Scar Endometriosis Presenting as Chronic Lower Abdominal Pain: A Surgeon's Perspective

Endometriosis is defined as the abnormal presence of endometrial tissue outside the uterus. Scar endometriosis could go unnoticed or can present with symptoms such as pain in the lower abdomen or as tender nodular lesions over the surgical scar which are usually misdiagnosed as keloid, haematoma, hypertrophied scar, desmoids tumour, cutaneous tumour and stich granuloma. W e report a case in a 35 years old female patient who was treated for pelvic inflammatory disease with no relief. W e diagnosed the scar lesion as stich granuloma/hypertrophied scar/desmoid tumour. She underwent wide local excision of the Nodular swellings on the caesarean scar with primary closure. HPE confirmed it as scar endometriosis. Patient is relieved of pain abdomen and is symptom free with no recurrence on follow up till date. KEY WORDS : Scar endometriosis, PID, Abdominal wall endometriosis. Scar endometriosis patients are usually misdiagnosed as it is often confused with other surgical conditions as they have similar clinical presentations and features. Sometimes these patients present with painful nodular swellings on the previous caesarean scars and are misinterpreted as hypertrophied scar, keloid, haematoma, stitch granuloma or cutaneous [4] tumors. W e report a case in a 35 years old patient wh o wa s treated for Pelvic Inflamma tory Disease for almost one and a half years with no relief. On examination we diagnosed the lesion over the caesarean scar as hypertrophied scar / stich granulom a / desm oids tum or. She underw ent exploration w ith w ide local excision of the two nodular swellings and histopathological examination confirmed as Case Report

Endometriosis is called as a disease of theories. This was first described by Rokitansky in 1860 as the presence of endometrial tissue [1 ,2 ] outside the uterus. A bdom inal w all endom etriosis is usually seen follow ing obstetric and gynaecological surgeries. Scar endometriosis may also go unnoticed when a patient presents with symptoms such as acute or chronic lower abdomen pain and are treated [3] as Pelvic inflammatory disease or cystitis. Corresponding author: Dr. Ambikavathy . M, Asst. prof, Dept of General Surgery, Sri Devaraj Urs Medical College, Kolar, Karnataka. E-mail: [email protected] Mob : 9980337428 J Clin Biomed Sci 2012 ; 2 (4)192 Bhaskaran A et al scar endometriosis. W e report this case to stress on the modes of presentation of endometriosis cases to the surgical out patient departments. CASE ILLUSTRA TION A 35 Y ears old female patient with a history of previous caesarean section for her first pregnancy about one and a half years back, presented to us with chronic pain in the lower abdomen and on the caesarean scar region, after one month following surgery. She had been treated as PID conservatively with no relief. On thorough abdomen examination we found two tender nodular swellings on either ends of the pfannenstiel surgical scar measuring 3x2 cms firm and indurated at skin surface on the right of scar and 4x3cms raised above the skin surface to the left of scar [Fig-1]. Surface was nodular, tender, red to black in colour, firm in consistency, present in the skin and subcutaneous plane. Rest of the abdomen was normal. W ith a diagnosis of stich granuloma / hypertrophied scar/ desmoids tumour, we got an FNAC of the lesion and it was inconclusive. Ultrasound of the abdomen and pelvis reported as cystic swellings in the subcutaneous plane above the rectus sheath. The patient underwent exploration and wide local excision with 1cm margin of the lesion along w ith the underlying fasia. Operatively the lesion was very vascular with dense adhesions in the skin and subcutaneous tissue abutting on rectus sheath . There was no peritoneal extension of the lesion. The wound was primarily closed after thorough wash with saline [Fig-1 inset]. Histopathological exam ination of the specimen reported as section shows epidermis, dermis, subcutaneous tissue and fascia. Dermis and subcutaneous tissue show s illdefined nodular areas consisting of fibrofatty tissue, and fibromuscular tissue within which are seen endometrial glands lined by columnar and cuboidal epithelium. Some glands show dilation. Endometrial stroma are seen at places. No Fig: 1- preoperative photograph showing nodular lesions on the caesarean scar. Inset - operative photograph showing wide excision of the lesion followed by primary closure of the wound. Fig: 2 - Microphotograph showing skin with dilated endometrial glands in dermis. (H&E 400x) J Clin Biomed Sci 2012 ; 2 (4) 193 Bhaskaran A et al evidence of granulom a or m alignancy seen. Features are consistent w ith scar endometriosis.[Fig- 2] The patient was discharged with danazol 100 mg tid for six months and is symptom free on follow up till date with no recurrence .

Endometriosis is known to occur in 10 - 15% of women during their reproductive age [1] and upto 50% in infertile women. Scar endometriosis has an incidence of 0.03%- 0.15% usually occurring following obstetric and gynaecological surgeries and laparoscopic procedures. V arious theories have been put forward to explain this condition. Iatrogenic dissemination or implantation of the endometrial fragments during surgical procedures into the incision site is known to cause scar endometriosis. Patients have seven times risk of endometriosis if a first degree relative is [2,3] affected. The presentations of symptoms vary from each individual some have cyclical pain at menses, chronic lower abdominal pain/ chronic pelvic pain. Some times patients present with nodular swellings in the scar region or may be found incidently as seen in our case who was [3,4] previously treated for PID. L iteratures have described m any diagnostic modalities such as FNAC, MRI, [5,6,7] USG, CT SCAN, etc. In our case FNAC w as in conclusive. E xcision biopsy and histopathological examination has been very accurate in diagnosing this condition. Medical treatment with gonodotropin agonists, oral contraceptives, danozol, leuprolide acetate have been tried with no regress in the size of the lesions, but they give only sym ptom atic relief. M alignant transformation are known to occur hence follow [8,9] up is advised.

Scar endometriosis should be considered when a female patient presents to the surgeons with pain in the lower abdomen and painful nodules on the surgical scar following caesarean sections or hysterectomy. D ifferen tial d iag n o sis o f scar endometriosis should be included among the other surgical diagnosis such as hypertrophied scar, haematoma, stich granuloma, desmoids tumour and soft tissue tumours at the site of caesarean/hysterectomy scars. W ide local excision is the surgical treatment of choice for scar endometriosis. Regular follow up is mandatory in these patients as they are known to recur. Adequate care during and after obstetric/gynaec surgery with thorough saline wash of surgical wound can prevent scar endometriosis.

1. D ouglas C , R otym i O . E xtragenital endometriosis. A Clinicopathological review of a G lasgow hospital experience w ith case illustrations. J O bstet G ynaeccol 2004; 24(7):804-808. 2. Gunes M, Kayikcioglu F, Ozturkoglu E, H A berala A . Incisional endom etriosis after caesarean section, episiotom y and other gynaecological procedures. J Obstet Gynaecol Res 2005; 13(5): 471- 475. 3. Khoo J. Scar endometriosis presenting as an J Clin Biomed Sci 2012 ; 2 (4)194 Bhaskaran A et al acute abdomen: A case report. Aust N Z J Obstet Gynaecol 2003;43(2): 164-165. 4. Thapa A, Kumar A, Gupta. Abdominal wall endometriosis ; Report of a case and how much we know about it?. The Internet Journal of Surgery 2007;9(2). DOI:10.5580 /1690 5. Catalina-fernadezi, Lopez-presa D, Saenz- santamaria J. Fine needle aspiration cytology in cutaneous and subcutaneous endome triosis. Acta Cytol 2007; 51:380-4. 6. Francina G, Giardiello C, Angelone G, Cristaino S, Finelli R, Tromonto G. Abdominal wall endometriosis in delivery scars : Sonographic and color Doppler findings in a series of 12 patients. J Ultrasound Med 2000; 22:10. 7. Balleyguir C, Chapron C, Chopin N, Heleno O, Menu Y. Abdominal wall and surgical scar endometriosis. Magnetic resonance imaging. Gynecol Obstet Invest 2003 ; 55 : 220-4. 8. Rivlin ME, Das SK, Patel RB, Meeks GR. Leuprolide acetate in the management of caesarean scar endometriosis. Obstet Gyneco 1995 ; 85 : 838-9. 9. Javert CT . Pathogenesis of endometriosis based on endom etrial hom eoplasis direct extension, exfoliation, lymphomatic and haematogenous metastasis. Cancer 1949 ; 2(3) 399-410. Source of Support: Nil Conflict of Interest: Nil J Clin Biomed Sci 2012 ; 2 (4) 195