Author Information
Thakurdesai A*, Tiwari N**, Chaudhari H***.
(* Final Year MBBS student, ** Assistant Professor, *** Associate Professor and Head of Unit, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
The presence of functioning endometrial tissue outside the uterine cavity is known as endometriosis. Scar endometriosis is the occurrence of endometriosis at the surgical scar site. It is a rare condition and may be difficult to diagnose. It follows after any obstetrical or gynecological surgery. The clinical presentation is pain and swelling at the scar site which may or may not coincide with menstruation. A case report of a patient with a painful swelling at the scar site of cesarean section is presented. High clinical suspicion clinches the diagnosis and surgical excision with a histopathology report proves it. The pathogenesis, diagnosis and treatment of this rare condition are discussed here.
Introduction
Endometriosis is the occurrence of functioning endometrial tissue outside the uterine cavity.[1] Endometrial tissue can be found in the pelvis or in extra pelvic locations such as the abdominal wall, lungs, skin, brain, urinary tract and gastrointestinal tract.[2] Classical endometriosis characteristically presents with changes in the intensity of pain and the size of implants during menstruation.[3] The overall incidence of endometriosis is 5% to 10% in women of reproductive age. Scar endometriosis is an extremely rare clinical entity. The diagnosis is difficult and may be delayed if high clinical suspicion is not exercised.[4] The present report describes a case of scar endometriosis which was promptly diagnosed and aptly treated.
Case Report
A 24 year old lady P1L1 with previous lower segment cesarean section (LSCS) presented to the outpatient department with pain and swelling over the left side of the abdomen during menstruation for the past 6 months. The pain was well localised and relieved after menstruation. There were no other aggravating or relieving factors. She had no other complaints and no significant past medical history. She underwent a lower segment cesarean section four years back for oligohydramnios and delivered a female child. Her past menstrual cycles were regular, 30 days in length, moderately painful with bleeding for 4 days. On examination, her vital parameters were stable. On abdominal examination, the LSCS scar was healthy. An approximately 1cm well defined, tender mass was felt on the left side of the scar under the skin. Clinically, the differential diagnosis were scar endometriosis, sebaceous cyst, epidermoid cyst and incisional hernia. Ultrasonographic examination of the mass showed a hypoechoic nodule with posterior acoustic shadowing. A provisional diagnosis of scar endometriosis was thus put forth. After preoperative investigations and fitness, she was posted for excision of the scar endometrioma under spinal anesthesia. A 3cm transverse incision was taken just above the palpable swelling on the left lower abdomen. The endometriotic mass was excised completely after opening the rectus sheath with the help of a cautery (figures 1, 2). Complete hemostasis was achieved. The rectus sheath was closed and skin was approximated with Ethilon no. 1 sutures. The procedure was uneventful. The excised mass was sent for histopathology (figure 3). The diagnosis of scar endometriosis was confirmed by histopathology. She was given antibiotics and analgesics and was discharged uneventfully in the due course.
Thakurdesai A*, Tiwari N**, Chaudhari H***.
(* Final Year MBBS student, ** Assistant Professor, *** Associate Professor and Head of Unit, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
The presence of functioning endometrial tissue outside the uterine cavity is known as endometriosis. Scar endometriosis is the occurrence of endometriosis at the surgical scar site. It is a rare condition and may be difficult to diagnose. It follows after any obstetrical or gynecological surgery. The clinical presentation is pain and swelling at the scar site which may or may not coincide with menstruation. A case report of a patient with a painful swelling at the scar site of cesarean section is presented. High clinical suspicion clinches the diagnosis and surgical excision with a histopathology report proves it. The pathogenesis, diagnosis and treatment of this rare condition are discussed here.
Introduction
Endometriosis is the occurrence of functioning endometrial tissue outside the uterine cavity.[1] Endometrial tissue can be found in the pelvis or in extra pelvic locations such as the abdominal wall, lungs, skin, brain, urinary tract and gastrointestinal tract.[2] Classical endometriosis characteristically presents with changes in the intensity of pain and the size of implants during menstruation.[3] The overall incidence of endometriosis is 5% to 10% in women of reproductive age. Scar endometriosis is an extremely rare clinical entity. The diagnosis is difficult and may be delayed if high clinical suspicion is not exercised.[4] The present report describes a case of scar endometriosis which was promptly diagnosed and aptly treated.
Case Report
A 24 year old lady P1L1 with previous lower segment cesarean section (LSCS) presented to the outpatient department with pain and swelling over the left side of the abdomen during menstruation for the past 6 months. The pain was well localised and relieved after menstruation. There were no other aggravating or relieving factors. She had no other complaints and no significant past medical history. She underwent a lower segment cesarean section four years back for oligohydramnios and delivered a female child. Her past menstrual cycles were regular, 30 days in length, moderately painful with bleeding for 4 days. On examination, her vital parameters were stable. On abdominal examination, the LSCS scar was healthy. An approximately 1cm well defined, tender mass was felt on the left side of the scar under the skin. Clinically, the differential diagnosis were scar endometriosis, sebaceous cyst, epidermoid cyst and incisional hernia. Ultrasonographic examination of the mass showed a hypoechoic nodule with posterior acoustic shadowing. A provisional diagnosis of scar endometriosis was thus put forth. After preoperative investigations and fitness, she was posted for excision of the scar endometrioma under spinal anesthesia. A 3cm transverse incision was taken just above the palpable swelling on the left lower abdomen. The endometriotic mass was excised completely after opening the rectus sheath with the help of a cautery (figures 1, 2). Complete hemostasis was achieved. The rectus sheath was closed and skin was approximated with Ethilon no. 1 sutures. The procedure was uneventful. The excised mass was sent for histopathology (figure 3). The diagnosis of scar endometriosis was confirmed by histopathology. She was given antibiotics and analgesics and was discharged uneventfully in the due course.
Figure 1. Endometriotic mass held with Babcock's forceps intraoperatively.
Figure 2. Site after excision of the mass.
Figure 3. The excised mass.
Discussion
Endometriosis is a disease of women in the reproductive age group. Various theories for the etiopathogenesis of endometriosis have been suggested like vascular or lymphatic dissemination and retrograde menstruation.[5] The most plausible theory is direct mechanical transplantation of endometrial implants to the wound edge during surgery.[6] The ectopic endometrial implants attract an inflammatory response leading to pain, fibrosis and adhesions. These implants are responsive to cyclical hormonal changes and bleed and increase in size during menstruation thus giving rise to cyclical change in pain intensity. However, not all patients may complain of such characteristic changes in pain intensity. The diagnosis is made by a thorough history, clinical examination, ultrasonography (USG) and histopathology of the excised tissue. The usual clinical signs and symptoms are tenderness on palpation, a raised and hypertrophic scar or a localised swelling. On USG, a scar endometrioma may appear as a fixed solid, cystic, polycystic or a mixed nodule, depending on the amount of glandular and stromal components. A roundish heterogeneous hypoechoic area in the abdominal incision with spiculated margins and fibrotic changes and peripheral hyperechogenicity due to inflammation is a common finding.[7] Intraoperatively, endometriotic lesions grossly appear as small dark red, black or bluish cysts or nodules on the surface of peritoneal or pelvic organs. Scar endometriosis appears as a bluish or blackish swelling with tarry contents and surrounding fibrosis. Histology shows ectopic presence of endometrial glands, spindled endometrial stroma and hemosiderin deposition within macrophages or in the stroma. In many cases, such diagnostic findings are not present or the glands and stroma may be obscured by hemorrhage, hemosiderin laden macrophages or foamy cells.[3] Treatment includes hormonal suppression and surgical excision. Oral contraceptive pills, progesterone, GnRH agonists or androgenic agents may be used for hormonal suppression. The duration of treatment should be at least three months. Medical treatment however, provides only partial symptomatic relief and permanent regression is rare.[5,8] Surgical excision is the definitive treatment. Complete excision with clear margins is diagnostic as well as therapeutic. It is the preferable method to prevent recurrences.[9]
Conclusion
High clinical suspicion is the key to prompt diagnosis and treatment of scar endometriosis, a rare entity which can be difficult to diagnose. Surgical excision is the treatment of choice as it has excellent results.
References
Discussion
Endometriosis is a disease of women in the reproductive age group. Various theories for the etiopathogenesis of endometriosis have been suggested like vascular or lymphatic dissemination and retrograde menstruation.[5] The most plausible theory is direct mechanical transplantation of endometrial implants to the wound edge during surgery.[6] The ectopic endometrial implants attract an inflammatory response leading to pain, fibrosis and adhesions. These implants are responsive to cyclical hormonal changes and bleed and increase in size during menstruation thus giving rise to cyclical change in pain intensity. However, not all patients may complain of such characteristic changes in pain intensity. The diagnosis is made by a thorough history, clinical examination, ultrasonography (USG) and histopathology of the excised tissue. The usual clinical signs and symptoms are tenderness on palpation, a raised and hypertrophic scar or a localised swelling. On USG, a scar endometrioma may appear as a fixed solid, cystic, polycystic or a mixed nodule, depending on the amount of glandular and stromal components. A roundish heterogeneous hypoechoic area in the abdominal incision with spiculated margins and fibrotic changes and peripheral hyperechogenicity due to inflammation is a common finding.[7] Intraoperatively, endometriotic lesions grossly appear as small dark red, black or bluish cysts or nodules on the surface of peritoneal or pelvic organs. Scar endometriosis appears as a bluish or blackish swelling with tarry contents and surrounding fibrosis. Histology shows ectopic presence of endometrial glands, spindled endometrial stroma and hemosiderin deposition within macrophages or in the stroma. In many cases, such diagnostic findings are not present or the glands and stroma may be obscured by hemorrhage, hemosiderin laden macrophages or foamy cells.[3] Treatment includes hormonal suppression and surgical excision. Oral contraceptive pills, progesterone, GnRH agonists or androgenic agents may be used for hormonal suppression. The duration of treatment should be at least three months. Medical treatment however, provides only partial symptomatic relief and permanent regression is rare.[5,8] Surgical excision is the definitive treatment. Complete excision with clear margins is diagnostic as well as therapeutic. It is the preferable method to prevent recurrences.[9]
Conclusion
High clinical suspicion is the key to prompt diagnosis and treatment of scar endometriosis, a rare entity which can be difficult to diagnose. Surgical excision is the treatment of choice as it has excellent results.
References
- Sedhain N, Dangal G, Karki A, Pradhan H, Shrestha R, Bhattachan K, et al. Caesarean scar Endometriosis. J Nepal Health Res Counc. 2018;15(3):292–294.
- Tatli F, Gozeneli O, Uyanikoglu H, Uzunkoy A, Yalcin HC, Ozgonul A, et al. The clinical characteristics and surgical approach of scar endometriosis: A case series of 14 women. Bosn J Basic Med Sci. 2018 Aug 1;18(3):275–278.
- Danielpour PJ, Layke JC, Durie N, Glickman LT. Scar endometriosis - a rare cause for a painful scar: A case report and review of the literature. Can J Plast Surg. 2010;18(1):19–20.
- Gupta P, Gupta S. Scar Endometriosis: a Case Report with Literature Review. Acta Med Iran. 2015 Dec;53(12):793–95.
- Al-Jabri K. Endometriosis at caesarian section scar. Oman Med J. 2009 Oct;24:294–95.
- Uzunçakmak C, Güldaş A, Ozçam H, Dinç K. Scar endometriosis: a case report of this uncommon entity and review of the literature. Case Rep Obstet Gynecol. 2013;2013:386783.
- Francica G. Reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar. World J Radiol. 2012 Apr;4(4):135–140.
- Sengul I, Sengul D, Kahyaoglu S, Kahyaoglu I. Incisional endometriosis: a report of 3 cases. Can J Surg. 2009 Oct;52:444–45.
- Uçar MG, Şanlıkan F, Göçmen A. Surgical Treatment of Scar Endometriosis Following Cesarean Section, a Series of 12 Cases. Indian J Surg. 2015 Dec;77(2):682–86.
Citation
Thakurdesai A, Tiwari N, Chaudhari H. Cesarean Scar Endometriosis. JPGO 2019. Vol. 6. No. 8. Available from:https://www.jpgo.org/2019/08/cesarean-scar-endometriosis.html
Thakurdesai A, Tiwari N, Chaudhari H. Cesarean Scar Endometriosis. JPGO 2019. Vol. 6. No. 8. Available from:https://www.jpgo.org/2019/08/cesarean-scar-endometriosis.html