{"paper_id":"7adecd47-ace5-4872-a2f2-1544cb010397","body_text":"Review began\n 04/08/2026 \nReview ended\n 05/04/2026 \nPublished\n 05/09/2026\n© Copyright \n2026\nGupta et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.108541\nPrimary Periumbilical Endometriosis Mimicking\nUmbilical Hernia in a 37-Year-Old Woman: A\nReport of a Rare Case\nSarmistha Gupta \n, \nRajalakshmi Srinivasan \n1.\n Radiology, Medcare Royal Speciality Hospital, Dubai, ARE \n2.\n Obstetrics and Gynaecology, Medcare Royal Speciality\nHospital, Dubai, ARE\nCorresponding author: \nSarmistha Gupta, \ndrsarmisthagupta@gmail.com\nAbstract\nThis case report describes a rare presentation of primary periumbilical endometriosis, also known as Villar’s\nnodule, highlighting the diagnostic difficulties and the importance of maintaining clinical suspicion. A\n37‑year‑old woman presented with a one‑year history of cyclical periumbilical pain along with severe\nmenorrhagia and dysmenorrhea. Initial ultrasonography suggested an umbilical hernia, but subsequent\nimaging, including repeat ultrasound and contrast‑enhanced MRI, revealed subcutaneous periumbilical\nnodules without evidence of intraperitoneal extension or associated pelvic endometriosis. An incidental\nintramural uterine fibroid was also noted. The patient underwent surgical excision of the periumbilical\nnodules along with myomectomy. Histopathological examination confirmed the diagnosis of endometriosis.\nHer postoperative recovery was uncomplicated, and she remained asymptomatic at the six‑month follow‑up.\nThis case underscores the need to consider primary periumbilical endometriosis in women presenting with\ncyclical umbilical pain and demonstrates that early diagnosis and complete surgical excision can lead to\nfavorable clinical outcomes.\nCategories:\n Obstetrics/Gynecology, General Surgery\nKeywords:\n endometriosis, fibroid, hernia, menorrhagia, myomectomy, umbilicus\nIntroduction\nEndometriosis is a chronic and progressive condition characterized by the presence of functional\nendometrial glands and stroma located outside the uterine cavity \n[1]\n. It is a benign, oestrogen-dependent\npathological condition that affects approximately 6-15% of women during their reproductive years \n[2]\n.\nAccording to the World Health Organization (WHO) estimates, approximately 10% of women of\nreproductive age, around 190 million globally, are affected by endometriosis \n[3]\n.\nThis condition most commonly involves pelvic organs such as the ovaries and uterine ligaments, but in rare\ncases, about 0.5-1%, it occurs outside the uterine cavity. These extragenital manifestations can involve sites\nlike the intestinal tract, lungs, thoracic region, and surgical scars. Among these, primary umbilical\nendometriosis is the rarest form, characterized by ectopic endometrial tissue within the umbilicus \n[1,4]\n.\nUmbilical endometriosis may present as either primary (spontaneous) or secondary (following surgical\nmanipulation). The primary form, which occurs in the absence of prior abdominal or umbilical surgery, is\nexceptionally uncommon. Pathogenesis remains debated, with hypotheses including retrograde\nmenstruation with coelomic metaplasia, lymphatic or hematogenous spread, and coelomic transformation\nof multipotent cells \n[4]\n.\nClinically, patients often present with an umbilical nodule that appears red, purple, or black, and shows\ncyclical pain, swelling, discoloration, and occasionally bleeding in sync with menstrual cycles. The\nsymptoms differ among individuals and may include dysmenorrhea, dyspareunia, dyschezia, and dysuria. It\naffects 70% of women with chronic pelvic pain. Pelvic pain frequently begins before menstruation, though\nsome cases remain asymptomatic and are detected only during infertility evaluation \n[5,6]\n.\nDifferential diagnoses often include umbilical hernia, granuloma, melanoma, or subcutaneous tumors\n[4]\n. Diagnosis is challenging because umbilical endometriosis often mimics conditions such as hernias, cysts,\nor tumors, and imaging lacks specific features \n[7]\n. While ultrasound and MRI can help localize subcutaneous\nlesions and assess vascularity, definitive diagnosis requires surgical excision followed by histopathological\nconfirmation \n[4,8]\n.\nHere, we present the case of a 37‑year‑old woman presenting with primary periumbilical endometriosis\nmanifested by cyclical pain and nodules without evidence of pelvic involvement, alongside an incidental\nintramural fibroid. We discuss diagnostic challenges, imaging findings, and surgical management, providing\ninsight to guide clinicians in recognizing and treating this rare extragenital presentation. This case report\n1\n2\n \nOpen Access Case Report\nHow to cite this article\nGupta S, Srinivasan R (May 09, 2026) Primary Periumbilical Endometriosis Mimicking Umbilical Hernia in a 37-Year-Old Woman: A Report of a\nRare Case. Cureus 18(5): e108541. \nDOI 10.7759/cureus.108541\n\nhas been reported in line with SCARE (Surgical CAse REport\n) criteria \n[9]\n.\nCase Presentation\nClinical history\nA 37-year-old woman, para 1, presented with severe menorrhagia, dysmenorrhea, and cyclic pain localized\nto the umbilicus during the immediate premenstrual and menstrual phases for the preceding year. Her\nobstetric history revealed a lower segment cesarean section (LSCS) performed six years earlier through a\nPfannenstiel incision. There was no prior history of endometriosis, and notably, her current symptoms\nstarted only one year ago.\nInvestigations\nAn ultrasound performed at an outside facility a month prior to this presentation suggested an umbilical\nhernia containing omentum. However, a repeat abdominal ultrasound at our hospital revealed two solid-\ncystic hypoechoic subcutaneous nodules with well‑defined margins, measuring 8.9 x 5 x 5.3 mm in the\nimmediate supraumbilical region, along the midline of the abdomen. The lesions were superficial, located\nwithin the subcutaneous fat, and were painful during the perimenstrual phase (Figure \n1\n).\nFIGURE\n 1: Ultrasound image showing a well-defined oval solid-cystic\nhypoechoic subcutaneous nodule (arrow) measuring 8.9 × 5 × 5.3 mm in\nthe immediate supraumbilical region along the midline of the abdomen.\nThere was no facial defect in the underlying abdominal wall beneath the lesion, indicating that it was not a\nhernia. This was further confirmed by dynamic assessment using the Valsalva manoeuvre and cough\nimpulse, which revealed no to‑and‑fro movement of the lesion, thereby excluding the possibility of an\numbilical hernia.\nBased on the cyclical nature of pain and imaging findings, endometriosis was suspected, and an MRI with\ncontrast was recommended for confirmation. The MRI demonstrated two oval solid lesions located\nsuperficially within the subcutaneous fat of the umbilical region, with no communication with the\nperitoneal cavity or intraperitoneal extension (Figures \n2\n, \n3\n).\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n2\n of \n7\n\nFIGURE\n 2: Sagittal T1 FS postcontrast MRI sequence shows enhancing\nsubcutaneous solid lesion (arrow) within the umbilicus. \nNo\nintraperitoneal extension is seen. Anteverted bulky uterus is seen due\nto an intramural leiomyoma\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n3\n of \n7\n\nFIGURE\n 3: Axial T2 FS MRI image showing a hyperintense signal\nintensity subcutaneous lesion (arrow) \nwithin the umbilicus. \nNo\nintraperitoneal extension is seen.\nThe first lesion measured 1.5 × 1.9 × 0.8 cm, and the second measured 1.3 × 1.5 × 0.7 cm. Both lesions showed\nintermediate signal intensity on T1-weighted images and hyperintense signal on T2 fat-suppressed\nsequences, with homogeneous post-contrast enhancement. Gradient sequences showed a few tiny foci of\nblooming, suggestive of hemorrhagic components. There was no evidence of intraperitoneal extension.\nImportantly, no endometriotic deposits were identified in the ovaries or elsewhere in the abdomen and\npelvis.\nAn incidental finding of an intramural fibroid measuring 5.7 × 5.5 × 5.2 cm was noted at the uterine fundus,\nindenting the endometrium.\nDiagnosis\nBased on clinical history and imaging, a diagnosis of primary periumbilical endometriosis with an associated\nintramural fibroid was made.\nManagement\nThe patient underwent surgical management, including laparoscopic myomectomy along with laparoscopic\nexcision of the umbilical nodules. Surgery was performed one day prior to menstruation, which facilitated\npalpation and intraoperative identification of the lump due to its characteristic bluish appearance.\nIntraoperatively, three closely clustered nodules were identified and were removed together with a wide\nmargin of about 1 cm. The nodules were close to, but not involving, the umbilicus; hence, umbilical\npreservation was achieved, with the incision placed along the lower margin of the umbilicus. No pelvic\nendometriosis was identified intraoperatively.\nHistopathological examination of the excised umbilical lesion showed a fragment of adipose tissue along\nwith hemorrhage and muscle tissue showing multiple foci of endometrial gland and stroma embedded\nwithin it, with no evidence of atypia, confirming the diagnosis of umbilical endometriosis (Figure \n4\n).\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n4\n of \n7\n\nFIGURE\n 4: Histopathology showing fragments of muscle tissue (H&E\nstain) with multiple foci of endometrial glands and stroma embedded\nwithin (×40).\nOutcome\nThe patient had an uneventful postoperative recovery with no complications. Pain and menorrhagia\nresolved completely following surgical excision of the umbilical nodules and myomectomy.\nFollow-up\nAt the three-month follow-up, the patient remained asymptomatic with no evidence of recurrence of\numbilical endometriosis or fibroid-related symptoms. She reported a significant improvement in overall\nquality of life.\n \nDiscussion\nUmbilical endometriosis is a rare manifestation of extragenital endometriosis, with the majority of cases\nrepresenting primary disease rather than secondary implantation. Approximately 70-75% of reported cases\nare spontaneous in origin and are commonly referred to as Villar’s nodule, first described by Villar in 1886,\nand represents a small subset of cutaneous endometriosis and is believed to arise through mechanisms such\nas lymphatic or hematogenous dissemination of endometrial cells or metaplastic transformation \n[2,5,10,11]\n.\nBecause of its low prevalence and nonspecific clinical presentation, umbilical endometriosis is often\nmisdiagnosed as more common umbilical conditions such as hernia, granuloma, abscess, or neoplastic\nlesions \n[4,7,12]\n. In contrast, secondary abdominal wall endometriosis is typically related to prior surgical\nprocedures, most commonly cesarean section, and occurs within or adjacent to the surgical scar due to direct\nimplantation of endometrial tissue at the time of surgery \n[13]\n.\nThe present case is noteworthy as it represents primary periumbilical endometriosis, diagnosed six years\nafter a cesarean section and notably occurring in the absence of clinical, radiological, or intraoperative\nevidence of pelvic endometriosis. Although the patient had undergone a Pfannenstiel cesarean incision, the\nlesion was located at the umbilicus, anatomically distant from the surgical scar, and developed several years\nafter the procedure. The absence of direct umbilical manipulation and the delayed presentation support a\nprimary rather than a secondary etiology. A similar case was reported by Beyene et\nal. in which primary\numbilical endometriosis developed nine years after a cesarean section and in the absence of any prior\numbilical intervention, supporting that remote cesarean history alone does not necessarily indicate\nsecondary implantation \n[14]\n. Primary umbilical endometriosis in the absence of direct umbilical surgery has\nbeen similarly documented in case series and literature reviews, reinforcing the need for clinical vigilance\neven in women with remote surgical histories \n[5,15]\n.\nThe pathogenesis of primary umbilical endometriosis remains incompletely understood. The predominant\ntheories include lymphatic or hematogenous dissemination of endometrial cells, coelomic metaplasia of\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n5\n of \n7\n\nprimitive cells, and transformation involving embryonic remnants such as the urachus \n[4]\n. A systematic\nliterature review demonstrated support for both lymphovascular spread and metaplastic transformation in\npatients lacking concomitant pelvic disease \n[16]\n. In the present case, the absence of pelvic endometriosis on\ncontrast-enhanced MRI and the lack of intraoperative or surgical pathological evidence of pelvic lesions\nsuggest a pathophysiological basis more consistent with distant cell migration or local metaplasia, rather\nthan direct surgical implantation or contiguous extension.\nClinically, umbilical endometriosis most commonly presents as a firm umbilical or periumbilical nodule\nassociated with cyclical pain, swelling, discoloration, or occasionally bleeding in synchronization with\nmenstrual cycles \n[5,7]\n. In the present patient, cyclical periumbilical pain was the dominant presenting\nfeature without continuous bleeding. This presentation aligns with the findings of Dridi et al. in their\nmonocentric series of umbilical endometriosis cases, identifying pain as the most frequent presenting\ncomplaint, while bleeding and ulceration were comparatively uncommon \n[5]\n. The patient’s severe\ndysmenorrhea and menorrhagia were attributable to an incidental intramural uterine fibroid rather than\npelvic endometriosis, making this a notable case of coexisting but pathophysiologically distinct\ngynecological pathology.\nImaging serves as an important adjunct in the evaluation but lacks pathognomonic, disease-specific\nradiologic features. Ultrasound typically demonstrates a nonspecific subcutaneous mass, and\nmisclassification as an umbilical hernia is a frequently reported diagnostic pitfall \n[12,15,17]\n. In the present\ncase, the initial ultrasound misinterpreted the periumbilical endometriotic lesion as an umbilical hernia,\nhighlighting this diagnostic challenge. MRI, however, provides superior soft-tissue characterization and\nenables the exclusion of intraperitoneal or pelvic involvement. In our patient, the imaging pattern showed\nenhancing subcutaneous periumbilical lesions without any pelvic involvement, which is consistent with the\nimaging characteristics described in previous reports \n[7,8,12]\n.\nAccurate diagnosis requires histopathological confirmation following surgical excision. Wide local excision\nwith clear margins remains the gold standard of treatment, offering excellent symptom resolution and low\npostoperative recurrence \n[5,8,11]\n. Total omphalectomy is often recommended for large, infiltrative, or\nrecurrent lesions. However, for smaller nodules, umbilicus-sparing wide local excision is a reasonable\napproach, offering symptom resolution, as demonstrated in this case. In the present case, the excision\nperformed during menstruation facilitated intraoperative identification due to characteristic lesion\ncoloration, and the umbilicus was preserved for cosmetic reasons. Previous reports note that endometriosis\nnodules often become more painful, increase in size, and appear bluish or black during menstruation, which\ncan improve their visibility during surgery \n[18,19]\n. At the six-month follow-up, the patient remained\nasymptomatic, which is consistent with the favorable outcomes reported in recent case series \n[8,11]\n and\naligns with Hirata et al. \n[11]\n, who also documented a low incidence of postoperative recurrence of umbilical\nlesions.\nHormonal therapies, including combined oral contraceptives, progestins, and gonadotropin-releasing\nhormone analogues, may provide temporary symptomatic relief but do not eradicate lesions and carry the\nrisk of symptom recurrence after cessation \n[2,5]\n. As a result, medical management is generally reserved for\npatients who are not surgical candidates or who decline operative intervention.\nThis case report presents a rare instance of primary periumbilical/umbilical endometriosis supported by\nclear clinicoradiologic correlation and definitive histopathological confirmation following\numbilicus‑sparing wide local excision, resulting in complete symptom resolution. The main limitation is\nthat this is a single‑patient report with limited follow‑up, and although no pelvic involvement was\nidentified clinically or radiologically, microscopic disease cannot be entirely excluded.\nConclusions\nThis case underscores the importance of considering primary periumbilical endometriosis in women\npresenting with cyclical umbilical or periumbilical pain and nodules, even in the absence of direct umbilical\nsurgery or pelvic disease. Early clinical suspicion, appropriate imaging, and complete surgical excision are\nessential to achieve a definitive diagnosis, prevent recurrence, and improve the patient's quality of life.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nSarmistha Gupta\nAcquisition, analysis, or interpretation of data:\n  \nSarmistha Gupta, Rajalakshmi Srinivasan\nDrafting of the manuscript:\n  \nSarmistha Gupta\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n6\n of \n7\n\nCritical review of the manuscript for important intellectual content:\n  \nRajalakshmi Srinivasan\nDisclosures\nHuman subjects:\n Informed consent for treatment and open access publication was obtained or waived by all\nparticipants in this study. Medcare Royal Speciality Hospital Ethics & Research \nissued approval\nMRSH/ER/003. \nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors\ndeclare the following: \nPayment/services info:\n All authors have declared that no financial support was\nreceived from any organization for the submitted work. \nFinancial relationships:\n All authors have declared\nthat they have no financial relationships at present or within the previous three years with any\norganizations that might have an interest in the submitted work. \nOther relationships:\n All authors have\ndeclared that there are no other relationships or activities that could appear to have influenced the\nsubmitted work.\nAcknowledgements\nWe would like to thank HealthMinds Consulting Pvt. 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Radiol Case Rep. 2023, 18:685-8.\n10.1016/j.radcr.2022.10.094\n \n2026 Gupta et al. Cureus 18(5): e108541. DOI 10.7759/cureus.108541\n7\n of \n7","source_license":"CC0","license_restricted":false}