A Collection of Cases With Pain as a Primary Presenting Symptom

Scar Endometrioma

Authors:
Philip Collins, DO, and Rebecca Moore, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Citation:
Collins P, Moore R. Scar endometrioma. Consultant. 2017;57(9, Suppl.):S6-S7.

A 32-year-old woman presented to a primary care office with left lower-quadrant pain that had been present intermittently for approximately 5 years and had worsened over recent months. The pain had begun not long after she had undergone abdominoplasty.

The pain was located in the lateral portion of the scar from the patient’s previous Pfannenstiel incision from a cesarean delivery. She reported that the pain was worse at certain times, including during menstrual periods, but it never fully went away. She also noted that she sometimes would feel a small lump in the area of the pain. Her gynecologist had performed pelvic ultrasonography, which showed no abnormalities. The gynecologist, suspecting a possible hernia, had referred her to primary care for the remainder of the workup. Findings of a review of systems was otherwise negative.

Physical examination. Physical examination revealed a soft abdomen with mild tenderness to palpation in the left lower quadrant, and a palpable superficial mass measuring approximately 2 × 2 cm in diameter.

Diagnostic tests. A computed tomography scan of the abdomen and pelvis with oral contrast revealed asymmetric enlargement of the left rectus abdominis muscle, possibly due to a mass or hematoma, consistent with the palpable abnormality observed on examination. This finding was discussed with the patient, and she denied any trauma that she could recall. Magnetic resonance imaging (MRI) with intravenous contrast of the abdomen was then ordered, the results of which showed an enhancing 20 × 12-mm lesion within the left rectus abdominis muscle at the level of the low-transverse anterior abdominal wall incision (Figure). Given her history of cesarean delivery and worsening pain with menses, scar endometrioma became the most likely diagnosis.

Treatment. The patient underwent successful surgical removal of the mass by way of an incision through the previous Pfannenstiel incision. Through extensive scar tissue, the mass was found within and below the fascia. The mass was removed as 2 fragments, the first measuring 3 × 2 × 1.5 cm and the second measuring 3.5 × 2.7 × 1.5 cm. Pathology test results confirmed the diagnosis of endometriosis.

Outcome of the case. Following surgical removal of the endometrioma, she quickly recovered, and her symptoms resolved.

Discussion. Endometriosis is a common disorder involving abnormal growth of tissue resembling endometrium present in locations other than the uterine lining.¹ It is estimated to be present in 6% to 10% of women of reproductive age and 25% to 35% of women with infertility.¹ Endometriosis more commonly affects women of reproductive age than postmenopausal women, although the latter has been reported.

Symptoms of endometriosis can vary significantly, ranging from being asymptomatic to causing severe pain. When pain is present, it typically occurs with menses, and many women with it also experience infertility. Most commonly, lesions are found on peritoneal surfaces of reproductive organs and adjacent structures within the pelvis but rarely can be found in other locations. One such location is the scar from prior abdominal surgical procedures.

Scar endometriomas represent a rare form of endometriosis and account for 0.03% to 0.15% of endometriosis cases.² Scar endometriomas are typically found in low-transverse abdominal wall incisions used for uterine procedures such as cesarean deliveries. Diagnosis can be difficult, but the condition should be considered in women who have undergone abdominal surgery.

Ultrasonography has been shown to sometimes identify endometriomas, but the size of the mass can be a factor.² MRI can assist in preoperative planning and also can help to better visualize the soft tissue. Ultimately, the diagnosis must be confirmed with biopsy and/or excision.³

Nonsurgical treatment options include the use of oral contraceptives, gonadotropin-releasing hormone agonists, and aromatase inhibitors.^4,5 However, surgical removal is the treatment of choice for women with severe disease, those who wish to preserve fertility, those with adhesions, and those who wish for curative treatment.¹

While scar endometriomas are a rare finding, the diagnosis must be kept in mind in cases of women with abdominal pain of unclear etiology, especially women of childbearing age with a history of abdominal surgical procedures. This diagnosis should especially be considered when the scar from that surgical procedure becomes tender with menses.⁶ 

References:

1. Sarajari S, Muse KN Jr, Fox MD. Endometriosis. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013:chap 56.
2. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, Tramontano G. Abdominal wall endometriomas near cesarean delivery scars: sonographic and color Doppler findings in a series of 12 patients. J Ultrasound Med. 2003;22(10):1041-1017.
3. Hoffman BL. Endometriosis. In: Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM, eds. Williams Gynecology. 3rd ed. New York, NY: McGraw-Hill; 2016:chap 10.
4. Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44(2):89-95.
5. Schoelefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its association with caesarean section and gynaecological procedures. J Obstet Gynaecol. 2002;22(5):553-554.
6. Al-Jabri K. Endometriosis at caesarian section scar. Oman Med J. 2009;​24(4):294-295.

NEXT: Atypical Presentation of Angina

Scar Endometrioma

Authors:
Philip Collins, DO, and Rebecca Moore, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Citation:
Collins P, Moore R. Scar endometrioma. Consultant. 2017;57(9, Suppl.):S6-S7.

A 32-year-old woman presented to a primary care office with left lower-quadrant pain that had been present intermittently for approximately 5 years and had worsened over recent months. The pain had begun not long after she had undergone abdominoplasty.

The pain was located in the lateral portion of the scar from the patient’s previous Pfannenstiel incision from a cesarean delivery. She reported that the pain was worse at certain times, including during menstrual periods, but it never fully went away. She also noted that she sometimes would feel a small lump in the area of the pain. Her gynecologist had performed pelvic ultrasonography, which showed no abnormalities. The gynecologist, suspecting a possible hernia, had referred her to primary care for the remainder of the workup. Findings of a review of systems was otherwise negative.

Physical examination. Physical examination revealed a soft abdomen with mild tenderness to palpation in the left lower quadrant, and a palpable superficial mass measuring approximately 2 × 2 cm in diameter.

Diagnostic tests. A computed tomography scan of the abdomen and pelvis with oral contrast revealed asymmetric enlargement of the left rectus abdominis muscle, possibly due to a mass or hematoma, consistent with the palpable abnormality observed on examination. This finding was discussed with the patient, and she denied any trauma that she could recall. Magnetic resonance imaging (MRI) with intravenous contrast of the abdomen was then ordered, the results of which showed an enhancing 20 × 12-mm lesion within the left rectus abdominis muscle at the level of the low-transverse anterior abdominal wall incision (Figure). Given her history of cesarean delivery and worsening pain with menses, scar endometrioma became the most likely diagnosis.

Treatment. The patient underwent successful surgical removal of the mass by way of an incision through the previous Pfannenstiel incision. Through extensive scar tissue, the mass was found within and below the fascia. The mass was removed as 2 fragments, the first measuring 3 × 2 × 1.5 cm and the second measuring 3.5 × 2.7 × 1.5 cm. Pathology test results confirmed the diagnosis of endometriosis.

Outcome of the case. Following surgical removal of the endometrioma, she quickly recovered, and her symptoms resolved.

Discussion. Endometriosis is a common disorder involving abnormal growth of tissue resembling endometrium present in locations other than the uterine lining.¹ It is estimated to be present in 6% to 10% of women of reproductive age and 25% to 35% of women with infertility.¹ Endometriosis more commonly affects women of reproductive age than postmenopausal women, although the latter has been reported.

Symptoms of endometriosis can vary significantly, ranging from being asymptomatic to causing severe pain. When pain is present, it typically occurs with menses, and many women with it also experience infertility. Most commonly, lesions are found on peritoneal surfaces of reproductive organs and adjacent structures within the pelvis but rarely can be found in other locations. One such location is the scar from prior abdominal surgical procedures.

Scar endometriomas represent a rare form of endometriosis and account for 0.03% to 0.15% of endometriosis cases.² Scar endometriomas are typically found in low-transverse abdominal wall incisions used for uterine procedures such as cesarean deliveries. Diagnosis can be difficult, but the condition should be considered in women who have undergone abdominal surgery.

Ultrasonography has been shown to sometimes identify endometriomas, but the size of the mass can be a factor.² MRI can assist in preoperative planning and also can help to better visualize the soft tissue. Ultimately, the diagnosis must be confirmed with biopsy and/or excision.³

Nonsurgical treatment options include the use of oral contraceptives, gonadotropin-releasing hormone agonists, and aromatase inhibitors.^4,5 However, surgical removal is the treatment of choice for women with severe disease, those who wish to preserve fertility, those with adhesions, and those who wish for curative treatment.¹

While scar endometriomas are a rare finding, the diagnosis must be kept in mind in cases of women with abdominal pain of unclear etiology, especially women of childbearing age with a history of abdominal surgical procedures. This diagnosis should especially be considered when the scar from that surgical procedure becomes tender with menses.⁶ 

References:

1. Sarajari S, Muse KN Jr, Fox MD. Endometriosis. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013:chap 56.
2. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, Tramontano G. Abdominal wall endometriomas near cesarean delivery scars: sonographic and color Doppler findings in a series of 12 patients. J Ultrasound Med. 2003;22(10):1041-1017.
3. Hoffman BL. Endometriosis. In: Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM, eds. Williams Gynecology. 3rd ed. New York, NY: McGraw-Hill; 2016:chap 10.
4. Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44(2):89-95.
5. Schoelefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its association with caesarean section and gynaecological procedures. J Obstet Gynaecol. 2002;22(5):553-554.
6. Al-Jabri K. Endometriosis at caesarian section scar. Oman Med J. 2009;​24(4):294-295.

NEXT: Atypical Presentation of Angina

Scar Endometrioma

Authors:
Philip Collins, DO, and Rebecca Moore, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Citation:
Collins P, Moore R. Scar endometrioma. Consultant. 2017;57(9, Suppl.):S6-S7.

A 32-year-old woman presented to a primary care office with left lower-quadrant pain that had been present intermittently for approximately 5 years and had worsened over recent months. The pain had begun not long after she had undergone abdominoplasty.

The pain was located in the lateral portion of the scar from the patient’s previous Pfannenstiel incision from a cesarean delivery. She reported that the pain was worse at certain times, including during menstrual periods, but it never fully went away. She also noted that she sometimes would feel a small lump in the area of the pain. Her gynecologist had performed pelvic ultrasonography, which showed no abnormalities. The gynecologist, suspecting a possible hernia, had referred her to primary care for the remainder of the workup. Findings of a review of systems was otherwise negative.

Physical examination. Physical examination revealed a soft abdomen with mild tenderness to palpation in the left lower quadrant, and a palpable superficial mass measuring approximately 2 × 2 cm in diameter.

Diagnostic tests. A computed tomography scan of the abdomen and pelvis with oral contrast revealed asymmetric enlargement of the left rectus abdominis muscle, possibly due to a mass or hematoma, consistent with the palpable abnormality observed on examination. This finding was discussed with the patient, and she denied any trauma that she could recall. Magnetic resonance imaging (MRI) with intravenous contrast of the abdomen was then ordered, the results of which showed an enhancing 20 × 12-mm lesion within the left rectus abdominis muscle at the level of the low-transverse anterior abdominal wall incision (Figure). Given her history of cesarean delivery and worsening pain with menses, scar endometrioma became the most likely diagnosis.

Treatment. The patient underwent successful surgical removal of the mass by way of an incision through the previous Pfannenstiel incision. Through extensive scar tissue, the mass was found within and below the fascia. The mass was removed as 2 fragments, the first measuring 3 × 2 × 1.5 cm and the second measuring 3.5 × 2.7 × 1.5 cm. Pathology test results confirmed the diagnosis of endometriosis.

Outcome of the case. Following surgical removal of the endometrioma, she quickly recovered, and her symptoms resolved.

Discussion. Endometriosis is a common disorder involving abnormal growth of tissue resembling endometrium present in locations other than the uterine lining.¹ It is estimated to be present in 6% to 10% of women of reproductive age and 25% to 35% of women with infertility.¹ Endometriosis more commonly affects women of reproductive age than postmenopausal women, although the latter has been reported.

Symptoms of endometriosis can vary significantly, ranging from being asymptomatic to causing severe pain. When pain is present, it typically occurs with menses, and many women with it also experience infertility. Most commonly, lesions are found on peritoneal surfaces of reproductive organs and adjacent structures within the pelvis but rarely can be found in other locations. One such location is the scar from prior abdominal surgical procedures.

Scar endometriomas represent a rare form of endometriosis and account for 0.03% to 0.15% of endometriosis cases.² Scar endometriomas are typically found in low-transverse abdominal wall incisions used for uterine procedures such as cesarean deliveries. Diagnosis can be difficult, but the condition should be considered in women who have undergone abdominal surgery.

Ultrasonography has been shown to sometimes identify endometriomas, but the size of the mass can be a factor.² MRI can assist in preoperative planning and also can help to better visualize the soft tissue. Ultimately, the diagnosis must be confirmed with biopsy and/or excision.³

Nonsurgical treatment options include the use of oral contraceptives, gonadotropin-releasing hormone agonists, and aromatase inhibitors.^4,5 However, surgical removal is the treatment of choice for women with severe disease, those who wish to preserve fertility, those with adhesions, and those who wish for curative treatment.¹

While scar endometriomas are a rare finding, the diagnosis must be kept in mind in cases of women with abdominal pain of unclear etiology, especially women of childbearing age with a history of abdominal surgical procedures. This diagnosis should especially be considered when the scar from that surgical procedure becomes tender with menses.⁶ 

References:

1. Sarajari S, Muse KN Jr, Fox MD. Endometriosis. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013:chap 56.
2. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, Tramontano G. Abdominal wall endometriomas near cesarean delivery scars: sonographic and color Doppler findings in a series of 12 patients. J Ultrasound Med. 2003;22(10):1041-1017.
3. Hoffman BL. Endometriosis. In: Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM, eds. Williams Gynecology. 3rd ed. New York, NY: McGraw-Hill; 2016:chap 10.
4. Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44(2):89-95.
5. Schoelefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its association with caesarean section and gynaecological procedures. J Obstet Gynaecol. 2002;22(5):553-554.
6. Al-Jabri K. Endometriosis at caesarian section scar. Oman Med J. 2009;​24(4):294-295.

NEXT: Atypical Presentation of Angina