Open Journal of Obstetrics and Gynecology, 2012, 2, 244-246 OJOG Published Online September 2012 (
Cesarean scar abscess: A case repor t and a review of
the literature*
Takako Taguchi1, Seiji Mabuchi1#, Toshio Kimura2, Tadashi Kimura1
1Department of Ob s tetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
2Department of Gynecology, Ashiya Municipal Hospi t a l , Ashiya, Japan
Received 4 May 2012; revised 8 June 2012; accepted 20 June 2012
Cesarean section and the resultant Cesarean scar are
known to be associated with obstetric complications
in subsequent pregnancies. Cesarean scar is also as-
sociated with gynecological conditions that can ad-
versely affect the patient’s quality of life. We describe
a very rare case of Cesarean scar abscess that deve-
loped 8 years after a Cesarean delivery, which was
managed by emergency hysterectomy.
Keywords: Cesarean Section; Cesarean Scar Dehiscence;
The increasing rates of Cesarean section and its compli-
cations are global issues in developed countries. Cesa-
rean section and the resultant Cesarean scar in the lower
uterine segment are known to be associated with obstet-
ric complications in subsequent pregnancies, such as
uterine rupture; Cesarean scar pregnancy (CSP); placenta
previa; and placenta accreta, increta, or percreta. Cesar-
ean scars are also associated with gynecological condi-
tions that can ad versely affect the patient’s quality of life,
e.g., abnormal uterine bleeding, chronic pain, or secon-
dary infertility [1].
We herein describe a very rare case of Cesarean scar
abscess that developed 8 years after a Cesarean delivery,
which was m a naged by emergency hysterectomy.
A 44-year-old Japanese woman (gravida 1, para 1) visited
our hospital complaining of abdominal pain that had
lasted for 2 weeks accompanied by uterine bleeding. Her
obstetric history included a lower uterine segment trans-
verse Cesarean section 8 years earlier. Her medical his-
tory was unremarkable. Physical examinations including
pelvic examination revealed a body temperature of 39˚C,
marked bloody cervical discharge with an odious smell,
cervical motion tenderness, and lower abdominal ten-
derness, but no rebound tenderness. Transvaginal ultra-
sonography showed a normal-sized uterus with an 8 × 7
cm spherical mass in the lower uterine segment, which
was located on the scar cau sed by the previous Cesarean
section. The inner part of the mass was irregular (both
hyperechogenic and anechogenic). Both ovaries were
normal, and there was no intraperitoneal fluid. Labora-
tory tests revealed an elevated white blood cell count
(12,120/mm3), an elevated C-reactive protein level (14.9
mg/dl), and a negative pregnancy test result. She was
admitted, and initial treatment with antibiotics was per-
formed on the same day. A subsequent pelvic magnetic
resonance imaging (MRI) examination revealed an 11 ×
10 × 9 cm exophytic tumor in the lower uterine segment.
Both transvaginal ultrasonography and pelvic MRI sug-
gested that the tumor was connected to the uterine cavity
through a small defect in the lower anterior wall of the
uterus, which might have been a Cesarean scar defect. A
diagnosis of Cesarean scar abscess was suspected. As her
infectious symptoms progressed and she did not want to
preserve her fertility, we offered her abdominal hyste-
rectomy. Exploratory laparotomy revealed a 12 × 10 × 10
cm elastic mass arising from the lower anterior uterine
wall, which was adherent to the right pelvic sidewall, and
total abdominal hysterectomy was performed (Figure 1).
Grossly, the mass contained bloody purulent discharge
and was connected to the uterine cavity by a thin piece of
tissue. A pathological examination showed a bundle-like
mass of muscle tissue without any findings of degene-
rated leiomyoma. The cavity of the tumor and the tissue
connecting it to th e uterus were lined with colu mnar cells
resembling those found in the endocervical epithelium.
Culturing of the abscess contents produced Enterobacter
cloacae. The diagnosis of Cesarean scar abscess was
confirmed. The patient received intravenous antibiotics
for 2 days after the surgery and was discharged.
*Conflicts of Interest Statement: The authors declare that no conflicts
of interest exist.
#Corresponding author.
T. Taguchi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 244-246 245
Figure 1. Photographs of Cesarean scar abscess. (A) A photo
taken from the back of the uterus; (B) A photo taken from the
left side of the uterus.
Cesarean scar abscess, a rare late complication of Cesa-
rean section, is caused by infection of the “diverticulum”
at the site of the Cesarean scar. Its precise incidence is
unknown; however, to the best of our knowledge, only
two cases have been reported in the English literature
[2,3] (Table 1). The following mechanisms have been
reported to lead to the formation of Cesarean scar ab-
scesses: The formation of scar dehiscence, a myometrial
discontinuity at the site of a previous Cesarean scar, is
caused by unknown mechanisms. A lack of coordinated
muscular contractions around Cesarean scar dehiscence
allows the accumulation of menstrual debris and diver-
ticulum formation. The accumulation of menstrual blood
in the diverticulum can result in intermittent bleeding
and/or abdominal pain and can also promote infection
In previous reports, abnormal uterine bleeding and
lower abdominal pain were observed in 82% [4] and
46.3% [5] of women with Cesarean scar dehiscence, re-
spectively. Moreover, recent reports have demonstrated a
clear association between scar dehiscence and secondary
infertility. According to a report by Gubbini et al., se-
condary infertility was ob s erved in 35% of women with a
history of irregular bleeding associated with a Cesarean
scar defect [6]. It is hypothesized that the persistence of
menstrual blood in the cervix negatively influences mu-
cus quality, obstructs sperm transport through the cervi-
cal canal, affects sperm quality, and/or interferes with
embryo implantation. Collectively, these reports suggest
that a significant number of patients with scar dehiscence
suffer symptomatic complications that require treatment.
Since there are no treatment guidelines based on a
good level of evidence, the treatment for Cesarean scar
dehiscence should be chosen on an individual basis de-
pending on the presence of clinical symptoms and
whether the patient wishes to preserve their fertility.
In recent transvaginal ultrasound studies, Cesarean scar
dehiscence was observed in 57.5% - 100% of women
with a history of Cesarean section [7], which is a much
higher rate than the incidence of CSP or uterine rupture,
the most catastrophic complications of Cesarean section.
Therefore, a policy of routine surgical management
would not be cost effective, and hence, difficult to justify.
However, as recent reports have suggested that surgical
reconstruction of Cesarean scar dehiscence might resolve
the patient’s clinical symptoms and restore their fertility,
surgical treatment might be beneficial and should be
considered in symptomatic cases. So far, many surgical
techniques have been proposed to correct Cesarean scar
dehiscence. Of these, wedge excision of the Cesarean
scar dehiscence either by laparotomy or laparoscopy [8]
and a resectoscopic treatment called “isthmoplasty” were
reported to be successful [1]. As wedge excision of a
Cesarean scar can result in postoperative adhesion, which
might affect the patient’s fertility, a hysteroscopic app-
roach might be the first-choice treatment for patients
who wish to preserve their fertility. In cases involving
patients who do not want to preserve their fertility or
cases involving a large diverticulum, hysterectomy
mig ht b e the optimal treatment. As shown in Table 1, as
Table 1. Summary of the reported cases of Cesarean scar abscess.
Author [Ref] Diaz-Garcia, et al. [2] Ou, et al. [3] Present case
Age 36 41 44
Number of C/S 1 2 1
Time after C/S (year) 6 More than 3 8
Symptoms Fever, abdominal pain Fever, abdominal pain, AUB Fever, abdominal pain, AUB
Size of abscess (cm) 2.4 × 3 × 1.9 9 × 6 × 5 12 × 10 × 10
Treatment Antibiotics followed b y l a p a r o s copic
and hysteroscopic reconstruction Antibiotics followed b y t o t a l
abdominal hysterectomy Antibiotics followed b y t o t a l
abdominal hysterectomy
AUB: abnormal uterine bleeding; Ref: ref erence n umber; C/S: C esarean s ection.
Copyright © 2012 SciRes. OPEN ACCESS
T. Taguchi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 244-246
conservative medical treatments using antibiotics failed
in all three reported cases, prompt surgical treatment is
recommended for Cesarean scar abscess.
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