Reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar

AIM:To highlight sonographic and clinical characteristics of scar endometrioma with special emphasis on size-related features.METHODS:Thirty women(mean age 30.6 years,range 20-42 years)with 33 scar endometriomas(mean diameter 27.1 mm,range 7-60 mm)were consecutively studied by Sonography and Color Doppler examination prior to surgery.Pathological examination was available in all cases.RESULTS:The most frequent(24 of 33 nodules,74%) sonographic B-mode aspect of endometrioma was that of an inhomogenously hypoechoic roundish nodule with fibrotic changes(in the form of hyperechoic spots or strands),a peripheral inflammatory hyperechoic ring,spiculated margins and a single vascular pedicle entering the mass at the periphery.On average,1.6 cesarean sections were recorded per patient(range 1-3).The median interval between the last cesarean section and admission to hospital was 36 mo(range 12-120 mo) and the median duration of symptoms before admission was 25.7 mo(range 0.5-80 mo).13 patients had 13 large endometriomas(≥30 mm)with a mean lesion diameter of 41.3±9.02 mm(range 30-60 mm).Seventeen women had 20 small endometriomas with a mean lesion size of 18.2±5.17 mm(range 7-26 mm).The mean interval between the last cesarean section and admission to hospital(66.0 mo vs 39.6 mo,P<0.01) and the mean duration of symptoms before admission(43.0 mo vs 17.4 mo,P<0.01)were significantly longer in patients with large endometriomas;in addition,a statistically significant higher percentage of patients with large implants had undergone previous inconclusive diagnostic examinations,including either computed tomography/magnetic resonance imaging/fine needle biopsy/laparoscopy(38.4%vs 0%,P<0.05).On sonography,large endometriomas showed frequent cystic portions and fistulous tracts(P<0.02),loss of round/oval shape(P<0.04)along with increased vascularity(P <0.04).CONCLUSION:Endometrioma near cesarean section scar is an often neglected disease,but knowledge of its clinical and sonographic findings may prevent a delay in diagnosis that typically occurs in patients with larger(≥ 3 cm)endometriomas.