Presentation
Irregular menstrual cycle and abdominal pain. History of the removal of a left adnexal endometrioma 5 years ago. History of multiple cesarean deliveries.
Patient Data
Bulky uterus with a markedly thickened junctional zone measuring up to 28 mm and multiple myometrial cysts, suggesting uterine adenomyosis.
Multiple intramural uterine masses display low signals on both T1 and T2 images, with mild enhancement on the post-contrast study and free on ADC. One anterior uterine wall mass displays a high T1 signal suggesting hemorrhagic transformation. This picture is suggestive of multiple intramural fibroids with one of them showing hemorrhage and red degeneration.
Multilocular left adnexal cystic lesion with multiple thin septations seen entangling the normal ovary in between. The cyst displays a low signal on T1, a high signal on T2, no enhancement of the walls or septae on the postcontrast study, no soft tissue component, no papillary projections, and free on ADC. Note the gonadal vessels passing within/closely related to the cyst to supply the ovary. This picture is suggestive of peritoneal inclusion cyst with the possibility of associated deep pelvic endometriosis.
Anterior abdominal wall mass seen adherent to the left rectus abdominus muscle at the site of the cesarean scar ,it display low signal on T1 and T2 images with homogenous enhancement on the postcontrast study suggesting anterior abdominal wall endometriosis.
Case Discussion
Endometriosis is one of the known complications of cesarean delivery. Endometriosis may affect the ovary causing endometriomas, the uterus causing adenomyosis, deep pelvic regions, and the anterior abdominal wall at the site of cesarean scar.
Deep pelvic endometriosis is always associated with pelvic adhesions which may complicate with inclusion cyst like this case.
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