Incisional Endometriosis following Caesarean Section - A Case Report

Scar endometriosis can be located at the skin, subcutaneously in the uterine scar and intraperitone- ally. The incidence reported of abdominal scar endometriosis is 0.03 to 0.4%. Cyclical pain in the scar asso- ciated with the patients menstrual cycle is common. MRI is the most sensitive imaging method. Histopatho- logical evaluation are confirmatory for the condition. Surgical excision of the scar is the treatment of choice. We report a case of caesarean section scar endometriosis treated at a medical college hospital.

caesarean section, pregnancy, scar endometriosis. Case Report A 30 year old Para 5, living 3, dead 2 underwent lower section caesarean section 2 years back presented to gynecology out patient department with complaints of pain in caesare- an scar site from 1 year. The pain aggravated during the menstrual periods. A firm and ten- der swelling of dark brown color measuring 2×2 cm was found at the left edge of the cae- sarean scar and was not fixed to the rectus sheath.

Endometriosis was first defined by Rokitansky in 1860 as the presence and proliferation of the endometrium outside the uterine cavity. It usu- ally occurs in the pelvic sites such as ovaries, posterior cul -de-sac, uterine ligaments, pelvic peritoneum, bowel and rectovaginal septum. Extrapelvic endometriosis can be found in unu- sual places like nervous system, thorax, urinary tract, gastrointestinal tract and in cutaneous tissues.[1] Incisional endometriosis/ scar endo- metriosis usually occurs in abdominal wall fol- lowing surgeries especially early hysterectomy and caesarean section (Fig 1). The incidence of scar endometriosis following hysterectomy is 1.08-2.0% and after LSCS is 0.03 - 0.4%.[2] Its occurrence on the perineum, after episiotomy is still rare. Patients present with symptoms of pain and swelling at the incision site which be- come more prominent during menstrual peri- ods.[3,4] It is often misdiagnosed as stitch granu- loma, keloid, haematoma, or an abscess. Fig 1. Caesarean Section scar 100 Journal of Clinical and Biomedical Sciences J Clin Biomed Sci 2016; 6(3): 100-102 Incisional Endometriosis following Caesarean Section Sonography revealed a well defined hypo echoic lesion in the subcutaneous region beneath the abdominal external scar. Mild vas- cularity was noted on color Doppler. MRI re- vealed an oval lesion mildly hyper intense to muscle on T2 in the left lateral aspect of LSCS scar. Focal thinning of anterior myometrium was noted in mid segment of body of uterus with a linear cleft extending from endometrial cavity into myometrium (Fig 2). A wide excision of the abdominal scar was performed under spinal anaesthesia. The excised scar was hard in consistency, reddish brown in colour and highly vascular. Scar en- dometriosis was confirmed by histopathologi- cal examination (Fig 3). There was no recur- rence of the symptoms up to six months of out patient follow-up.

Scar endometriosis on the abdominal wall is most commonly seen following surger- ies on the uterus and the fallopian tubes. The endometrial tissue may be implanted in the scars during the surgical procedures and may proliferate on hormonal stimulation (cellular transport theory). The other explanation is that the neighborhood tissue may undergo metaplasia which leads to scar endometriosis (coelomic metaplasia theory).[5] The endometrial tissue may also reach the surgical scar through lymphatic and vascu- lar routes. In a series of incisional endometrio- sis after caesarean section studied over 30 years, the incidence was found to be 0.08%. The average time from surgery to the clinical presentation of endometriosis varied form 3 months to 12 years in different case series. [5] Presence of cyclic pain in an incisional mass is pathognomonic of scar endometriosis. MRI is considered more sensitive and also specific than sonography in the diagnosis of scar endo- metriosis.[7] The incidence of concomitant pelvic endometriosis with scar endometriosis has been reported to be from 14.3% to 26%. Ideal- ly all patients must be examined for concomi- tant pelvic endometriosis. [8] Histopathology is confirmatory. Wide local excision is the pre- ferred treatment. Lesions extending deep to the muscles and fascia may require a synthetic mesh replacement or a tissue transfer for clo- sure after resection. Recently usage of leupro- lide depot has been found to be beneficial.[6] Fig 2. MRI image of the scar Fig 3. Histopathology of the scar showing endometriosis 101

Scar endometriosis is a rare condition. It should be considered in the differential diag- nosis in women presenting with painful symp- toms with menstruation. The treatment of choice is surgical resection of the endometrio- sis with wide margins.

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