Obstructive Uropathy Secondary to Pelvic Endometriosis: A Scary Story!

Abstract

Introduction

Endometriosis presents as—1. superficial, 2. ovarian endometrioma, and 3. deep infiltrating endometriosis. Obstructive uropathy can rarely result from endometriosis, especially in premenopausal women—incidence being 0.3%–12%.

Case

A 40-year-old married, working female presented to ER with severe left-sided flank pain radiating, lump abdomen, heavy menstrual bleeding, and inability to pass urine. Physical examination revealed a large 24-week lump abdomen. Imaging studies were done with USG showing a large cystic left adnexal mass which was followed by CT urography showing hydroureteronephrosis and a large cystic mass of 10 cm compressing the urinary bladder and ureter, along with uterine adenomyosis. Emergency cystoscopy and left DJ stenting was done to relieve the obstruction which resulted in relief from flank pain. This was followed by laparoscopic hysterectomy with left salpingo-oophorectomy with right salpingectomy and adhesiolysis. Postoperative imaging showed complete resolution of ureteral obstruction and hydronephrosis. Histopathology confirmed endometriotic cyst and adenomyosis.

Discussion

Endometriosis can present with a wide spectrum of symptoms. Involvement of the urinary system in cases of endometriosis might result in compromise of renal function over time. Prompt surgical management is essential in cases of obstructive uropathy. Cases similar to ours have demonstrated the importance of prompt decompression of urinary tract by emergency DJ stenting followed by definitive surgical management of underlying endometriosis. Modern endometriosis management included the conservative laparoscopic surgery and ureterolysis followed by the resection of concomitant endometriosis and a broad-based multidisciplinary approach, centered on a patient’s symptoms and priorities.

Conclusion

This case underscores the importance of considering endometriosis as a differential diagnosis of women presenting with urological symptoms as well as the need for collaboration between urologist and gynecologist in such cases solidifying that the rapid intervention and multidisciplinary line of management is essential for optimal patient outcome.

Introduction

Endometriosis is a chronic, inflammatory, hormonal, immunological, systemic, and diverse disease which can present with three distinct phenotypes—superficial endometriosis, ovarian endometrioma, and deep infiltrating endometriosis [1]. Obstructive uropathy often leads to hydroureteronephrosis and potential renal damage if not decompressed timely. Out of many common causes such as renal calculus and abdomino-pelvic tumors, endometriosis is a relatively uncommon cause of obstructive uropathy, often involving ureters and rarely, kidneys. The incidence of endometriosis involving the urinary system ranges from 0.3% to 12% [2].

Endometriosis of the urinary tract and endometrioma are differentials to be suspected especially in cases of premenopausal women presenting with unilateral or bilateral obstructive uropathy of uncertain cause. Timely diagnosis and intervention with the help of a multidisciplinary approach help to prevent irreversible renal damage.

Case

A 40-year-old married, working female presented to emergency room with severe left-sided radiating flank pain, lump abdomen, heavy menstrual bleeding and inability to pass urine. She had one previous LSCS and suffered from type 2 diabetes mellitus, hypertension and hypothyroidism. Physical examination revealed a large 24-week lump abdomen, which was cystic in consistency with tenderness. Imaging studies by USG revealed a large cystic left adnexal mass which was followed by CT urography showing hydroureteronephrosis and a large cystic mass of 10 cm compressing the urinary bladder and ureter, along with uterine adenomyosis. (Fig. 1) Cystic mass was diagnosed as an endometriotic cyst with hemorrhagic content. Considering the urgency of the situation, an emergency cystoscopy and left DJ stenting was done to relieve the obstruction which in turn resulted in alleviation of flank pain. As the patient was anemic, she was transfused with 2 units of packed red cells followed by laparoscopic hysterectomy with left salpingo-oophorectomy with right salpingectomy and adhesiolysis. Laparoscopically, there was a left adnexal cyst around 10 cm x 12 cm, smooth surface. Chocolate-colored material was aspirated from the cyst. The right sided ovary was found to be normal and was preserved. (Fig. 2).

Fig. 1.

CT urogram showing left renal hydronephrosis (A) and left adnexal cyst pressing on ipsilateral ureter (B)

Fig. 2.

Laparoscopy showing large cystic left adnexal mass (A) and vault after removal of cyst and uterus with preserved right ovary (B)

Postoperative imaging showed complete resolution of left ureteral obstruction and hydronephrosis. Her lower abdominal pain also subsided and till date she is in perfect health. Histopathology confirmed endometriotic cyst and adenomyosis.

Discussion

Endometriosis can present with a wide spectrum of symptoms, including chronic pelvic pain, dysmenorrhea, dyschezia, and in rare cases obstructive uropathy. Types of endometriosis affecting the genital tract could be classified as superficial and deep, and depending on the location could be classified as upper urinary tract and lower urinary tract. Most commonly, the urinary bladder is affected. Endometriosis of the upper urinary tract most commonly involves the ureter, particularly the left-sided one. The disease in the ureter could cause extrinsic/ intrinsic compression. Diagnosis of endometriosis involves cystoscopy and biopsy. In case of superficial disease, only TUR of the lesion is sufficient. However, with deep endometriosis, a partial cystectomy is needed. For ureteral endometriosis, in case of obstruction and AKI, the most important step would be relief of the obstruction by a D-J stent or PCN tube.

Deep infiltrating endometriosis of bladder and ureter might result in compromise of renal function over time. Even though hormonal therapy has a strong clinical response, once fibrosis sets in, medications are unlikely to relieve obstruction. Therefore, in order to avoid irreversible loss of kidney function, prompt surgical management is essential. In case of obstructive uropathy, relief of obstruction followed by definitive corrective surgery is indicated. In case fertility is not desired, hysterectomy with bilateral salpingo-oophorectomy is ideal.

A case similar to ours was encountered by Correia MI, et al. [3], wherein on routine examination of a 29-year-old woman revealed altered renal function. This prompted series of further imaging and a suspicion of endometrioma was confirmed by exploratory laparotomy, and the renal function was salvaged by bilateral ureteral D-J stent placement [3].

Another case was of a 65-year-old patient who presented with symptoms like our patient. Thereafter, the patient underwent a CT scan that demonstrated the existence of an irregular, infiltrative right adnexal mass 7 × 5.5 × 9.5 cm, severe chronic right hydroureteronephrosis with severe cortical thinning secondary to obstruction of the right lower ureter by the right pelvic mass. She underwent exploratory laparotomy with excision of mass, right radical nephrectomy, right ureteral resection, lower anterior resection, partial excision of the bladder, and colostomy due to severe renal compromise. The histopathology report indicated that the mass was focal endometrial-type complex hyperplasia with focal atypia arising in a background of endometriosis [4].

For urinary tract endometriosis, conservative laparoscopic surgery provides long-lasting symptom alleviation and shows a low rate of anatomical relapse. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage. Modern endometriosis management requires a broad-based and multidisciplinary approach, centered on patient’s symptoms and priorities.

Conclusion

To conclude, obstructive uropathy due to endometriosis although being rare is a possibility and a challenging condition as well.

Our case demonstrates successful management of obstructive uropathy and large endometriotic cyst with timely D-J stenting followed by definitive surgery which effectively resolved the obstruction as well as preserved the renal function.

This case underscores the importance of considering endometriosis of the urinary tract as well as endometriotic ovarian cysts, as a differential diagnosis of women presenting with urological symptoms, as well as the need for collaboration between urologist and gynecologist in such cases, emphasizing that rapid intervention and multidisciplinary line of management is essential for optimal patient outcome.

Author Contribution

All authors whose names appear on the submission: (1) made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; (2) drafted the work or revised it critically for important intellectual content; (3)approved the version to be published; and (4) agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

No funding was received to assist with the preparation of this manuscript.

Declarations

Conflict of interest

All authors declare that they have no conflict of interest and nothing to disclose.

Ethical Approval

ILS Hospital Ethics Committee has confirmed that no ethical approval is required.

Consent for Publication

The participant has consented to the submission of the case report to the journal.