Advances in the treatment of post-cesarean hysterectomy diverticulum
1.What is post cesarean section diverticulum (PCSD)?
PCSD was first reported by Spanish scholars in 1955, and in recent years, with the increase of cesarean delivery rate in China, the number of patients with abnormal menstruation after cesarean delivery has increased. The accumulation of menstrual blood in the depression leads to prolonged menstruation, vaginal bleeding between periods, and even infertility and dysmenorrhea.
2. The exact cause is not known. Possible causes are.
(1) The structure of the cervical and uterine body muscle tissues are different, the upper edge of the incision is short and thick, the lower edge is thin and long, the incision is easily poorly aligned, in addition the incision is located close to or on the cervix with less blood flow.
(2) Infection factors, which affect the normal repair of the cesarean incision and the formation of diverticula.
(3) Ectopic endometrium at the uterine incision.
(4) Posteriorly tilted and retroflexed uterus.
(5) PCSD is related to the number of cesarean deliveries, and the incidence increases with the increase of the number of cesarean deliveries.
3.What are the clinical manifestations of PCDS?
The main manifestations are abnormal vaginal bleeding, such as prolonged menstruation, intermenstrual bleeding, infertility, dysmenorrhea, etc. If diverticular pregnancy occurs, it can lead to uterine rupture and hemorrhage.
Possible causes of prolonged menstruation.
(1) Decreased thickness or even absence of myometrium at the diverticulum and poor contraction at the diverticulum site after cyclic shedding of the endometrium.
(2) After cyclic shedding of the endometrium, the diverticular wound is an incisional scar with poor blood flow and prolonged wound repair time.
(3) The endometrium inside the diverticulum is not shed synchronously with the endometrium of the uterine cavity.
(4) The passage between diverticulum and uterine cavity is narrow, resulting in poor or delayed discharge of intra-diverticular membranes through the uterine cavity.
(5) The accumulation of blood and fluid in the diverticulum is easy to be complicated by infection and bleeding.
Causes of combined infertility and dysmenorrhea in patients: It may be related to the accumulation of menstrual blood in the uterine cavity and uterine incision diverticulum, causing chronic inflammation and deterioration of the uterine environment.
4. How is PCSD diagnosed?
PCSD can be diagnosed by vaginal ultrasound, hysterosalpingogram, hysteroscopy, MRI, etc. Vaginal ultrasound and hysteroscopy are commonly used in clinical practice.
The diagnosis is based on the following.
(1) History of lower uterine cesarean section.
(2) Prolonged menstruation and dripping menstruation, excluding other diseases such as gonorrhea, endometrial polyps, gynecological tumors, etc.
(3) Vaginal ultrasound: Ultrasound shows one or several wedge-shaped or cystic axillary dark areas at the anterior wall incision of the lower uterine segment that are connected to the uterine cavity, where the thickness of the myometrium is reduced, usually 2-4 mm thick at the thinnest point.
(4) Hysteroscopy: The diagnosis can be confirmed by the formation of a “live flap” of fibrous tissue at the lower edge of the incision in the anterior wall of the lower uterine segment and in most cases the presence of old blood in the depression.
(5) Hysterosalpingogram: diverticular niche in the anterior wall of the lower uterus is diagnostic.
(6) MRI: MRI has more advantages in showing soft tissues, but it is expensive. Patients with abnormal menstrual symptoms but undiagnosed by vaginal ultrasound can be considered for MRI examination.
5.How is PCSD treated?
There is no uniform standard for the management of this disease. The treatment methods currently used are hormonal therapy, transvaginal surgery, hysteroscopic surgery, open or laparoscopic surgery.
(1) Hormonal therapy.
Possible mechanism: Hormones have a procoagulant effect and can increase the integrity of the endothelium of the blood vessels, causing the endothelial tissue in the diverticulum to develop and shed simultaneously with the endothelium of the uterine cavity.
At present, all small samples of oral contraceptives have been studied, some studies suggest that they are effective, while others suggest that there is no relief of menstruation after using them.
(2) Transvaginal surgery: has the advantage of being minimally invasive, but care should be taken to adequately push the bladder open during surgery to prevent the possibility of bladder injury. The current study sample is small and the efficacy needs to be further evaluated.
(3) Hysteroscopic surgery: The hysteroscope is used to electrically incise the scar tissue at the lower edge of the incision and electrocoagulate the diverticular wound. Intraoperative hysteroscopic surgery should be performed with care and time control to prevent complications such as uterine perforation, bladder injury and water intoxication.
(4) Laparoscopic surgical treatment: it can suture the anterior wall of the uterus, reduce the stimulation of the pelvic and abdominal cavities on the trauma surface, reduce pelvic and abdominal adhesions, and have fast recovery after surgery. There are good prospects for development.
(5) Open surgery: the incisional scar is excised and the uterine incision is re-sutured in the open abdomen.
6.How to prevent PCSD?
Uterine suture method is the decisive factor affecting the repair of uterine incision scar. Doctors should pay attention to the selection of cesarean incision, improve the suture technique, pay attention to the spacing and tightness of suture, and try to make the incision well aligned to reduce the incidence of PCSD.