{"paper_id":"5a04e13a-7868-4a7f-a344-1a8c5776b106","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nEndometriosis is defined as the presence of endometrial glands \nand stroma outside the uterus. It affects 10-15% of all women of \nreproductive age i.e. 18-45 years, 1,2 and 70% of women had chronic \npelvic pain.3 Endometriosis occurs in abdominal, extra abdominal and \nremote areas. Scar endometriosis is reported in only 0.03-0.15% of \nall cases of endometriosis. Several reproductive factors have been \nconsistently associated with risk for endometriosis, such as early \nage at menarche,4‒6 late menopause, frequent menstrual cycles 7,8 low \nparity,6,9,10 use of oestrogen pills, 11 oestrogen producing tumours, \nobesity has also been put forward. 12,13 The cause of endometriosis \nis unclear, but several theories have been reported. One possible \nmechanism is retrograde menstruation. This retrograde flow, along \nwith potential hematogenous or lymphatic circulation, may result in \nthe seeding of endometrial tissue in ectopic sites. Another theory is \ndirect implantation of endometrial tissue during surgical procedures \nlike LSCS, Hysterectomy, Myomectomy, Episiotomy etc. Other \nfactors, such as genetic, environmental, hormonal, inflammatory or \nimmunological may also result implantation of endometrial tissues on \nectopic sites.14‒17 \nClinical presentation of endometriosis varies in women. Patients \noften present with symptoms such as inter menstrual bleeding, \ndysmenorrhoea, dyspareunia, dyschezia and dysuria. 18 Pelvic pain \nmay present before onset of menstruation. Often, endometriosis can \nbe asymptomatic, only diagnosed during evaluation for infertility. The \nlesions can be peritoneal lesions, superficial implants or cysts on the \novary, or deep infiltrating disease. 19 Classification of endometriosis \nassociated symptoms have been established by the American Society \nfor Reproductive Medicine (ASRM) based on the morphology of \nperitoneal and pelvic implants such as red or pink, white and black \nlesions, percentage of involvement of organ. Endometriosis in bowel, \nurinary tract, fallopian tube, vagina, cervix, skin or other locations are \nidentified as per ASRM guidelines. Stages of endometriosis according \nto ASRM guidelines are stage I, II, III, and IV . These are based on the \npoint scores and correspond to minimal, mild, moderate and severe \nendometriosis. Early diagnosis and intervention could ultimately \nimprove the quality of life and preserve fertility.20\nObjective\nThe goal of this paper is to highlight an atypical case of scar \nendometriosis. \nCase report\nA 39years old female patient came to Gynaec OPD of NIUM \nHospital on 6th May 2019 with the complaint of supra pubic swelling \nwhich was gradually increasing in size since last 6months. She also \ncomplained that the pain in lump is worse during menstruation. Her \nage of menarche was 15years. She is having regular menstruation \nwith normal flow, but history of dysmenorrhoea is present. She had \nno history of other systemic illness. Her married life was 18years. \nShe had two children both were delivered by LSCS and history of one \nspontaneous abortion was also present. The patient was tubectomized \nafter caesarean section. Her last child birth was 10years back. \nAccording to her history before surgery she was fit and well with no \ndocumented history of endometriosis. Vitals were normal and her \nBMI was 26.2Kg/m2. \nOn examination a supra pubic swelling size approximately 8X5cm \nwas found at the site of lower part of caesarean scar. On palpation \nlocal temperature was raised, mass was irregular extending to pelvic \nregion. (Figure 1) On vaginal examination uterus found anteverted, \nbulky, mobile and fornices free. On initial examination it was \ndiagnosed as a lump. Consultant gynaecologist advised for USG and \nCytology of lump. USG was done on 14/5/2019 findings suggested \nthat large well defined hypoechohic solid lesion approximately \n8.6X6.5X7.1cms noted in subcuteneous plane in mid line of lower \nanterior abdominal wall and supra pubic region suggestive of \nendometriosis. For confirmation FNAC was done on the same day \ni.e. 14/5/2019 which reported benign cellular stromal fragments \nof endometrium with occasional benign glands. No granuloma or \nmalignancy was found. These findings suggested endometriosis. Extra \nabdominal endometriosis occurs at the time of surgical procedures like \nmyomectomy, hysterectomy or LSCS etc. Here in this case previous \nhistory of two LSCS was present, which suggested the swelling may \nbe due to direct implantation of endometrial tissue during caesarean \nsection. This endometrial tissue grows every month in response to \nhormones especially oestrogen. Oestrogen helps in proliferation of \nEndocrinol Metab Int J. 2019;7(5):140‒142. 140\n©2019 Tabassum et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , \nwhich permits unrestricted use, distribution, and build upon your work non-commercially.\nCase report of atypical scar endometriosis\nVolume 7 Issue 5 - 2019\nTabassum K, Ambar S, Habiba S\nDepartment of Obstetrics and Gynaecology, National Institute \nof Unani Medicine, India\nCorrespondence: Tabassum K, Associate professor, Dept \nof Obstetrics and Gynaecology, National Institute of Unani \nMedicine, Bangalore, India, T el 78460 74142, \nEmail  \nReceived: July 22, 2019 | Published: September 30, 2019\nAbstract\nScar endometriosis is an infrequent type of extra pelvic endometriosis that is rather close \ntogether with obstetrical and gynaecological surgeries. Scar endometriosis is reported in \nonly 0.03-0.15% of all cases of endometriosis. We are reporting a case of 39years old \nfemale patient presenting with scar endometriosis 10 years after her last lower segment \ncaesarean section. The patient came to the Gynaec OPD, NIUM Hospital on 6 th May 2019 \nwith the compliant of supra pubic swelling since 6months, which was growing slowly. \nHer menstrual history was regular, but she had lower abdominal pain during menstruation. \nPatient had two children delivered by LSCS. On clinical history, examination, USG and \nFNAC finding the swelling was diagnosed as scar endometriosis. \nKeywords: endometriosis, abdominal scar, LSCS and prevention \nEndocrinology & Metabolism International Journal\nCase Report\n Open Access\n\n\nCase report of atypical scar endometriosis\n141\nCopyright:\n©2019 Tabassum et al.\nCitation: Tabassum K, Ambar S, Habiba S. Case report of atypical scar endometriosis. Endocrinol Metab Int J. 2019;7(5):140‒142. \nDOI: 10.15406/emij.2019.07.00259\nendometrial tissue every month, hence the supra pubic swelling was \nincreasing slowly. \nFigure 1 Pubic swelling.\nDiscussion \nScar endometriosis is rare entity usually follows previous \nabdominal surgery, especially early hysterectomy and caesarean \nsection. There are numerous sites where extra pelvic endometriosis \nhas been reported. These include lungs, pleura, bladder, kidney, \nbowel, omentum, umbilicus and abdominal wall. 21 Endometriosis \ninvolving the abdominal wall is a rare occurrence, however, it should \nbe considered in the differential diagnosis of abdominal wall masses \nin females. The typical clinical scenario involves a parous female with \na history of gynaecological or obstetrician surgery presenting with a \npainful nodule or lump. The severity of pain and size of the lump \nmay vary with menstrual cycle. In this case the patients remained \nwithout a diagnosis for 10years. Gynaecological history and physical \nexamination is important in finalizing the diagnosis. The history \nrevealed that the pain coincide with her menstrual cycle. The clinical \nexamination revealed a soft, non reducible swelling located in pubic \nregion. It was tender on palpation. On initial examination it was \ndiagnosed as a lump. Based on the gynaecological history of a cyclical \nincrease in the size and severity of pain an endometrioma was also \nincluded in the differential diagnosis.22\nSurgical scar endometriosis is believed to result from deposits \nof endometrial cells during surgical intervention. These cells are \nthen stimulated by oestrogen to produce endometriomas. Although \nrelatively uncommon, it was well documented in clinical practice that \nscar endometriosis occur with different types of incisions where contact \nhas possibly occurred with endometrial tissue. 23 The endometriomas \nmay develop 1-20years post operatively, example include caesarean \nsection, laparoscopy, tubal ligation and hysterectomy. Of these \ncaesarean section and hysterectomy are the most common. 24 The \nincident after caesarean section is difficult to determine, but estimates \nrange from 0.03% to 0.47%. 25 Minaghlia et al analyzed 30years of \nincisional endometriosis after caesarean section reported the incidence \nof scar endometriosis to be 0.08%.26 Frequency of scar endometriosis \nincrease by number of caesarean section and laparoscopy performed \nin recent years.27 Other authors have reported an incidence of 0.2% in \nall caesarean sections performed. (28) To make a definitive preoperative \ndiagnosis of endometriosis is difficult.28\nPositive histology confirms the diagnosis of endometriosis; \nnegative histology does not exclude it, whether histology should be \nobtained if peritoneal disease alone is controversial. Visual inspection \nis usually adequate but histological confirmation of at least one lesion \nis ideal. Compared to laparoscopy, transvaginal ultrasound has no \nvalue in diagnosing peritoneal endometriosis, but it is a useful tool \nboth to make and to exclude the diagnosis of an ovarian endometrioma. \nTVS may have a role in the diagnosis of disease involving the bladder \nor rectum. Medical imaging plays a role in locating the mass and \nruling out hernia and other conditions, for example lipoma, abscess \nand suture granuloma. MRI remains the most useful imaging modality \nto exclude other pathology. 28 In this case the scar endometriosis was \ndiagnosed by USG and was confirmed by FNAC of the lump. \nConclusion\n Endometriosis is a debilitating disease that impacts the quality of \nlife of adolescent and adult patients. Delayed diagnosis is common and \nmay lead to a decline in reproductive potential and fertility. A semi or \nnon-invasive diagnostic biomarker would be a useful tool to identify \npatients early in the disease process and thus improving outcomes, \nincluding less pain and better fertility. The occurrence of abdominal \nwall scar endometriosis after caesarean section has been a definite \nentity; steps to prevent this complication have not been explained. \nLiterature recommends that through cleaning, irrigation with saline \nand closure of abdominal wound will prevent scar endometriosis. \nAcknowledgments\nNone.\nConflicts of interest\nThe authors declare that there is no conflict of interest.\nFunding\nNone.\nReferences\n1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):1789‒1799. \n2. Noaham KE. World Endometriosis Research Foundation Global Study of \nWomen’s Health consortium. Impact of endometriosis on quality of life \nand work productivity: a multicenter study across ten countries. Fertil \nSteril. 2011;96(2):366‒373.\n3. Carter JE. Combined hysteroscopic and laparoscopic findings in patients \nwith chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994;2(1):43‒47. \n4. Missmer SA, Hankinson SE, Spiegelman D, et al. Incidence of \nLaparoscopically Confirmed Endometriosis by Demographic, \nAnthropometric, and Lifestyle Factors. American Journal of \nEpidemiology. 2014;160(8):784‒796. \n5. Darrow SL. Menstrual Cycle Characteristics and the Risk of \nEndometriosis. Epidemiology. 1993; 4(2):135‒142.\n6. Missmer S, Hankinson S, Spiegelman D, et al. Reproductive \nhistory and endometriosis among premenopausal women. Obstet \nGynecol. 2004;104:965‒974.\n7. Matalliotakis I, Cakmak H, Fragouli Y , et al. Epidemiological \ncharacteristics in women with and without endometriosis in the Yale \nseries. Archives of Gynecology and Obstetrics. 2008;277(5):389–393. \n8. Sangi‒Haghpeykar H, Poindexter Ar. Epidemiology of endometriosis \namong parous women. Obstet Gynecol. 1995;85(6):983‒992. \n9. Candiani G, Danesino V , Gastaldi A, et al. Reproductive and menstrual \nfactors and risk of peritoneal and ovarian endometriosis. Fertil \nSteril. 2009;56(2):230‒234. \n10. Peterson CM, Johnstone EB, Hammoud AO, et al. Risk factors associated \nwith endometriosis: importance of study population for characterizing \n\n\nCase report of atypical scar endometriosis\n142\nCopyright:\n©2019 Tabassum et al.\nCitation: Tabassum K, Ambar S, Habiba S. Case report of atypical scar endometriosis. Endocrinol Metab Int J. 2019;7(5):140‒142. \nDOI: 10.15406/emij.2019.07.00259\ndisease in the ENDO Study. American Journal of Obstetrics and  \nGynaecology. 2013;208(6):451.\n11. Vercellini P, Eskenazi B, Consonni D, et al. Oral contraceptives and risk \nof endometriosis: a systematic review and meta‒analysis. Hum Reprod \nUpdate. 2011;17(2):159‒170. \n12. Apter D, Reinilä M, Vihko R. Some endocrine characteristics of \nearly menarche, a risk factor for breast cancer, are preserved into \nadulthood. International Journal of Cancer. 1989;44(5):783‒787. \n13. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, \nand adenomyotic nodules of the rectovaginal septum are three different \nentities. Fertil Steril. 1997;68(4):585–596.\n14. Farland LV , Shah DK, Kvaskoff M, et al. Epidemiological and Clinical \nRisk Factors for Endometriosis. In: D’Hooghe T, Editor. Biomarkers for \nEndometriosis. Springer Science; New York. 2015;5(6):233‒234.\n15. Anaf V , Simon P, El Nakadi I, et al. Hyperalgesia, nerve infiltration and \nnerve growth factor expression in deep adenomyotic nodules, peritoneal \nand ovarian endometriosis. Hum Reprod. 2002;17(7):1895‒1900.\n16. Wang G, Tokushige N, Markham R, et al. Rich innervations of deep \ninfiltrating endometriosis. Hum Reprod. 2011;24(4):827‒834. \n17. Berkley KJ, Rapkin AJ, Papka RE. The pain of \nendometriosis. Science. 2005;308:1587–589. \n18. Sinaii N, Plumb K, Cotton L, et al. Differences in characteristics among \n1,000 women with endometriosis based on extent of disease. Fertil \nSteril. 2008;89(3):538‒545. \n19. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, \nand adenomyotic nodules of the rectovaginal septum are three different \nentities. Fertil Steril. 1997;68(4):585–596.\n20. American Society for Reproductive Medicine. Revised American Society \nfor Reproductive Medicine classification of endometriosis. Fertil Steril. \n2015;67(5):817‒821.\n21. Markham SM, Carpente SE, Rock JA. Extrapelvic endometriosis. Obstet \nGynecol Clin north Am. 1989;16(1):193‒219.\n22. Brenner C, Wohlgemuth S. Scar Endometriosis. Surg Gynecol Obstet.  \n1990;170(6):538‒540.\n23. Koger KE, Shatney CH. Hodge K, et al. Surgical scar endometroima. \nSurg Gynaecol Obstet. 1993;177(3):244‒246.\n24. Bumpers HI, Butler KL, Best IM. Endometroima of the abdominal wall. \nAm J Obstet Gynecol. 2002;187(6):1709‒1710.\n25. Wolf Y , Haddad R, Werbin N, et al. Endometriosis in abdominal scars: a \ndiagnostic pitfall. Am Surg. 1996;62(12):1042‒1044.\n26. Minaghlia S, Mishell R, Ballanrd CA. Incisional endometriosis after \ncaesarean section: a case series. J of Reproductive Med for the Obstet and \nGynaecol. 2007;52(7):630‒634.\n27. Aydin O. Scar endometriosis‒a gynaecological pathology often presented \nto the general surgeon rather than the gynaecologist. Report of two cases. \nLangebeck’ s archives of surgery. 2007;392(1):105‒109.\n28. Khanmash MR, Omari AK, Gasaimeh GR, et al. Abdominal \nwall endometriosis. An overlooked diagnosis. Saudi Med J.  \n2003;24(5):523‒525.","source_license":"CC0","license_restricted":false}