What is it?
An isthmocele is a defect in the anterior wall of the uterine isthmus, a sac-like dilation of the muscular wall of the uterus communicating with with the uterine cavity, which arises at the site of a previous cesarean section.
It is caused by a defect in post-cesarean scarring, and the most common risk factors are both surgical (localization of the uterine scar, discrepancy in the thickness of the suture margins, cesarean section conducted in labor with a cervical dilatation >5 cm, appearance of adhesions between the uterus and the anterior abdominal wall), and patient-related (presence of retroflexed uterus, multiple cesarean sections).
It is specific for approximately 25-30% of women who have had one or more cesarean sections.
Which are the symptoms?
It is usually asymptomatic and is diagnosed on occasion during a gynecologic ultrasound scan.
When symptomatic, the typical symptom is abnormal uterine bleeding in the postmenstrual phase, due to the reservoir effect: blood accumulates in the sac during menstruation and is then released slowly, taking on a dark red coloration. There may also be chronic pelvic pain, pain during the menstrual cycle (dysmenorrhea) and secondary infertility due to blood stagnation that can interfere with the quality of cervical mucus and spermatozoids, and with embryo implantation. In pregnancy, the main complications related to the presence of an isthmus are placental abnormalities (placenta previa, placenta accreta), abnormalities of the site of pregnancy (cervical pregnancy or scar pregnancy), dehiscence of the uterine scar and, in very rare cases, rupture of the uterus both during and at the end of pregnancy.
- abnormal uterine bleeding
- pelvic pain
- secondary infertility
- abnormalities in placentation: placenta previa, placenta accreta
- ectopic cervical pregnancy (scar pregnacy)
- rupture of the uterus in case of pregnancy
- suture dehiscence
How is it diagnosed?
Transvaginal ultrasonography represents the first level diagnostic test in the diagnosis of isthmocele and guarantees the surgeon the possibility to adequately plan the intervention. It allows a good characterization of the pathology because it helps to evaluate the site, size of the defect and the thickness of the residual myometrium at the level of the scar: this last parameter allows to define the histmocele of mild (<2.5 mm) or severe (>2.5 mm) degree. Second level diagnostic investigations used in the study of the isthmocele are sonohysterography (which allows to better investigate the morphology of the uterine cavity and of the isthmocele through the infusion of ultrasound contrast media in the cavity), hysterosalpingography and diagnostic hysteroscopy. On rare occasions, it is necessary to use other diagnostic techniques, such as MRI or CT.
How is it treated?
Treatment of the isthmocele should be agreed upon based on a number of characteristics, such as the symptoms present, the size of the defect, and the patient's desire to become pregnant. The ultrasonographic finding of an isthmocele in an asymptomatic woman not desiring offspring does not indicate any therapy. In the case of a symptomatic patient, not desirous of offspring and with a mild defect, it is appropriate to propose a medical estro-progestin or progestin therapy (also by means of intrauterine device), possibly in continuous regimen, in order to reduce or stop the menstrual flow. In case of failure of medical therapy, these patients can be proposed an operative hysteroscopy that aims to eliminate the margins of the defect, and, when they are realigned with the surrounding healthy tissue, the continuity of the cervical canal is regained and the correct passage of menstrual flow is restored. On the contrary, in the case of women in search of offspring or in the presence of a severe defect, it is appropriate to propose to the patient a surgical treatment that aims at the definitive correction of the defect through the excision of the present scar tissue and the packaging of a new uterine suture. This type of surgery allows for the use of two different surgical approaches: a vaginal approach, faster and with better postoperative recovery, and a laparoscopic approach. Our center is specialized in the vaginal surgical approach and, thanks to the presence of surgeons who perform this procedure routinely and with high experience in the field of vaginal surgery, excellent postoperative and reproductive results have been obtained.
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