A 29-year-old had previously undergone two caesarean sections, the second five months previously at a district general hospital. The operation and immediate postoperative period were uneventful. Three months later she noticed a purulent discharge from her wound. She was advised to take antibiotics and to dress the wound daily but despite this the discharge continued and she presented to us.
She gave a history of primary infertility of 6 years, for which she was never evaluated. On examination her vital signs were within normal limits. Abdominal examination revealed a pus-draining sinus through the Pfannenstiel scar (Fig. 1). As per speculum examination there was mucoid discharge; per vaginally, the uterus was anteverted to 6-8-week size, with restricted mobility and appeared adherent anteriorly.
Her haemoglobin was 102 g/l. Other haematological investigations were within normal limits. A cartilage-based nucleic acid amplification test (CBNAAT) of a sample of the wound discharge for diagnosis of tuberculosis, was negative. Transabdominal ultrasonography was suggestive of a pelvic fluid collection with a sinus tract. On fistulogram, the contrast opacified as a blind-ending cavity measuring 8 x 2 cm, with an irregular outline and evidence of contrast in the pelvic cavity adjacent to gut loops. Magnetic resonance imaging revealed a peripherally enhancing collection in the abdominal wall communicating with the uterus and the exterior through the abdominal wall.
Laparotomy for excision of the fistulous tract was arranged. Intraoperatively, on excising the scar we found two fistulous tracts with granulation tissue around them. The first tract connected the skin to the uterine cavity, with necrosis of the anterior uterine wall. The second tract commenced in the skin and ended at another point on the skin. The patient gave informed consent for excision of the fistulous tracts and/or total abdominal hysterectomy. However, it was deemed that there was no scope for excision and to avoid the risk of sepsis the decision was made for a total abdominal hysterectomy. Both ovaries were normal. On gross examination, there was evidence of granulation tissue in the endometrial cavity and necrosis in the anterior uterine wall (Fig. 2). A specimen was sent for histopathological examination.
The postoperative period was uneventful. The histopathological examination revealed granulomatous inflammation suggestive of tuberculosis. She responded well to anti-tubercular therapy.
The patient for discharged on the 10th postoperative day on anti-tubercular drugs. She presented for follow-up after 6 weeks with a well healed scar.