27year old P2 L2 came with h/o pain abdomen on and off since 7years, increased since 2 months.
HISTORY OF PRESENTING ILLNESS:
27year old para 2 living 2 came with pain abdomen since 7years, increased since 2months, sudden in onset, progressive in nature, pain over suprapubic region, pricking kind of pain, aggravates significantly during menstrual cycles and relives after taking medications. Pain associated with the mass. Mass present over the cesarean scar , tender in nature , protrudes during menstrual cycles.
No history of menorrhagia
No history of intermittent bleeding No history of abdominal distension No history burning micturition
No history of increased frequency of micturition No history of constipation
No history of loss of appetite No history of loss of weight
No history of twinning and congenital Anomalies
MENSTRUAL HISTORY : LMP : 20/11/2020
Past cycles : 3-4 days/30days , 2-3 pads per day , pain ++, no clots
OBSTETRIC HISTORY : PARA 2 LIVING 2 , 2FTLSCS
1st- conceived spontaneously , FTLSCS, male baby, at present 7years alive, healthy
2nd- conceived spontaneously, FTLSCS, male , at present 4years alive and healthy
MEDICAL HISTORY :
no history of Diabetes, Hypertension , Tuberculosis, seizures, bronchial asthma
PAST SURGICAL HISTORY:
Underwent open appendectomy 10years back Underwent open cholecystectomy 10years back
Underwent 2 LSCS 7 and 4 years back with concurrent tubal sterilisation Family history : nothing significant
Personal history : diet mixed , normal appetite, regular bowel and bladder , sleep not disturbed
General physical examination:
Patient aged 27years , moderately built , moderately nourished , oriented to time, place, person.
No pallor, Icterus , cyanosis, clubbing, lymphadenopathy, Edema
VITALS: PULSE- 90/MIN
Blood pressure – 130/80mmhg
Inspection – Abdomen scaphoid shaped
All quadrants moves equally on respiration Multiple healed scars present
- Right hypochondriac region 10cm healed scar,suggestive of cholecystectomy healed by primary intention.
- Suprapubic transverse healed scar suggestive of cesarean section healed by primary intention.
- 3*3cm circular scar with black pigmentation in subumblical region.
No dilated veins, all hernial orifices normal
Palpation : Soft
No local rise of temperature
3*3cm circular hard mass with black pigmentation in subumbilical region, tender with restricted mobility and felt arising from skin to deep down.
No Other mass palpable Percussion : tympanic notes in all 9 quadrants Auscultation: bowel sounds heard
Local examination :External genitalia normal
No excoriation No discharge
Per speculum : Cervix and vagina normal
Per vaginal examination: cervix firm , directed downwards backwards, Uterus normal size, anteverted. Fornices free and non tender
Cvs: s1 s2 heard . No murmurs
Rs: B/L normal vesicular breath sounds heard. No added sounds Cns: normal
*USG abdomen: well defined subcutaneous hypoechoic lesion 3*2.5cm in lower abdomen at incision site. Showing increased vascularity.
? Subcutaneous scar endometriosis.
DIFFERENTIAL DIAGNOSIS :
STITCH GRANULOMA DESMOND TUMOUR HEMATOMA NEUROMA
P2L2 with scar endometriosis with previous 2 LSCS
Excision of scar endometriosis
Endometriosis is a benign disease, defined as presence of ectopic (outside the uterus ) endometrial gland and stroma.
Previous LSCS /late marriages/ late child birth / genital tract obstruction / frequent and prolonged menstrual cycles / nulliparity / early menarche
Theories of sites of endometriosis: 1. Pelvic endometriosis- Retrograde metaplasia
2. Abdominal viscera – coelomic metaplasia 3.Pelvic peritoneum- coelomic metaplasia 4.Rectovaginal septum – coelomic metaplasia 5.umbilicus – coelomic metaplasia
- Abdomen scar – direct implantation
- Episiotomy scar – direct implantation
- Vagina and cervix – direct implantation
- Lymph nodes – Lymphatic spread
- Other- vascular genetic immunologic
Scar endometriosis is a rare entity reported in gynaecology literature and presents in women who has undergone previous abdomen or pelvic surgeries . It is defined by the implantation or/and growth of endometrial tissue postsurgically at the incision site. Most commonly accepted theory for scar endometriosis is Direct endometrial implantation to wound edge during abdominal or pelvic surgeries.
The incidence of scar endometriosis has been shown to be less than 2%with the most common subtype being post cesarean section.
Symptoms : Dull aching abdominal pain Dysmenorrhea
Disorders of menstruation Dyspareunia
Only 20% of women will show up with symptoms
*USG abdomen shows , irregular walls with low level echos within and occasional high level echogenic areas which are blood clots.
*CT/MRI has no additional advantage than USG Haematological investigations will be normal
However CA-125 is increased in endometriosis although levels are lower than they are in ovarian carcinoma
*Laparoscopic findings : Powder burns / Gunshot lesion
This requires both surgical excision and hormonal suppression 1- Progestational drugs 20-100mg p/o for 6months, have been used to treat symptomatic endometriosis.medroxyprogesterone acetate is mostly used.
Levonorgestrel containing IUDs has recently been used for treatment of rectovgainal endometriosis
- Oral contraceptive pills ,can be given cyclic or continuous fashion, however monophasic formulation seems more logical than multiphasic pill for continuous therapy.the usual regime is continuous treatment with one pill daily for 6-12 months.
- GNRH agonist – causes pseudomenopause and pseudo pregnancy.given for 6months.
- Gestrinone – is a 19- nortestosterone derivative steroid having androgenic, antiprogestinic, antiestrogenic actions,thus extensively used in endometriosis.given 2.5mg-10mg On a twice or thrice weekly schedule.
- Danazol can also be used. But not used now a days.
It is believed that hormonal suppression is only partially effective.
For endometriosis hormonal suppression may be effective but in scar endometriosis hormonal supplements aren’t useful.surgery is the choice.
Surgical treatment : Excision
Surgery for the treatment of endometriosis can be performed via laparotomy or laparoscopy. Laparoscopy offers advantage over laparotomy in better visualisation,less time,less tissue trauma,desiccation,smaller incision and speedy postoperative recovery. Post operative adhesions and complications may also be less in laparoscopy.
Peritoneal implants of endometriosis can be ablated with unipolar or bipolar electro surgical instruments or lasers or excised by sharp dissection.
POST OPERATIVE MANAGEMENT
In order to control the recurrence, progesterone can be given for 4-5 months.
If the scar is relatively large then can be given up to 9months.
- Hugh S. Taylor , Lubna Pal , Emre seli. Speroff’s Clinical gynaecology, endocrinology and infertility. 9th ed. 2019.
- Werner, Moschos , Griffith, Beshay,Rahn, Richardson,Hoffman. Williams gynaecology. Study guide.2nd ed. The McGraw-hill companies,2012.
- Tanos B, Anteby SO. Caesarean scar endometriosis.Int J Gynaecol Obstet.1994;47:163-6
- wolf G, Singh K. Cesarean scar endometriosis ;A review , Obstet Gynecol surv.1989;44: