{"paper_id":"b9ab59d4-7df6-4984-b66e-a7fcbd5ce05b","body_text":"~ 355 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(3): 355-357 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(3): 355-357 \nReceived: 04-03-2021 \nAccepted: 06-04-2021 \n \nDr. Geeta Jain \nProfessor, Department of \nObstetrics and Gynaecology, GMC, \nHaldwani, Uttarakhand, India  \n \nDr. Kiran Kunwar \nDepartment of Obstetrics and \nGynaecology, GMC, Haldwani, \nUttarakhand, India \n \nDr. Poonam Bisht \nDepartment of Obstetrics and \nGynaecology, GMC, Haldwani, \nUttarakhand, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Kiran Kunwar \nDepartment of Obstetrics and \nGynaecology, GMC, Haldwani, \nUttarakhand, India \n \nExtra-pelvic scar site endometriosis: A gynaecologist's \nperspective \n \nDr. Geeta Jain, Dr. Kiran Kunwar and Dr. Poonam Bisht \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i3f.945 \n \nAbstract \nExtra –pelvic endometriosis is a rare condition, usually associated with the surgeries where uterus is \nincised or rarely at episiotomy sit e. Since we gynaecologists are somewhere responsible for the condition, \nwe must be able to diagnose and treat it properly. The condition is of ten misdiagnosed and suture \ngranuloma, incisional hernia, haematoma, perineal abscess,  primary or metastatic cance r are kept in \ndifferentials. We here report two  cases of scar endometriosis developed in the abdominal wa ll scar after \ncaesarean section and one at perineal episiotomy site after vaginal delivery. \n \nKeywords: scar endometriosis, caesarean section, vaginal delivery ,episiotomy, uterine incision \n \nIntroduction  \nEndometriosis is defined as functioning endometrial tissue outside the uterine cavity. \nEndometrial implants, however, have been reported in many unusual sites outside the pelvis \nincluding the abdom inal wall  and perineum . The latter may occur in those procedures where \nuterus is opened or incised [1–5]. Incidence of scar endometriosis following hysterotomy is 1.08-\n2% whereas after caesarean section the incidence is 0.03-0.4% [¹¹]. Perineal scar endometriosis is \na very rare entity occurring in about 0.03-0.15% [16]. \nEndometriosis of the abdominal wall /perineum may be difficult to diagnose; it is often \nmistaken-both clinically and with diagnostic imaging -for other abnormal conditions such as a \nmetastatic disease, desmoid tumor, lipoma, sarcoma cysts, nodular and proliferative fasciitis, fat \nnecrosis, haematoma, abscess, suture granuloma and incisional hernia 2–5. This may be partly due \nto the fact that abdominal wall endometriosis is a comparatively unknown  entity that has \nscarcely received attention. \n \nCase Reports \nCase 1 \nWe report here a case of a 27 yrs old female patient who presented with a pai nful lump on the \nlateral aspect of a pfannensteil incision after a caesarean section done 4 years back. Sh e reported \nthat she was continuously having a pain in left lumbar region since 2 1/2 years. One year back \npatient started feeling a nodular mass on the  left lateral aspect of incision, which had gradually \nincreased in size. She also stated that the nodule  pain aggravates during menstruation. The \npatient had no history of other diseases and was otherwise healthy.  \nPhysical examination revealed a 3×3cm hard, round, tender mass at the left lateral margin of the \ncaesarean scar. The overlying skin was normal. \nUltrasound of the abdomen was performed and revealed a well defined hypoechoic nodule \n~1.7×1.7×0.9 cm is seen in parietal wall in left para -median location approximate 3-4 cm from \nthe mid-line closely abetting the caesarean scar  [Fig.1]. On Doppler , there was no vascularity \nseen. The lesion is well defined to the abdominal wall and no proximity to uterus/intraperitoneal \nstructures is seen ? stitch line granuloma ? scar endometriosis. \n \n \n \n \n  \n  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 356 ~ \n \n \nFig 1: Ultrasound: 1.7x1.7x0.9 cm well defined hypoechoic nodule \n \nThe final diagnosis was made by sonographically guided FNAC. \nSmear showed mainly acute inflammatory exudates material \nconsisting of plenty number of neutrophils, frequent \nmacrophages lying in necrotic background. Frequent cell \naggregates, monolayered sheath, stri ps and groups of epithelial \ncells are seen. Cells are mainly columnar to cuboidal and round \nin shape with uniform cell and nuclear size and ma intained \npolarity. At few places, loss of polarity with enlarged atypical \nlooking nuclei and prominent nucleoli ar e seen, suggesting \nendometriosis in nodule. \nThe patient was posted for a wide local excision of the \nabdominal wall lump  [Fig. 2 ]. A lump of 3x 3 cm which was \nfirm in consistency, situated above external oblique aponeurosis \nwas excised with clear margin.  The p ostoperative period was \nuneventful. Histopathology showed fibroadipose tissues with \ninterspersed glands and stroma of endometriosis which \nconfirmed the diagnosis of endometriosis in abdominal wall scar \n[Fig.3]. \n \n \n \nFig 2: Intraoperative mass with hemorrahgic spot \n \n \n \nFig 3: Histopathologic view of endometriotic gland and stroma \n \nCase 2 \nA 26 year old female was seen in the gynae OPD with the \ncomplaints of pain at the lateral aspect of caesarean scar for the \nlast 5 months. She reported that she started feelin g a nodular \nmass at right end of caesarean scar which had gradually \nincreased in size. The patient stated that this nodule was tender \nand pa in aggravates during menstrual cycle. However, the \noverlying skin was normal. Her personal history revealed that a \ncaesarean section had been performed 5 years back for fetal \ndistress at term gestation. The patient had no history of other \ndiseases and was otherwise healthy. \nLocal examination revealed a 4 x 4 cm hard, tender nodule felt \non right lateral end of caesarean scar. Ultrasound was advised \nwhich was suggestive of a well defined hypoechoic nodule \n~3.9×3.7×0.9 cm seen in parietal wall in right para -median \nlocation approximately 3 cm from mid -line ? scar endometriosis \n? suture granuloma. Wide excision of the mass  which also \ninvolved the rectus sheath  was undertaken. Histopathology \nreport showed presence of endometrial -like glands, spindled \nendometrial s troma within the soft tissue and muscle of the \nabdominal wall, along with inflammatory cells and surrounding \nfibrosis along with hemosiderin deposition either within the \nmacrophages or in the stroma suggesting diagnosis of scar \nendometriosis. The patient’s  postoperative course was \nuneventful, and her pain subsided. \n \nCase 3 \nA 32 year old lady P1L1 came with complaint o f swelling and \npain in episiotomy site since 2 year and aggrevated since 6 \nmonths. She took treatment of antibiotic course several times in \nview of peineal abscess. Though, pain and swelling still peristant \nand increased during menstruation . She had deliv ered vaginally \nwith episiotomy 8 year back. \nOn local examination, swelling present in right v ulva at \nepisiotomy site around 3x3  cm ,firm to har d in consistency and \ntender to touch. Per rectal examination suggestive of same mass \nand rectal mucosa free . Ultasound was advised which was \nsuggestive of ? perineal abscess. Based on high clinical \nsuspicion of episiotomy site endometriosis , patient was po sted \nfor wide local excision of mass.  Intraoperatively, 3 x 4  cm \nnodule was excised with hemorrahgic spots  [Fig.4 and 5 ]. \nSpecimen sent for histopathological examination which was \nsuggestive of presence of endometrial glands with stroma and \nhemosiderin lad en macrophages ie. episiotomy site \nendometriosis. During her follow up , the patient is free from \npain and swelling in perineal region.  \n \n \n \nFig 4: Endometriotic spot (arrow) \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 357 ~ \n \n \nFig 5: Specimen of excised mass \n \nDiscussion \nEndometriosis is the presence of fu nctioning endometrial tissue \noutside the uterine cavity  [13, 14], whereas endometrioma is a \nwell-circumscribed ma ss. The various sites for extra pelvic \nendometriosis are bladder, kidney, bowel, omentum, lymph \nnodes, lungs, pleura, extremiti es, umbilicus, h ernial sacs,  \nabdominal wall  [4] and episiotomy site b ut its most frequent \nlocation is in the abdominal wall [7]. Endometriosis involving the \nabdominal wall is an unusual phenomenon which should be \nconsidered in the differential diagnosis of abdominal wall \nmasses in women.  \nScar endometriomas are usually associated with operations in \nwhich the uterus is opened [1–6] and is believed to be the result of \ndirect inoculation of the abdominal fascia or subcutaneous tissue \nwith endometrial cells during surgical inter vention and \nsubsequently stimulated by estrogen to produce endometriomas. \nIn clinical practice, its occurrence has be en well documented in \nincisions of any type where there has been possible contact with \nendometrial tissue, including episiotomy,  cesarean s ection, \nhysterotomy, ectopic pregnancy, laparoscopy and tubal ligation  \n[8].  \nThe usual clinical presentation is a painfu l nodule in a parous \nwoman with a history of gynecological or obstetrical surgery. \nTime interval between operation and presentation has varied \nfrom 3 months to 10 years in different studies  [¹²]. Most patients \npresented with a palpable mass at the site of max imum \ntenderness in the region of the surgical scar. The intensity of \npain and size of nodule vary with menstrual cycle. \nSonography sh owed these masses to be solid, hypoechoic \nlesions in the abdominal wall /episiotomy site and to contain \ninternal vascularity on Doppler examination. MRI may also aid \nto the preoperative diagnosis and assessement of local extent of \ndisease. Sonograghy, MRI and fine needle aspiration cytology \ncan be used but it is usually diagnosed by surgical excision 3 and \nhistopathological examination.  \nMalignant change of endometriosis in a cesarean scar / \nepisiotomy site is rare [9]. Follow up of endometriosis patients is  \nimportant because of the chances of recurrence which was 5-9% \n[15] in abdominal wall endometriosis and 3.3% [16] in perineal \nendometriosis and may require re-excision.  \nWe, as gynaecologists should be aware of the condition and \nmust be able to diagnose th e condition. The condition is often \nmisdiagnosed and many patients are referred to general surgeon \nfor the same because the clinical presentation suggests a surgical \ncause. Though diagnosis is difficult to make but even if it is \ndiagnosed, often patients a re given GnRH analogue like \nleuprolide to treat the condition which is of no use. Wide \nexcision of the endometriotic nodule is the treatment of choice. \n \nConclusion \nClinically, scar site endometriosis  is often misdiagnosed. Thus, \nawareness of the entity avo ids delay in diagnosis. High index of \nsuspicion of scar endometriosis should be kept in mind \nwhenever a woman complaints of pai n and nodular mass at the \nsite of stitch line, with a previous history of any obstetrical or \ngynecological surgery. USG and FNAC may be helpful in pre -\noperative diagnosis. Medical treatment is not helpful and wide \nexcision is the treatment of choice. Regul ar follow up is \nnecessary to detect recurrence. \n \nReferences \n1. Patterson GK, Winburn GB. Abdominal wall \nendometriomas: report of eig ht cases. Am J Surg \n1999;65:36-39 \n2. Koger KE, Shatney CH, Hodge K, McClenathan JH. \nSurgical scar endometrioma. Surg Gynecol O bstet \n1993;177:243-246. \n3. Seydel AS, Sickel JZ, Warner ED, Sax HC. Extrapelvic \nendometriosis: diagnosis and treatment. Am  J Surg 1996; \n171:239-241 \n4. Dwivedi AJ, Agrawal SN, Silva YJ. Abdominal wall \nendometriomas. Dig Dis Sci 2002;47:456-461. \n5. Blanco RG, Parith ivel VS, Shah AK, Gumbs MA, Schein \nM, Gerst PH. 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Indian J Med Sci. \n2005;59:495-8. [PubMed]. \n13. Pathan ZA, Dinesh US, Rao R. Scar endometriosis. J Cytol \n2010;27:106-8. \n14. Gajjar KB, Mahendru AA, Khaled MA. Caesarean scar \nendometriosis presenting as an acute abdomen: A case \nreport and review of literature. Arch Gynecol Obstet \n2008;277:167-9. \n15. Lopez-Soto A, Sanchez-Zapata MI, Martinez-Cenden JP et \nal. Cutaneous endometriosis : Presentation of 33 cases and \nliterature review . Eur J Obstet Gynaecol Repr od Biol  \n2018;221:58-63. \n16. Zhu L , Lang J , Wang H. Presentation and management of \nperineal endometriosis. Int J Gynecol Obstet 2009;105:230-\n232.","source_license":"CC0","license_restricted":false}