Scar endometriosis is a term given to endometriosis occurring in a cesarian section scar. It can be located in the skin, subcutaneous tissue, rectus muscle/sheath, intraperitoneally, or in the uterine myometrium (within uterine scar).
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Epidemiology
The reported incidence of abdominal scar endometriosis following cesarean section is 0.03-0.6% 6.
Clinical presentation
Patients may complain of tenderness to palpation and a raised, unsightly hypertrophic scar. Most patients have cyclical pain (up to 70%) 5. The pain is usually intermittent and associated with the patient's menstrual cycle but it may be constant in nature. Some reports state that only as low as 20% of the patients exhibited cyclical symptoms. The overlying skin may be hyperpigmented due to the deposition of hemosiderin. Some patients may be asymptomatic 4.
Pathology
It is thought to be caused by the implantation of endometrial stem cells at the surgical site at the time of uterine surgery.
Radiographic features
For general imaging features of endometriosis: refer to the parent article.
Ultrasound
Sonographic features are not specific. A subcutaneous nodule having relatively irregular borders, a heterogeneous, but predominantly hypoechoic echotexture with internal scattered hyperechoic echoes surrounded by a hyperechoic ring of variable width, and vascularity may be present. Occasionally cystic changes may be present 6.
CT
Well-defined soft tissue nodule with heterogenous post-contrast enhancement and streaky appearance in the surrounding tissue.
MRI
The most sensitive imaging modality. Often accurately locates the lesion in relation to a previous C-section scar, with signal characteristics similar to that of background endometriosis.
Treatment and prognosis
Surgical excision with clear resection margins is the favored treatment in symptomatic patients. Medical treatment with hormonal suppression (GnRH analogs) can offer temporary improvement in symptoms, with a low success rate 4.
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