Chronic or cyclical pain in the cesarean section scar

Specialty: Gynecology and breast.

• Abdominal wall endometriosis
• pain in previous hysterotomy
• pain in cesarean section scar

Why it occurs

• Endometriosis of the abdominal wall scar (iatrogenic seeding of endometrial cells during cesarean section that grow due to hormonal influence)
• Isthmocele (diverticulum or healing defect in the anterior wall of the uterus in the hysterotomy area)
• Neuroma from amputation or entrapment of ilioinguinal or iliohypogastric nerves in the cesarean section suture
• Dense peritoneal adhesions between the uterus and the anterior abdominal wall

Initial workup

High resolution soft tissue ultrasound to evaluate masses in the anterior abdominal wall located under the scar. Detailed transvaginal ultrasound in the sagittal plane to measure residual myometrial thickness in the uterine scar (diagnosis of isthmocele). Pelvic MRI if there are doubts about infiltration or deep adhesions. Puncture biopsy of the abdominal wall mass if accessible.

Standard management

• Ibuprofen 400-600 mg every 8 hours orally during days of pain
• Continuous combined oral contraceptives to induce amenorrhea and atrophy of ectopic endometrial scar tissue
• Pure progestogens such as Dienogest 2 mg per day orally. The definitive treatment for abdominal wall endometriosis is complete surgical excision of the mass with free margins. For symptomatic isthmocele, treatment includes correction by hysteroscopy (isthmoplasty) or laparoscopy (note: the exclusive use of hormones usually relieves the symptoms of wall endometriosis temporarily, but they recur after stopping the regimen).