Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures
Abstract
AIM: To report 11 cases of incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. The diagnostic approaches and therapies for incisional endometriosis are also evaluated. METHODS: Eleven patients who presented with a painful nodule that was increasing in size during menstruation on the scar of a previous gynecologic procedure were examined retrospectively. RESULTS: All patients presented with a palpable painful lesion, located on the cesarean section incision, perineal episiotomy incision or the vaginal cuff after hysterectomy. All masses were increasing during menstruation and all patients had been having cyclical pain that worsened during menstrual periods. The mean age of the patients was 28.2 years. The onset of symptoms was referred at variable intervals after surgery ranging between 2 and 11 years (mean: 5.72 years). Ultrasound examination confirmed hypoechoic mass septated with cystic and solid components in the abdomen without intra-abdominal communications. All endometriotic masses were completely excised under general anesthesia. The excised masses were sent for microscopic examination which confirmed the diagnosis of endometriosis. CONCLUSION: Incisional endometriosis seems to be common in women who have had a cesarean section, although it does occur after other procedures and de novo. It is suggested that caution is exercised during gynecologic procedures to avoid transplantation of endometrium to the anterior abdominal wall. The preferred management is to excise the lesion completely even if this necessitates fascial excision.
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Gunes et al. (2005) describe a mechanical transplantation theory in which the endometrium is accidentally transplanted into the surgical scar in patients with no history of endometriosis prior to surgical procedures.
“Gunes et al. (2005) describe a mechanical transplantation theory in which the endometrium is accidentally transplanted into the surgical scar in patients with no history of endometriosis prior to surgical procedures.”
From Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review (2024) · cites this paper as [30]
Gunes et al. (2005) note a theory of metaplasia in which scar endometriosis appears de novo.
“Furthermore, they note a theory of metaplasia in which scar endometriosis appears de novo [30].”
From Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review (2024) · cites this paper as [30]
Typical cases of abdominal incision endometriosis appear following cesarean deliveries.
“inadvertent, iatrogenic transfer of endometrial tissue is the most likely reason that results in abdominal incision endometriosis, and typical cases appear following cesarean deliveries.15”
From Large Abdominal Wall Endometrioma Following Laparoscopic Hysterectomy (2011) · cites this paper as [15]
Inadvertent, iatrogenic transfer of endometrial tissue is the most likely reason that results in abdominal incision endometriosis.
“inadvertent, iatrogenic transfer of endometrial tissue is the most likely reason that results in abdominal incision endometriosis, and typical cases appear following cesarean deliveries.15”
From Large Abdominal Wall Endometrioma Following Laparoscopic Hysterectomy (2011) · cites this paper as [15]
The most plausible theory for scar endometriosis is direct mechanical implantation: endometrial tissue from uterine opening is accidentally implanted into the abdominal incision and grows to form a mass that increases in size during menses and becomes symptomatic.
“Most studies said that scar endometriosis involves surgical procedures in which the uterus is opened, endometrial tissue gets accidentally implanted into the abdominal incision and it grows to form a mass that increases in size during menses and becomes symptomatic, this is the most plausible theory named direct mechanical implantation [14].”
From Case report: Caesarean scar endometriosis – A rare entity (2021) · cites this paper as [14]
Endometrium during pregnancy creates a favorable microenvironment that makes transplantation and implantation particularly successful.
“In addition, in an old case report, it has been suggested that endometrium during pregnancy creates a favorable microenvironment with certain characteristics that make transplantation and implantation particularly successful [24].”
From Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section (2022) · cites this paper as [24]
Mechanical transplantation is responsible for the evolution of iatrogenic endometriosis, according to two reports.
“However, according to two reports, it is believed that mechanical transplantation is responsible for the evolution of iatrogenic endometriosis as the great majority of the cases of iatrogenic endometriosis occur after the incision of the gravid uterus [24].”
From Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section (2022) · cites this paper as [24]
The most accepted theory is direct iatrogenic implantation of the endometrium into the wound margin during abdominal or pelvic surgery.
“the most accepted theory is direct iatrogenic implantation of the endometrium into the wound margin during abdominal or pelvic surgery [11, 12].”
From Resection and Abdominal Wall Reconstruction for Cesarean Scar Endometriosis (2022) · cites this paper as [12]
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“7) Size and depth of lesion Gunes, et al.(11) 11 28.”
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“In addition, in an old case report, it has been suggested that endometrium during pregnancy creates a favorable microenvironment with certain characteristics that make transplantation and implantation particularly successful [24].”
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“Furthermore, they note a theory of metaplasia in which scar endometriosis appears de novo [30].”
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Scar endometriosis presenting as a painful abdominal mass
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“Although many theories have been postulated as to the cause of CSE, the most accepted theory is direct iatrogenic implantation of the endometrium into the wound margin during abdominal or pelvic surgery [11, 12].”
Background
- Authors
- Gunes, M., Kayikcioglu, F., Ozturkoglu, E., & Haberal, A.
- Venue
- Journal of Obstetrics and Gynaecology Research
- Publisher
- Wiley
- Published
- 2005-09-15
- Volume
- 31
- Issue
- 5
- Pages
- 471-475
- ISSN
- 1341-8076 (ISSN-L)
- 1447-0756
- OpenAlex
- W2071700883
- Cited by
- 169
- References
- 14
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 5 · 2023: 6 · 2022: 7 · 2021: 5 · 2020: 4 · 2019: 4 · 2018: 3 · 2017: 60 · 2016: 4 · 2015: 7 · 2014: 11 · 2013: 9 · 2012: 6
- FWCI
- 4.91
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of obstetrics and gynaecology research (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- cesarean section, episiotomy, hysterectomy, postoperative endometriosis, ultrasonography, surgical excision, endometrial transplantation
- MeSH terms
- Adult, Cesarean Section, Endometriosis, Episiotomy, Female, Humans, Retrospective Studies, Ultrasonography
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