Scar Endometriosis of the Abdominal Wall After Cesarean Delivery: A Rare Cause of Catamenial Abdominal Pain Abdominal Wall Scar Endometriosis Following Cesarean Delivery.

Abstract

Introduction:
Abdominal wall endometriosis (AWE) is an uncommon, estrogen-dependent inflammatory condition caused by ectopic endometrial glands and stroma within the abdominal wall. It is most often seen following obstetric or gynecologic surgery particularly cesarean delivery. Diagnosis is frequently delayed because presentations can mimic hernia, granuloma, abscess or soft-tissue tumors. Cyclical
(catamenial) pain in proximity to a prior surgical scar remains a key clinical clue while imaging may assist operative planning, definitive diagnosis requires histopathology.
Case report:
A 33-year-old multiparous woman (G4P3+1; living 4) presented with progressively worsening cyclical periumbilical pain that consistently exacerbated during menses. She had a history of three prior cesarean sections and other abdominal surgeries including umbilical hernia repair and inguinal hernia repair. Examination revealed a well-defined, tender abdominal wall nodule located approximately 5 cm lateral to the midline and 5 cm above the cesarean scar. Pelvic MRI demonstrated an enhancing lesion within the left lower abdominal wall with T1 hyperintensity, iso–T2 signal and diffusion restriction suggestive of AWE. The lesion was completely excised surgically intraoperatively it was a firm, well-circumscribed 5 × 3 × 2 cm mass immediately beneath the rectus sheath containing “chocolate-colored” material. Histopathology was done which showed endometrial glands and stroma within fibrofatty tissue admixed with skeletal muscle fibers. These histopathology features confirmed endometriosis. Recovery was uneventful and she remained symptom-free without recurrence at 6-month follow-up.
Conclusion:
AWE should be suspected in reproductive-aged women with cyclical pain and an abdominal wall mass after cesarean delivery even when the lesion is not directly within the scar line. MRI supports characterization and surgical planning but wide local excision with histologic confirmation is the cornerstone of definitive management and recurrence prevention.