Isthmocele, also known as cesarean scar defect, is an increasingly recognized complication of cesarean delivery, often associated with abnormal uterine bleeding, pelvic pain, and secondary infertility. This narrative review aims to provide a comprehensive overview of the condition, including its pathogenesis, risk factors, diagnostic methods, and current treatment options. The most significant risk factor for isthmocele formation is the number of previous cesarean sections, although other contributing elements include surgical technique, uterine position, and individual wound-healing capacity. Transvaginal ultrasound is the first-line imaging modality, while magnetic resonance imaging may provide enhanced visualization in selected cases. Management depends on the severity of symptoms, residual myometrial thickness, and reproductive goals. Treatment options range from conservative medical therapy to surgical interventions via hysteroscopic, vaginal, or laparoscopic approaches. Surgical correction is particularly indicated in symptomatic women with reproductive desire and thin residual myometrium. The choice of technique should be individualized on the basis of the characteristics of the defect, the presence of coexisting pathologies, and surgical expertise. Preventive strategies focus on optimal cesarean technique, with emerging evidence supporting the importance of suture method and postoperative ultrasound monitoring. Despite increasing awareness, standardized guidelines for diagnosis and treatment are lacking. A tailored approach remains essential, considering both clinical and anatomical variables. This review summarizes the current knowledge on isthmocele and highlights the need for further research to establish evidence-based protocols for diagnosis, prevention, and treatment.
Keywords: Cesarean; Hysteroscopy; Infertility; Isthmocele; Laparoscopy; Scar; Transvaginal.
An isthmocele, also referred to as a cesarean scar defect, is a small pouch or indentation that can develop in the uterine wall after a cesarean section. While many individuals with isthmocele do not experience symptoms, others may present with abnormal uterine bleeding, pelvic pain, or difficulties conceiving. The condition is increasingly recognized as a result of the rising global rate of cesarean deliveries and improved imaging techniques. Diagnosis is typically made using transvaginal ultrasound, which provides a detailed view of the uterine scar, although more advanced imaging such as saline infusion sonohysterography or magnetic resonance imaging (MRI) may be used in complex cases. Treatment decisions depend on several factors, including the severity of symptoms, the thickness of the remaining uterine wall, and the desire of future pregnancies. Options range from hormonal therapies to surgical interventions, such as hysteroscopic resection for small defects or laparoscopic and transvaginal repairs for more extensive cases. This article provides an overview of the condition, from how it forms to how it is diagnosed and treated. By improving awareness and understanding of isthmocele, this review supports informed decision-making and underscores the importance of individualized care. It also highlights the need for future research to develop standardized guidelines for diagnosis and treatment.
© 2025. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.