Skin Endometriosis at the Caesarean Section Scar: A Case Report and Review of the Literature

Abstract

Cutaneous endometriosis is one of the rare gynecological conditions. Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity. It commonly occurs in pelvic sites, such as the ovaries, cul-de-sac, bowel, or pelvic peritoneum. Endometriosis at the incisional scar is difficult to diagnose because of nonspecific symptoms. Usually, patients complain of pain at the site of the incision during menstruation. The main causes in most of the reported cases are obstetrical and gynecological surgeries. Endometrial tissues may be directly implanted in the scar during operation and, under hormonal stimulation, proliferate and form scar endometriosis. Diagnosis is usually made following histopathology. A wide excision is recommended to prevent recurrence. We report a case of a 33-year-old woman presenting with a brownish mass on the lateral aspect of the Pfannenstiel incision from a previous cesarean section scar. The symptoms appeared two years after her operation. The patient had cyclical pain and brownish discharge from the lesion during menstruation. Excision of the skin lesion with underlying subcutaneous tissue showed multiple, minute, firm hemorrhagic foci. Histopathology was performed and revealed a benign endometrial gland and stroma in the tissues, confirming the diagnosis of scar endometriosis. Cutaneous endometriosis is an uncommon gynecological condition and difficult to diagnose because of the nonspecific symptoms. Usually, it is confused with other dermatological and surgical diseases and delays the diagnosis and management. Surgical scar endometriosis following obstetric and gynecological procedures is more frequent recently due to an increase in the number of caesarian sections worldwide. Health care providers should suspect cutaneous endometriosis in any women with pain and a lump in the incisional scar after pelvic surgery.

A Rare Cause of Abdominal Pain: Scar Endometriosis

“…In USG scans, SE lesions usually appear as heterogeneous, hypoechoic, solid, and irregularly marginated round/oval nodules. Besides helping the diagnosis, CT and MRI may reveal the association of the mass with the abdominal cavity and play an important role in the exclusion of other lesions during differential diagnosis [13]. Mostly USG followed by CT or MRI was used at the stage of diagnosis also in our study.…”

“…In such a case, additional radiological procedures should be employed for the diagnosis. The first choice is abdominal USG, a fairly practical and easily accessible method, which provides information on the size, location, margins, and internal structure of the lesion [11–13]. In USG scans, SE lesions usually appear as heterogeneous, hypoechoic, solid, and irregularly marginated round/oval nodules.…”

“…Using USG alone without a subsequent CT or MRI would not produce a definitive diagnosis and would involve the risk of missing out other pathologies. CT and MRI were very helpful in revealing the localization and size of the mass palpated at the anterior abdominal wall, its relationship with the surrounding tissues, and whether there were any other pathologies in the abdomen [6, 13]. We believe that CT or MRI scans should be used more actively in patients who have had USG but whose SE diagnosis remains suspicious.…”

Ultrasound Imaging of Abdominal Wall Endometriosis: A Pictorial Review

“…Cutaneous endometriosis (CE) is known as the presence of endometrial tissues involving the skin. This condition is estimated to occur at approximately less than 1% of ectopic sites [ 17 ]. Generally, CE occurs secondarily to abdominal surgery, but can be primary, without any previous operations.…”

Ultrasound Characterization of Abdominal Wall Endometriosis

“…Endometriosis is a term describing any abnormal presences of endometrial stromal tissue outside the normal outlines of endometrial cavity [1] .endometriosis considered one of the common gynecological problem its incidence reaching to about 15% of women at productive age [2] the most common site of this entity is the pelvic region [3] , it is rarely found in extra pelvic region . the abdominal wall endometriosis (AWE ) considered one of the rare sites of endometriosis its incidence is about 0.3-3.5 % of population [4] .Although its predisposing factor is previous surgery mostly CS or other gynecological surgical interventions but it may include other abdominal wall endometriosis without any previous surgery [5] .Many theories are sets to describe the cause of this condition but the most accepted one is the implantation of endonmetrial tissue during surgery , which subsequently proliferate under hormonal effect [6,7] . the clinical symptoms of abdominal wall endometriosis include , periodic abdominal wall pain mainly during menses and palpable lump [8] .…”