Incisional endometriosis: a report of 3 cases.

Ilker Sengul, İlker Şengül, Sengul I, Sengul D, Demet Şengül, Demet Sengul, Serkan Kahyaoğlu, Kahyaoglu S, Serkan Kahyaoglu, İnci Kahyaoğlu, Inci Kahyaoglu, Kahyaoglu I
Canadian journal of surgery. Journal canadien de chirurgie · 2009 · vol. 52(5) , pp. 444–5 · PMID:19865584 · PMC2769132 · W169797390
article OA: green CC0 ⤵ 17 in-corpus citations
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This report describes three women who presented with painful abdominal wall masses, a condition that can be challenging to diagnose but is suggested by cyclic pain related to menses.

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Abstract

Endometriosis is defined as a growth of ectopic endometrial tissue outside the uterine cavity that responds to hormonal stimulation. It occurs most commonly in pelvic sites such as the ovaries, posterior cul-de-sac, ligaments of the uterus, pelvic peritoneum and rectovaginal septum and is found in 8%–15% of all menstruating women. Extrapelvic endometriosis is less common but can affect many sites, including the lungs, appendix, nose, umblicus, peritoneum and even the intestinal wall.1 The most common extrapelvic form of endometriosis is cutaneous endometriosis, mainly in scars following obstetric or gynecologic surgery.2 Surgical scar endometriosis following cesarean section has an incidence of 0.03%–0.4%.3 Because it is often mistaken for a suture granuloma, incisional hernia, lipoma, abscess, cyst or a strange body, diagnosis of this disease is not easy. However, a mass in a cesarean section scar with symptoms of cyclic pain related to menses is nearly pathognomonic. We report the cases of 3 women, aged 32, 22 and 30 years, respectively, who presented with a painful abdominal wall mass.
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Discussion

Incisional endometriosis is an underappreciated phenomenon in general surgery. The literature indicates that cesarean section scar endometriosis is very rare; however, it may occur more commonly than believed. In most patients, surgical scar endometriosis involves a painful mass that becomes swollen and more tender before menses. In the literature, the mean size of masses has been 3.1 (range 1.5–4.8) cm. Patients may present from months to years (mean 21 mo) after their last obstetric/gynecologic surgery.4 In our patients’ cases, presentation occured 5 years, 3 months and 12 months after surgery, respectively. It is hypothesized that failure to close the parietal and visceral peritoneum with sutures at the time of cesarean section may markedly increase the postoperative occurrence of an endometrioma in the incision scar. Furthermore, endometrial tissue can be transplanted and survive at ectopic locations.5 Therapy with oral contraceptives, progestins, medroxy-progesterone acetate and gonadotropin-releasing hormone agonists has been tried with minimal success.2 In some patients, the effects can be relatively long-lasting, but complete, permanent regression of endometriosis is rare with medical therapy. For cutaneous endometriosis, total surgical excision is considered to be the gold standard for both diagnosis and treatment. Resection must be complete with clear margins to prevent recurrence.

Conclusion

Cesarean section incisional endometriosis is very rare and difficult to diagnose. In addition, it is an underappreciated phenomenon in general surgery, so it may be more common than reflected in the literature. Familiarity with its signs and symptoms will increase awareness of this disease. Endometriosis should be included in the differential diagnosis of abdominal scar lesions following gynecological operations. A mass involving cesarean section scars with symptoms intensifying before each menses is almost pathognomonic. Medical treatment may decrease symptoms for some time; however, to provide both diagnostic and therapeutic intervention, surgical management is the best choice.

References

- 1.Mascaretti G, Di Berardino C, Mastrocola N, et al. Endometriosis: rare localizations in two cases. Clin Exp Obstet Gynecol. 2007;34:123–5. [PubMed] [Google Scholar] - 2.Taff L, Jones S. Cesarean scar endometriosis. A report of two cases. J Reprod Med. 2002;47:50–2. [PubMed] [Google Scholar] - 3.Picod G, Boulanger L, Bounoua F, et al. Abdominal wall endometriosis after cesarean section: report of fifteen cases. Gynecol Obstet Fertil. 2006;34:8–13. doi: 10.1016/j.gyobfe.2005.11.002. [DOI] [PubMed] [Google Scholar] - 4.Steck WD, Helwing EB. Cutaneus endometriosis. JAMA. 1965;191:167–70. doi: 10.1001/jama.1965.03080030011002. [DOI] [PubMed] [Google Scholar] - 5.Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44:89–94. doi: 10.1097/00006254-198902000-00003. [DOI] [PubMed] [Google Scholar]

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Condition tags

endometriosis

MeSH descriptors

Cesarean Section Cicatrix Endometriosis Abdominal Pain Abdominal Pain Abdominal Pain Adult Biopsy, Needle Cesarean Section Cesarean Section Cicatrix Cicatrix Cicatrix Endometriosis Endometriosis Endometriosis Female Follow-Up Studies Humans Immunohistochemistry

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