Abstract
Endometriosis is the presence of ectopic endometrial tissue outside the uterine cavity. Urinary tract endometriosis is rare and occurs in only about 0.3–12% of cases with the bladder being the most commonly affected organ (85%). Bladder endometriosis is a great masquerader and usually does not present with cyclical hematuria thus often delaying the diagnosis. We present such a rare case along with a review of the literature.
Keywords: Endometriosis, Bladder, Chocolate cyst
Introduction
Endometriosis is the presence of ectopic endometrial tissue outside the uterine cavity. It is seen in 5–10% of women of reproductive age group.1 The common sites are the ovaries, uterosacral ligaments, recto-vaginal septum and the posterior vaginal fornix.2 Its involvement of the urinary tract is rare, occurring in only 1–2% of cases.1 Presence of an isolated endometriotic tissue only in the urinary tract is even rarer and we present such a rare case along with review of literature.
Case report
A 45 years old para 2 female patient presented with history of dysuria of one-year duration. She gave no history of hematuria, pelvic pain or dyspareunia and her menstrual history was normal. She had taken repeated courses of antibiotics prescribed to her by various doctors over the last 1 year. Clinical examination was unremarkable. On evaluation, ultrasound of the abdomen and pelvis showed bulky uterus and irregular wall thickening at the dome of the urinary bladder (UB). Thinking of malignancy as a cause CECT abdomen and pelvis was done which showed 26 mm thickening at the left posterolateral wall of the UB and bulky uterus with 13 × 18 mm-sized fibroid. A cystoscopy was done which revealed a 2 cm bluish nodulo-cystic lesion over the dome of the UB suggestive of endometrioma. MRI Pelvis was done next which confirmed our suspicion of endometriosis of the UB by showing a 9 mm focal irregular wall thickening in the posterosuperior wall of UB and bulky uterus with 25 mm fibroid. There was no other extra uterine focus of the endometrioma. The finding of an isolated UB endometrioma prompted us to take her up for transurethral resection surgery. Preoperatively: a chocolate-colored paste-like material was seen on cutting the cystic lesions using 26 Fr continuous flow resectoscope with a medium-sized thin bipolar loop [Fig. 1, Fig. 2]. All the lesions were deroofed, the chocolate-colored cheesy material extruded, the overhanging walls resected flush with the surrounding bladder wall and then the bases were fulgurated to avoid an inadvertent bladder perforation. There was minimal bleeding during this resection which was taken care of by fulguration. The histopathology confirmed the endometriosis. Postoperatively she was put on Inj Goserelin acetate 3.6 mg subcutaneously monthly for three months and then switched to Tab Dienogest 2 mg OD for suppression of the menstruation. She has been on follow-up for more than two years and has remained asymptomatic. Patient consent for inclusion in study was also obtained.
Fig. 1.
Cystoscopic finding: Bluish nodulo-cystic lesions on the dome.
Fig. 2.
Chocolate-colored cheesy paste-like material.
Discussion
Urinary tract involvement by endometriosis is rare and is seen in only 1–2% of patients with bladder being the most common site.1 The presence of an isolated focus of endometriosis in the urinary tract alone is even rarer.
Endometriosis was first described in 19213 and the exact etiology still remains unclear. Of all the theories, the implantation or the retrograde menstruation theory is the most popular,4, 5, 6 according to which, endometriosis develops due to the seeding after retrograde menstruation through the fallopian tubes. Bladder being located in the dependent part of the anterior cul-de-sac, becomes the preferred site for implantation. which triggers an inflammatory reaction which leads to formation of adhesions between the bladder and the anterior uterine wall.7,8
Most of these patients remain asymptomatic. The rest may present with non-specific symptoms of pelvic or suprapubic pain, dysuria and frequency of micturition.9 A typical cyclical hematuria is seen in only 20–35% of patients because the bladder endometriosis rarely causes mucosal ulceration.9 40% of these symptomatic patients have an exaggeration of symptoms in the premenstrual phase.10 Our patient only had dysuria of one-year duration.
Ultrasound of the pelvis is usually the first investigation in which the location, the size of nodules and the distance between the lesion and the ureteric orifices are looked into. Combination of transabdominal, transvaginal and transrectal ultrasounds gives a good assessment of the endometriosis and their locations.9 Magnetic Resonance Imaging (Sagittal and axial T2 weighted and T1 weighted) is considered as the gold standard for diagnosis of bladder endometriosis with diagnostic accuracy of about 98%.9
Cystoscopy may be erroneously normal if the bladder endometriosis does not invade the sub-mucosa. Lesions are best seen in the pre-menstrual or menstrual phase when they are larger and more congested. They appear as irregularly shaped nodules which may be blue-black or blue-brown in color. However, at times, cystoscopy may inadvertently pick up a lesion when done for non-specific lower urinary tract symptoms as was in our case.
The choice of treatment for bladder endometriosis would depend on several factors such as the age, the patient's preference for preserving fertility, the extent of the disease, the presence of urinary symptoms and the menstrual dysfunction.9 Treatment can be medical, surgical or a combination of both. Medical treatment induces temporary disappearance of lesion, preserves fertility and is the treatment of choice in young patients. It includes agonist or antagonist of Gonadotropin Releasing Hormone (GnRH), progestins alone or combined oral contraceptives. They cause suppression of ovulation and suppresses menstruation. However, medical management is plagued by high disease recurrence rates (up to 56%) after cessation of medications.9 The patient has been on medication for the last two years with no recurrence. Complete surgical resection is the only way to prevent recurrence. The best option is partial cystectomy which can be done either through an open, laparoscopic or a robotic approach. A complete elimination of the endometriotic tissue results in significant pain relief and improved quality of life. Therefore, transurethral resection combined with medical management seems to be an ideal treatment for patients seeking childbirth in the future and peri-menopausal patients in whom the lesions would regress after menopause.9 This 45-year-old peri-menopausal female patient was chosen for transurethral resection followed by medical management and it worked out perfectly for her, with improved symptoms and quality of life.
Conclusion
Isolated bladder endometriosis is of rare occurrence. Symptoms can be non-specific and diagnosis may often be delayed. The right modality of treatment should be tailor-made to each and every patient to improve their chances of living pain-free, opting for future pregnancies and to improve their quality of life.
Patients/ Guardians/ Participants consent
Patients informed consent was obtained.
Ethical clearance
Not Applicable.
Source of support
Nil.
Disclosure of competing interest
The authors have none to declare.
Acknowledgements
None.
References
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