of data, Drafting the article, \nRevising it critically for important intellectual content, \nFinal approval of the version to be published\nErinna Mohamad Zon – Substantial contributions to \nconception and design, Analysis and interpretation of \ndata, Drafting the article, Final approval of the version to \nbe published\nAhmad Amir Ismail – Substantial contributions to \nconception and design, Acquisition of data, Drafting the \narticle, Revising it critically for important intellectual \ncontent, Final approval of the version to be published\nRahimah Abdul Rahim – Substantial contributions to \nconception and design, Acquisition of data, Drafting the \narticle, Final approval of the version to be published\n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.\nJ Case Rep Images Obstet Gynecol 2018;4:100036Z08AO2018. \nwww.edoriumjournals.com/case-reports/jcrog\nOmar et al. 4\nNik Rafiza Afendi – Substantial contributions to \nconception and design, Acquisition of data, Drafting the \narticle, Final approval of the version to be published\nAdibah Ibrahim – Substantial contributions to conception \nand design, Acquisition of data, Drafting the article, Final \napproval of the version to be published\nGuarantor of submission\nThe corresponding author is the guarantor of submission.\nsource of support\nNone\nconsent statement\nWritten informed consent was obtained from the patient \nfor publication of this case report.\nconflict of Interest\nAuthors declare no conflict of interest.\ncopyright\n© 2018 Ahmad Akram Omar et al. 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