Case History/Examination:

A 27-year-old woman presented with a history of pain and pinpoint cyclical bleeding at her cesarean scar during menstruation for 2 years. The dull ache worsened during menstruation. Her menstrual cycle was regular, occurring every 30 ± 2 days, with a flow of 5-6 days and associated dysmenorrhea, but no clots. Her last menstrual period was on January 6, 2024. Clinical examination showed normal vital signs. Per-abdominal examination revealed a non-mobile, hyperpigmented mass approximately 3×2 cm in size protruding from the left corner of the Pfannenstiel incision scar, tender upon palpation. A 5-cm indurated area surrounding the scar appeared healthy with no lumps. Methods: Differential diagnoses included surgical scar endometriosis, abscess, and complicated surgical scar hernia.The patient’s medical history included two cesarean sections via a Pfannenstiel incision. The first was performed 6 years ago due to cephalopelvic disproportion, and the second was done 2 years ago. Both pregnancies were uneventful, but she developed a surgical site infection (SSI) after the second procedure and received outpatient treatment at our center due to her refusal of hospital admission. Three months after her second delivery, she began experiencing bleeding from her cesarean scar site during menstruation, along with lower abdominal and back pain. An ultrasonography (USG) of the abdomen and pelvis was performed, showing an irregular heterogeneous lesion measuring approximately 0.8 cm × 0.71 cm with predominantly hypoechoic echotexture and scattered hyperechoic echoes internally, located within the previous LSCS scar, suggestive of scar endometriosis. With a provisional diagnosis of scar endometriosis, she was prescribed medical management with Paracetamol 500 mg and Norethisterone 5 mg for 2.5 months. The patient then underwent surgical excision of the scar endometriosis under spinal anesthesia. An elliptical incision was made around the scar tissue, and the endometrial tissue was excised with clear margins. On gross examination, the specimen consisted of a single piece of skin and hair-attached tissue, light brown to dark brown in color, firm in consistency, and measuring 3.5 × 1.8 cm. A specimen of subcutaneous tissue was sent for histopathological examination, which revealed endometrial glands lined by columnar cells within the dermis, surrounded by stroma(Fig 1). The adjacent area showed variable-sized blood vessels with hemorrhages and mixed inflammatory cells(Fig 2). No cellular atypia or granulomas were observed. The patient’s follow-up was uneventful. She reported significant improvement in symptoms with no recurrence of pain or bleeding at the scar site.