Abdominal wall endometriosis in a cesarean scar: a case report

Endometriosis affects 6-15% of reproductive-aged women, with abdominal wall endometriosis occurring in 1-12% of extrapelvic cases. Cesarean scar endometriosis, the most common abdominal wall endometriosis subtype, arises in 0.03-3.5% of post-cesarean patients, often presenting as cyclical pain or a palpable mass near surgical scars. Diagnostic challenges stem from nonspecific symptoms and imaging overlap with granulomas, hernias, or tumors.

A 25-year-old female Arab patient presented with a 1.6 cm tender subcutaneous nodule adjacent to her Pfannenstiel scar, worsening during menses. Ultrasound revealed a hypoechoic nodule, while magnetic resonance imaging showed a 15 × 12 mm subcutaneous lesion with low T1 and intermediate T2 signals. Despite imaging favoring granuloma, clinical suspicion for cesarean scar endometriosis prompted wide surgical excision. Histopathology confirmed endometrial glands, stroma, and hemosiderin-laden macrophages, confirming abdominal wall endometriosis. Postoperatively, cyclical pain resolved, with no recurrence at the 2-month follow-up.

Cesarean scar endometriosis, though rare, requires high clinical suspicion in patients with prior cesarean sections and cyclical symptoms. Multimodal imaging aids differentiation, but histopathology remains definitive. Surgical excision with clear margins is curative, preventing complications such as malignant transformation. This case highlights the interplay of surgical history, hormonal factors, and anatomical predisposition in cesarean scar endometriosis pathogenesis. Clinicians must prioritize early recognition and intervention to optimize outcomes in this underdiagnosed condition.