To evaluate the association between cesarean scar nice (CSN) and pelvic pain.
Design:
We performed a systematic review and meta-analysis. A comprehensive strategy was used to search MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and clinicaltrials.gov.
Setting:
PROSPERO registration was obtained (CRD42022346443).
Patients or Participants:
We included published manuscripts of randomized controlled trials, prospective and retrospective cohorts, and case series. Inclusion criteria was limited to studies including symptomatic patients with a radiologic diagnosis of a CSN, and those which evaluated pain as an outcome. Risk of bias was assessed with the Robins-I tool.
Interventions:
The primary outcome was prevalence of pelvic pain in patients with confirmed CSN. Other outcomes included the risk of pain in patients with CSN compared those without, and changes in pain symptoms following medical or surgical management of niche.
Measurements and Main Results:
Forty-seven studies reported on pain (dysmenorrhea, dyspareunia, chronic pelvic pain (CPP), suprapubic pain (SPP)) in patients with CSN. Patients with a CSN were at increased risk of dysmenorrhea (RR 2.25, 95%CI 0.90-5.62), dyspareunia (RR 2.05 95%CI 1.42-2.99), and CPP (2.72, 95%CI 1.63-4.54) compared to those without. In symptomatic patients with a confirmed niche, the prevalence of dysmenorrhea was 35.4% (95%CI 31.0-56.5); dyspareunia 20.1% (95%CI 14.3-48.7); CPP 20.2% (95%CI 15.9-36.2) and SPP 33.5% (95%CI 14.4-58.0). Both medical and surgical treatment of CSN were associated with a significant decrease in pain (OR 0.11, 95%CI 0.06-0.22, 17 studies, 999 patients, I2=83.0%). Most studies were high risk for measurement bias due to lack of standardization for outcome measures.
Conclusion:
There is a strong association between uterine niche and various pelvic pain symptoms. Providers should have a low threshold to assess for CSN in patients with a history of otherwise unexplained pain arising after cesarean delivery, and treatment should be strongly considered. Future studies require standardization of nomenclature and reporting for pain in this context.