Presentation
The patient was hospitalized due to a urinary tract infection. On physical examination, a lump was palpated in the right lower abdomen area around the Cesarian section scar. The lump was firm and tender to palpation. The patient was referred for an abdominal wall ultrasound for its further evaluation.
Patient Data
Lower abdomen ultrasound shows a well-defined round hypoechogenic mass with blood flow on Doppler. The mass is located in the patient's right abdomen wall muscles.
The typical mass location in the area of the Cesarian scar raised the possibility of endometriosis. Fibromatosis and other soft tissue tumors were included in the differential diagnosis.
Abdominal CT scan shows a lobulated mass within the lower part of the right rectus abdominis muscle. The mass is hyperattenuating compared with muscle.
The differential diagnosis remained unchanged from the previous ultrasound examination. Endometriosis was considered the most probable diagnosis, based on the typical location in the area of the Cesarian scar. Fibromatosis and other soft tissue tumors were included in the differential diagnosis as well.
Additional findings: Multiple hypodense wedge areas in the right kidney cortex, compatible with pyelonephritis.
Case Discussion
On detailed history taking, the patient complained about recurring events of right lower abdominal lump pain that occurs during her menses. The patient underwent surgery with full mass excision. Pathology confirmed the suspected diagnosis of endometriosis.
Cesarean section scars are the most common site of abdominal wall endometriosis, with an estimated incidence of approximately 0.03%–0.4%. Abdominal wall scar endometriosis is associated with pelvic endometriosis in 14.3%–26% of patients.
Soft tissue mass in the Cesarian section scar should be considered highly suspicious for endometriosis and lead to further anamnestic and imaging evaluation.
The preferred treatment is surgical excision with clear margins to prevent local recurrence. Hormonal therapy is reserved for patients with concomitant pelvic endometriosis.
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