Ultrasound images printed on thermal paper

Caesarean Scar Niche Repair

A caesarean scar niche (also called an isthmocele) is a fluid-filled or pouch-like defect in the uterine lining at the site of a previous caesarean section scar. Many niches cause no symptoms and do not need treatment. When symptoms occur, surgical repair can be an effective option.

When might repair be considered?

Symptoms that may be linked to a niche include:

  • Post-menstrual spotting or brown discharge for several days after a period
  • Prolonged or irregular uterine bleeding
  • Pelvic pain or dyspareunia (pain with intercourse)
  • Subfertility or difficulty conceiving, when other causes have been considered

Diagnosis is usually made with transvaginal ultrasound; sometimes saline infusion sonography (SIS) or MRI helps define the defect. I will interpret imaging in the context of your symptoms and discuss whether surgery is likely to help, or whether other treatments are more appropriate.

Surgical approaches

There is no single operation that suits everyone. Depending on the depth and width of the niche, the thickness of the uterine muscle below the scar, and your fertility plans, options may include:

  • Hysteroscopic niche resection — the niche is opened and trimmed from inside the uterine cavity, without abdominal incisions. Often used when the residual myometrium is thick enough to do this safely.
  • Laparoscopic (or robotic-assisted) repair — the scar is exposed from the abdomen and the defect is repaired in layers, sometimes with removal of thin scar tissue. This may be preferred when the wall of the uterus at the scar is very thin or when hysteroscopic treatment is not advised.
  • Combined hysteroscopic and laparoscopic steps in selected cases.

If you are planning future pregnancies, the choice of technique and timing of conception after repair are important — we discuss uterine rupture risk and delivery planning (often caesarean section) based on current evidence and your individual anatomy.

Recovery

Recovery depends on the procedure:

  • After hysteroscopic repair, many people return to usual activities within a few days, with light bleeding or discharge for a short time.
  • After laparoscopic repair, expect 1–2 weeks for light activities and 4–6 weeks before strenuous exercise, similar to other laparoscopic gynaecological surgery.

Read more in my Surgical Recovery Toolkit.

Dr Sam Holford

After a caesarean section

If your periods changed after a C-section, or you have persistent spotting or pain, a scar niche might be part of the picture — but not always. I can help you make sense of imaging and whether repair is right for you.

Book an appointment

FAQs

What is a caesarean scar niche?
A niche (sometimes called an isthmocele) is a small defect or “dip” in the uterine lining at the site of a previous caesarean scar. It can trap blood or fluid and may contribute to symptoms. Not everyone with a niche has problems — many are found incidentally and need no treatment.
What symptoms can a caesarean scar niche cause?
Possible symptoms include irregular bleeding or spotting (often after a period), prolonged light bleeding, pelvic pain, pain with sex, or difficulty conceiving. Symptoms overlap with other conditions, so assessment usually includes history, examination, and imaging such as ultrasound.
How is caesarean scar niche repair performed?
The approach depends on the size and shape of the niche, your symptoms, and whether you want future pregnancies. Options may include hysteroscopic resection (through the cervix, without abdominal cuts), laparoscopic (keyhole) repair, or a combined technique. I will recommend an approach that matches your anatomy and goals after a full discussion.
What is recovery like after niche repair?
Recovery varies with the technique. Hysteroscopic procedures often have very quick recovery (a few days). Laparoscopic repair involves small abdominal incisions and usually needs a few weeks before heavy exercise, similar to other keyhole gynaecological surgery. You will get tailored advice for your procedure.

Please note: This information is general in nature and not a substitute for medical advice tailored to your specific situation.