Many women who have had a cesarean section around them are always worried: since the cesarean section, their menstruation takes about 20 days to be clean every month, and when this month is just over, the next menstruation comes again, which seriously affects their quality of life, and their husbands have a lot of opinions about the repeated menstruation. What should I do? When encountering this kind of patients with irregular menstruation, the doctor will usually ask the patient to do a transvaginal ultrasound after consultation. At this time, the ultrasound suggests that there is an irregular liquid dark area at the lower uterine segment of the cesarean section, and there is no signal of blood flow within the area, which is considered to be the formation of uterine scar diverticulum. At this point, the patient will ask, “Doctor, what is uterine scar diverticulum? Uterine scar diverticulum, also known as post-caesarean section uterine scar defect (PCSD), is a water bag-like defect that forms at the uterine incision in the lower uterine segment after caesarean section. As the name suggests, the disease is related to cesarean section. Currently, most cesarean sections are performed with a transverse incision of the lower uterine segment, and due to the difference in contractility of the myometrium on each side of the lower uterine incision, the myometrium on the upper edge of the incision is significantly thicker than that on the lower edge of the incision, which is commonly seen in elective cesarean sections (without contractions) due to the insufficient formation of the lower segment, and is prone to a deviation from the high side of the incision. And emergency cesarean section usually into labor, the lower segment is fully formed, easy to incision is too low, the uterus is like a spring, the spring of the elective has not been fully stretched, the emergency has been stretched too much, and this difference with the number of cesarean section increases, coupled with the poor blood supply, coupled with poor suture docking or when the suture is too dense, resulting in ischemia and necrosis, with the number of cesarean section increases, uterine keloidal diverticulum incidence With the increase in the number of cesarean sections, the incidence of uterine scar diverticula increases. Of course, it may also be related to other factors such as suture materials and endometrial incision ectasia. The clinical manifestations of these patients are normal menstruation before cesarean section, normal menstrual cycle after surgery, but symptoms such as prolonged menstrual period, intermenstrual vaginal bleeding, postcoital bleeding (no contact bleeding on gynecological examination), infertility and dysmenorrhea. So how is PCSD clinically diagnosed? Cesarean section uterine scar diverticulum due to the lack of specificity of clinical manifestations, many diseases will appear in these clinical manifestations, and even 50% of patients have no obvious clinical manifestations, so the diagnosis is mainly dependent on auxiliary examination, which is the reason mentioned at the beginning of the article to let the patient do a vaginal ultrasound. Vaginal ultrasound and will be recommended to the patient in the 6th-8th day of menstruation to do (menstruation is completely clean after the diverticulum may disappear, like a bag of water inside the pouring out of the water, will be deflated, ultrasound there is no way to see it), vaginal ultrasonography shows: the uterus sagittal plane is the best display of uterine incision of diverticulum because of the lower uterine section of the incision at the mucous layer of the lack of flat, the myometrial layer of the echoes of some or all of the defects, the place to see the The irregular liquid dark area is connected to the uterine cavity, and the closest diverticulum to the mucosal layer can be distinguished as 2 mm. Because it is simple, noninvasive, and inexpensive, it is used as the first choice for screening for uterine scar diverticula. Hysteroscopy is now considered one of the definitive methods for diagnosing PCSD. Microscopic uterine scar diverticulum shows a band-like defect in the anterior wall incision of the uterine isthmus or the upper third of the cervical canal, the defect is usually surrounded by a ring of fibrous tissue, and dark brown mucus or blood stagnation can be seen inside; the local endometrial surface can be seen as a large number of capillary distribution, and sometimes obvious endometrial tissue growth can be seen inside the diverticulum. However, hysteroscopy also has blind spots, such as some diverticula such as round, droplet-type openings in the uterine fundus and inclusive diverticula. However, hysteroscopy cannot determine whether the myometrium is continuous at the diverticulum and the thickness of the myometrium at the thinnest part of the diverticulum. Magnetic resonance imaging (MRI): MRI shows discontinuity of the endometrium and myometrium at the diverticulum and partial or total loss of the base layer.Maria compared the thickness of the scar at the thinnest part of the diverticulum and the thickness of the uterine wall after laparoscopic repair with MRI, so that the size of the diverticulum could be measured more clearly, which is helpful for the choice of surgical method. MR hysterography has also been utilized and found that PCSD signal manifests as equal or high signal in T1WI and high signal in T2WI, and its sagittal morphology can be roughly classified into four types: shallow depression, triangle, small sac and sac pouch, but it has not yet been used as a routine examination. Having said that, how to choose it, the clinical first choice is transvaginal ultrasound, but pay attention to the time to choose in the 6-8 days of menstruation, choose three-dimensional ultrasound, because three-dimensional ultrasound can be three-dimensional observation of the diverticulum, diverticulum length, width, height, diverticulum the thinnest part of the thickness of the myocardium, and blood flow. Of course, patients are most concerned about what exactly should be treated? How to choose the treatment after a clear diagnosis is a difficult problem, there are surgical treatment and non-surgical treatment. Surgical treatment: Currently, the commonly used surgical methods are hysteroscopic surgery, laparoscopic surgery and transvaginal repair. Generally, the choice of surgery is based on the thickness of the muscle layer at the thinnest part of the diverticulum, rather than the size of the scar, and their common point is to eliminate the diverticulum. 1, surgical treatment: (1) hysteroscopic electrosurgery: hysteroscopic electrosurgery is difficult when the lower segment of the uterus is thicker, therefore, the myometrium > 3mm, the thickness of the lower segment of the uterus is less than 1cm choose hysteroscopic electrosurgery, its comparison with laparoscopic and transvaginal surgery, the operation time is shorter, the amount of blood loss is less, shorter hospital stay, less cost, it seems that it is the best surgical procedure, however, when the diverticulum at its thinnest point is 2mm, it is easy to cause perforation of the uterus Even damage to the bladder (the front of the uterus is the bladder), then hysteroscopy should not be chosen. (2) Laparoscopic surgery: when the myometrium is <2.5mm or when the scar is located higher up in the isthmus of the uterus, laparoscopy will be considered as an option, which compensates for the shortcomings of hysteroscopy, with a clear view of the operation, which can reduce the risks, shorter operation time, less intra-operative bleeding, and the symptoms of prolonged menstruation can also be improved. (3) Yin-type uterine scar repair: it is a newer type of surgery, applicable to all patients, and abdominal surgery can be removed and repaired as well. Yin-type goes in from the vagina, avoiding the second laparotomy, and the postoperative recovery is faster, and the difficulty lies in the fact that because cesarean section patients do not go through a vaginal delivery, the vagina is relatively tight, and the field of vision is already narrow, and it is also necessary to operate inside, so the difficulty is think about it. Total hysterectomy: the operation is thorough, applicable to patients without fertility, but many many patients with uterine scar diverticulum are in the reproductive age stage, the opening of the two-child policy, many patients still want to retain the reproductive function. Clinical application is less. Of course, clinically not only one surgical method, often one and more combined, specific also need to combine the patient's own situation, the thickness of the thinnest part of the diverticulum muscle layer, the location of the scar and the shape of the diverticulum to decide. After surgery, the vagina is filled with gauze for 24 hours, the incision can be healed in about 1 month, and the ultrasound is reviewed after 3 months, and the contraception is more than half a year after the surgery. 2, non-surgical treatment: (1) drug therapy: short-acting contraceptive pills can make some patients improve their symptoms, need to take more than three consecutive menstrual cycles, the role of oral contraceptives may be in its inhibition of the growth of the endometrium (endometrial cyclic shedding to form menstruation), which may reduce the cesarean section diverticulum at the menstrual blood retention. Therefore, it is only suitable for patients who need contraception and do not want surgical treatment. Herbal medicines and hemostatic drugs can improve the patient's symptoms, and these are currently only used as adjunctive treatments. (2) Mannitol (levonorgestrel birth control system): similar to the contraceptive pill, follow-up is required for at least six months, and there is not yet enough evidence to prove its effectiveness.