{'fraction_non_alphanumeric': 0.024585125998770743, 'fraction_numerical': 0.011524277811923786, 'mean_word_length': 5.2767598842815815, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Scar endometriosis-rare and painful entity: a case report

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. It is a major gynecological problem that affects 8-10% of women of reproductive age. Endometriosis is common in the pelvic organs like ovaries; pouch of Douglas, broad ligament, uterosacral ligament, fallopian tubes, rectosigmoid colon, bladder, and uterovesicle space, and also on other genital organs like episiotomy scars and bartholin glands. Extra pelvic endometriosis is a rare entity occurring in the following possible sitesin the order of their frequency: the peritoneum, the abdominal wall, and the bladder. Scar endometriosis is a rare entity. The majority of the cases have been reported after obstetrical or gynecological procedures such as caesarean delivery, hysterotomy, hysterectomy, episiotomy and tubal ligations. The reported incidence of scar endometriosis after caesarean section is 0.3-0.4% and the following hysterotomy is 12%. Although rare, but with an increasing number of caesarean section this complication is not infrequent. CASE REPORT


INTRODUCTION
Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. It is a major gynecological problem that affects 8-10% of women of reproductive age. 1 Endometriosis is common in the pelvic organs like ovaries; pouch of Douglas, broad ligament, uterosacral ligament, fallopian tubes, rectosigmoid colon, bladder, and uterovesicle space, and also on other genital organs like episiotomy scars and bartholin glands. 2 Extra pelvic endometriosis is a rare entity occurring in the following possible sites-in the order of their frequency: the peritoneum, the abdominal wall, and the bladder. Scar endometriosis is a rare entity. The majority of the cases have been reported after obstetrical or gynecological procedures such as caesarean delivery, hysterotomy, hysterectomy, episiotomy and tubal ligations. 3 The reported incidence of scar endometriosis after caesarean section is 0.3-0.4% and the following hysterotomy is 1-2%. 4 Although rare, but with an increasing number of caesarean section this complication is not infrequent.

CASE REPORT
A 32-year-old multiparous lady, para 2 with 2 live issues with the complaint of cyclical abdominal pain for 1 year. She underwent a caesarean section 9 years ago followed by repeat caesarean 5 years back. She started developing swelling and cyclical pain last year followed by a gradual increase in the size of the swelling. On examination, she was found to be obese (BMI-30.6 kg/m 2 ) with tenderness in the umbilical and hypogastric region.
On ultrasound, a heterogeneous hypoechoic lesion with significant internal vascularity of size 16×9×23 mm was noted in the right rectus sheath in the infra umbilical region. On MRI, a focal area of altered signal in the distal third of paramedian aspect of right rectus abdominis muscle in the infraumbilical region of size 20×8×22 mm suggestive of endometriosis. histopathological examination. The report confirmed scar endometriosis post-operative period was uneventful. A clinical follow-up and USG were done after two months. No abnormalities were detected.

DISCUSSION
Scar endometriosis is defined by the implantation or/and growth of endometrial tissue post-surgically at the incision site. It is a very rare entity. It affects 10-15% of fertile females; the most common age group is 25-35 years. 5 Caesarean section delivery is a very common cause. It can be rarely seen following an appendectomy, episiotomy, laparoscopic procedures, and inguinal herniorrhaphy. 6 The frequency of scar endometriosis is increasing these days because of the increase in caesarean section rates.
Various theories are postulated to explain the pathogenesis of endometriosis; however, the most accepted theory is the direct mechanical implantation of endometrial tissue on the scar site. Endometrial tissue directly implants into the caesarean section site and proliferates under the effect of estrogen. The strongest risk factor for the development of scar endometriosis is early hysterectomy like for hysterectomies for abortion. 7 The endometrial tissue may reach the surgical scar through lymphatic or vascular routes, thereby giving rise to scar endometriosis.
The diagnosis of scar endometriosis may be very challenging. Various differential diagnoses which may mimic the similar presentation include desmoid tumor, suture granuloma, fat necrosis, fibrosis, nodular fasciitis, ventral and incisional and hernias, hematomas, abscesses, and primary or metastatic malignancies. Cyclical changes in the severity of pain and size of endometrial implants during menstruation are classically seen in endometriosis. The patient usually complains of pain on palpation and an elevated unsightly hypertrophied scar or lump. However, in the largest reported series to date, only 20% of patients had these symptoms. 8 Various studies showed that time interval between surgery and onset of clinical features varied between 3 months to10 years, Biswas et al. reported clinical presentation after 5 years following caesarean section (LSCS). 9 Celik et al reported a case with a 2 year's time interval. 10 There are various methods for diagnosis of scar endometriosis such as ultrasonography, computed tomography, and magnetic resonance imaging. Imaging procedures help rather than confirm in obtaining an aforesaid differential diagnosis. The role of doppler sonography and fine-needle aspiration cytology (FNAC) is not much clear in the diagnosis of scar endometriosis. 11 Histopathological examination is the investigation of choice for the diagnosis of scar endometriosis. It is diagnosed by the presence of endometrial glands, stroma, and hemosiderin pigment. In our case, clinical presentation and radiological features were suggestive of the diagnosis of caesarean scar endometriosis which was further confirmed by histopathological examination.
Therapeutic management mainly includes surgical excision with clear margins along with reconstruction of damaged tissue. Medical treatment involving hormone suppression has been suggested to relieve clinical symptoms but, according to Al-Jabri, it only gives partial relief, and recurrence after the cessation of medication is constant. 12 Recurrence rates following surgery are variable but they are usually low.
No recurrence was reported by Uc ¸ar et al. for a followup period ranging from 12 to 60 months. 13