Postoperative Fibro-Inflammatory Pseudocyst of the Vesicouterine Space Mimicking a Chronic Hematoma: A Case Report

Chronic pelvic pain remains a challenging clinical problem due to its diverse underlying causes and often nonspecific presentation. Although common conditions account for most cases, rare postoperative or inflammatory cystic lesions within the vesicouterine space may mimic more common pelvic pathologies and create significant diagnostic uncertainty. These lesions may demonstrate imaging features that overlap with those of chronic hematomas and endometriotic cysts, further complicating the preoperative diagnosis. A woman in her mid-30s, gravida 3, para 1, with two previous miscarriages, presented with a several-month history of left lower abdominal and pelvic pain. Pelvic ultrasound demonstrated a cystic lesion with internal echoes located anterior to the lower uterine segment. MRI revealed an ovoid lesion adjacent to the anterior lower uterine segment, with imaging characteristics suggestive of a chronic hematoma. Due to persistent symptoms, laparoscopic exploration was performed. Intraoperatively, dense adhesions were identified between the uterus, cervix, and bladder. Following adhesiolysis and bladder dissection, a cystic lesion containing dense, friable, whitish-yellow material was identified within the vesicouterine space, and the visible cyst wall and its contents were excised. Histopathological analysis demonstrated a fibrous wall without epithelial or mesothelial lining, accompanied by chronic fibro-inflammatory changes, consistent with a pseudocyst. The patient had an uneventful recovery, with significant improvement in her symptoms. This case demonstrates the imaging overlap between chronic hemorrhagic collections and fibro-inflammatory pseudocysts and highlights the diagnostic challenge posed by uncommon lesions of the vesicouterine space. In this symptomatic patient, despite imaging findings suggestive of a chronic hematoma, a definitive diagnosis was established through surgical exploration and histopathological examination. The report contributes to the limited literature describing pseudocysts involving the vesicouterine space and emphasizes the need to consider postoperative fibro-inflammatory pseudocyst formation in the differential diagnosis of a non-enhancing vesicouterine lesion.