Episiotomy scar endometriosis misdiagnosed as a stitch granuloma eight years after vaginal delivery: a case report

Chetan Anand Raghunandan, Kaushik V Naik, Shripad Hebbar
In: International Journal of Reproduction, Contraception, Obstetrics and Gynecology · 2026 · vol. 15(10) , pp. 4154–4158 · doi:10.18203/2320-1770.ijrcog20263461 · W7214624650
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This case report describes a woman with episiotomy scar endometriosis misdiagnosed as a stitch granuloma for eight years, highlighting the importance of considering endometriosis in reproductive-age women with painful perineal lumps to ensure accurate diagnosis and surgical cure.

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This case report describes a 32-year-old woman with an eight-year history of a painful perineal mass at her episiotomy site, which was initially misdiagnosed as a stitch granuloma and treated unsuccessfully with antibiotics. The correct diagnosis of scar endometriosis was established only after surgical excision revealed chocolate-brown fluid and histopathology confirmed the presence of endometrial-like tissue within the scar. The authors note that the cyclical nature of the pain had been overlooked during prior consultations, highlighting how this condition mimics other common perineal lesions such as abscesses or Bartholin cysts. Complete surgical excision with healthy tissue margins resulted in uneventful recovery and no recurrence at twelve months, emphasizing the importance of considering endometriosis in reproductive-age women with long-standing painful perineal lumps even without spontaneous reporting of cyclical symptoms. This paper is centrally about endometriosis — specifically the diagnosis and management of extrapelvic endometriosis presenting as an episiotomy scar lesion.

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Abstract

Endometriosis of an episiotomy scar is an uncommon form of extrapelvic endometriosis in which endometrial-like tissue implants within a perineal obstetric scar and undergoes cyclical hormonal change. It is often misdiagnosed, because the classical triad of previous episiotomy, a tender perineal nodule, and cyclical pain is complete in only about half of cases, and because the swelling mimics common perineal conditions such as suture granuloma, abscess, or Bartholin cyst. We report a 32-year-old woman, para 2, with an eight-year history of a painful swelling at her left episiotomy site. The cyclical nature of the pain had been overlooked at several earlier consultations, and she had been treated empirically with antibiotics for a presumed antibioma without benefit. Pelvic ultrasound was normal, and a working diagnosis of stitch granuloma was made. At operation a firm mass of 4 by 3 cm was found over the left labia minora; on incision it released thick chocolate-brown fluid, an appearance typical of an endometriotic cyst. The lesion was excised completely with a 1 cm margin of healthy tissue, and histopathology confirmed endometriosis. Recovery was uneventful and she remained free of recurrence at 12 months. Scar endometriosis should be considered in any reproductive-age woman with a long-standing painful perineal lump at an episiotomy site, even when cyclical symptoms are not reported spontaneously. A directed menstrual history and complete surgical excision with a healthy tissue margin are the keys to diagnosis and cure.
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Episiotomy scar endometriosis misdiagnosed as a stitch granuloma eight years after vaginal delivery: a case report DOI: https://doi.org/10.18203/2320-1770.ijrcog20263461Keywords: Episiotomy scar, Extrapelvic endometriosis, Perineal endometriosis, Scar endometriosis, Stitch granuloma, Vulval massAbstract Endometriosis of an episiotomy scar is an uncommon form of extrapelvic endometriosis in which endometrial-like tissue implants within a perineal obstetric scar and undergoes cyclical hormonal change. It is often misdiagnosed, because the classical triad of previous episiotomy, a tender perineal nodule, and cyclical pain is complete in only about half of cases, and because the swelling mimics common perineal conditions such as suture granuloma, abscess, or Bartholin cyst. We report a 32-year-old woman, para 2, with an eight-year history of a painful swelling at her left episiotomy site. The cyclical nature of the pain had been overlooked at several earlier consultations, and she had been treated empirically with antibiotics for a presumed antibioma without benefit. Pelvic ultrasound was normal, and a working diagnosis of stitch granuloma was made. At operation a firm mass of 4 by 3 cm was found over the left labia minora; on incision it released thick chocolate-brown fluid, an appearance typical of an endometriotic cyst. The lesion was excised completely with a 1 cm margin of healthy tissue, and histopathology confirmed endometriosis. Recovery was uneventful and she remained free of recurrence at 12 months. Scar endometriosis should be considered in any reproductive-age woman with a long-standing painful perineal lump at an episiotomy site, even when cyclical symptoms are not reported spontaneously. A directed menstrual history and complete surgical excision with a healthy tissue margin are the keys to diagnosis and cure. 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DOI: https://doi.org/10.1016/j.ijgo.2009.01.022 Hakim H, Ben Halima S, Zouari A, Trabelsi D, Derbel M, Chaabane K, et al. Perineal endometriosis: a rare case of a unique sizeable nodule. Pan Afr Med J. 2021;38:47. DOI: https://doi.org/10.11604/pamj.2021.38.47.27737 Chen N, Zhu L, Lang J, Liu Z, Sun D, Leng J, et al. The clinical features and management of perineal endometriosis with anal sphincter involvement: a clinical analysis of 31 cases. Hum Reprod. 2012;27(6):1624-7. DOI: https://doi.org/10.1093/humrep/des067 El Houss S, Laasri K, El Yousfi Z, El Halfi I, Nassar I, Billah NM. Isolated perineal endometriosis? Yes... an exceptional location. Radiol Case Rep. 2023;18(11):4022-5. DOI: https://doi.org/10.1016/j.radcr.2023.07.072 Youssef AT. The ultrasound of subcutaneous extrapelvic endometriosis. J Ultrason. 2020;20(82):176-80. DOI: https://doi.org/10.15557/JoU.2020.0029 Egueh Nour A, Mahamoud Abdillahi C, Bennani S, Hared Bouh A, Bouknani N, Rami A. Perineal endometriosis on an episiotomy scar: diagnosis based on clinical, radiological, and hormonal criteria (case report). Pan Afr Med J. 2025;51:25. DOI: https://doi.org/10.11604/pamj.2025.51.25.48002 Downloads Published How to Cite Issue Section License Copyright (c) 2026 Chetan Anand Raghunandan, Kaushik Naik V., Shripad Hebbar This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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