The incidence of isthmocele may be higher than reported



Isthmocele, Uterine niche, Postcoital bleeding, Pelvic pain


Aim: Isthmocele, a long-term complication of Cesarean section (CS) surgery, has drawn increasing worldwide interest. However, not all women with this Cesarean scar defect (CSD) present with clinical symptoms. We studied a group of non-pregnant women with a CS history to determine the prevalence of isthmocele, the potential risk factors for its development, and the most common clinical complaints.

Methods: This study included women who had a cesarean operation more than 6 months ago, who were not pregnant between January 2017 and April 2017 and applied to the gynecology clinic for any reason. The exclusion criteria were the patients in the menopause period. Data was collected on 115 participants, including age, body mass index, duration after CS, and the number of CS surgeries that had been performed. Standardized scar parameters (residual myometrial thickness (RMT) and the depth and width of the triangular hypoechoic niche) were measured using transvaginal-ultrasonography (TVS). Isthmocele symptoms were categorized as asymptomatic, postmenstrual spotting, menometrorrhagia, chronic pelvic pain, dysmenorrhea, and infertility. Associations between isthmocele and menstrual complications were investigated. The relationship between isthmocele development and the reasons for the CS surgery were evaluated. 

Results: TVS examination diagnosed 17 women (14.78%) with isthmocele. Women who had undergone recurrent CS surgeries tended to have more visible isthmocele than those with a single CS surgery. The average isthmocele depth was 6.006 ± 0.7970 mm. Among the women with isthmoceles, elective CS surgery had been performed in six (35.3%), while 11 (64.7%) had the surgery at parturition. The presence of an isthmocele was frequently symptomatic, predominantly as postmenstrual spotting. Women with an isthmocele had significantly lower RMT values (5.57 ± 0.60 mm versus 8.78 ± 0.22 mm) than those without an isthmocele. There was no correlation between age, body mass index, and the presence of an isthmocele (p > 0.05). 

Conclusions: The incidence and prevalence of CSD is greater than most gynecologists realize. Isthmoceles can develop after just one CS surgery, leading to long-term complications that morbidly effect women for the rest of their lives. A reduction in the number of CS surgeries is the most effective way to decrease the prevalence of isthmoceles.


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World Health Organization Human Reproduction Programme. WHO statement on caesarean section rates. Reprod Health Matters. 2015;23:149-50.

Sipahi S, Sasaki K, Miller CE. The minimally invasive approach to the symptomatic isthmocele - what does the literature say? A step-by-step primer on laparoscopic isthmocele - excision and repair. Curr Opin Obstet Gynecol. 2017;29(4):257-65.

Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20(5):562-72.

Morris H. Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 1995;14:16-20.

Vervoort AJ, Uittenbogaard LB, HehenkampWJ, et al. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 2015;30:2695-702.

Nezhat C, Grace L, Soliemannjad R, et al. Cesarean scar defect: what is it and how should it be treated? OBG Management. 2016;28:32-53.

Roberge S, Boutin A, Chaillet N, Moore L, Jastrow N, Demers S, et al. Systematic review of Cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect. Am J Perinatol. 2012;29:465-471.

Schepker N, Garcia-Rocha GJ, von Versen-Hoynck F, et al. Clinical diagnosis and therapy of uterine scar defects after cesarean section in non-pregnant women. Arch Gynecol Obstet. 2015;291:1417-23.

Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HA, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43:372-82.

Tulandi T, Cohen A. Emerging manifestations of Cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol. 2016;23:893-902.

Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol. 2009;34:90-7.

Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24:180-6.

Bij de Vaate AJ, Brölmann HA, van der Voet LF, van der Slikke JW, Veersema S, Huirne JA. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011;37:93-9.

Wang CB, Chiu WW, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34:85-9.

Pomorski M, Fuchs T, Zimmer M. Prediction of uterine dehiscence using ultrasonographic parameters of cesarean section scar in the nonpregnant uterus: a prospective observational study. BMC Pregnancy Childbirth. 2014;14:365.

Vikhareva Osser O, Valentin L. Clinical importance of appearance of Cesarean hysterotomy scar at transvaginal ultrasonography in nonpregnant women. Obstet Gynecol. 2011;117:525-32.

Naji O, Abdallah Y, Bij De Vaate AJ, et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol. 2012;39:252-9.

Regnard C, Nosbusch M, Fellemans C, Benali N, van Rysselberghe M, Barlow P,et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol. 2004;23:289-92.

Pomorski M, Fuchs T, Rosner-Tenerowicz A, et al. Morphology of the cesarean section scar in the non-pregnant uterus after one elective cesarean section. Ginekol. Pol 2017;88:174-9.

Fabres C, Aviles G, De La Jara C, Escalona J, Muñoz JF, Mackenna A, et al The Cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med. 2003;22:695-700.

Sasaki K. Diagnosis and treatment of uterine isthmocele. OB Gyn News. 2015;50:8-9.

Ofili-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C, Gonzalez J, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008;31:72-7.

Lin YH, Hwang JL, Seow KM. Endometrial ablation as a treatment for postmenstrual bleeding due to cesarean scar defect. Int J Gynaecol Obstet. 2010;111:88-9.

Florio P, Gubbini G, Marra E, Dores D, Nascetti D, Bruni L, et al. A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele. Gynecol Endocrinol. 2011;27:434-8.

Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical hysteroscopic treatment of Cesarean-induced isthmocele in restoring fertility: a prospective study. J Minim Invasive Gynecol. 2011;18:234-7.

Uppal T, Lanzarone V, Mongelli M. Sonographically detected caesarean section scar defects and menstrual irregularity. J Obstet Gynaecol. 2011;31:413-6.

Chen Y, Han P, Wang YJ, et al. Risk factors for incomplete healing of the uterine incision after cesarean section. Arch Gynecol Obstet. 2017;296:355-61.

van der Voet LF, Bij de Vaate AM, Veersema S, et al. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121:236-244.

Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG. 2010;117:1119-26.

Başbuğ A, Doğan O, Ellibeş Kaya A, Pulatoğlu, Ç, Çağlar M. Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial. J Invest Surg. 2018 Apr 18:1-7.






Research Article

How to Cite

Karlı P, Şahin B, Kara F. The incidence of isthmocele may be higher than reported. J Surg Med [Internet]. 2018 Sep. 1 [cited 2022 Aug. 10];2(3):283-7. Available from: