When the endometrium tissue on the inner wall of the uterus attaches to anatomical areas outside the uterus, such as the ovary or the fallopian tubes, it is called endometriosis, that is, the chocolate cyst disease. This tissue called endometrium can also be seen, less frequently, in the urinary tract.
In about 1% of women with endometriosis the disease is seen in the urinary tract. Making a diagnosis of urinary tract endometriosis is extremely difficult, because many women with endometriosis may not notice that the disease affects the urinary tract.
If the patient has additional endometriosis lesions, it can be diagnosed while the cause of the severe pain linked to those lesions is being investigated. If the disease is present only in the urinary system, making the diagnosis can take time. For this reason it is sometimes missed. One of the reasons for the late diagnosis is that urinary tract endometriosis does not cause specific signs.
Does Late Diagnosis of Urinary Endometriosis Lead to a Serious Situation?
Unfortunately, involvement of the bladder does not cause a clear complaint either. What is seen in patients who do have complaints is pelvic pain and, rarely, blood in the urine. This blood is rather something that can be detected by a urine test than something visible to the eye. Involvement of the ureters (the urinary tubes) in particular can cause silent kidney loss.
Early diagnosis of ureteral involvement is therefore very important. In a significant proportion of patients with bladder or ureteral involvement, additional endometriosis lesions are found in the ovary, the bowel and the uterus as well. Detecting endometriosis in the ovary and the bowel is much easier. In these patients, if there is a nodule larger than 3 cm in the bowel in particular, ureteral involvement should come to mind.
What Are the Signs of Urinary Tract Endometriosis?
Although urinary system endometriosis does not always give signs, in some women it can cause infertility, an increase in urinary frequency and pain in the back area. But what should be kept in mind is that 50% of patients have no symptoms at all. In some women blood can be observed in the urine during menstruation. It is often confused with cystitis (a urinary tract or bladder infection).
How Is It Diagnosed?
In 85% of women with urinary tract endometriosis these cysts are found in the bladder. 10% are in the ureter, 4% in the kidneys and 2% in the urethra. One of the reasons why the differential diagnosis is so difficult is that the signs that occur closely resemble those of other urinary tract diseases.
In almost half of the patients with urinary tract endometriosis no signs are seen. In 25% there is pain in the flanks and in 15% there is a sign of excessive blood in the urine. The disease generally does not cause any sign until it becomes extremely severe. Endometriosis in the urinary tract usually causes blood in the urine, an inability to hold urine or frequent urination.
A urinary tract infection has similar signs. For this reason the diagnosis is extremely difficult. When there is suspicion, imaging is performed with transvaginal ultrasound. In some cases MRI can be preferred instead of ultrasound. In addition, urine analysis, biopsy and histology are used.
Treatment Methods
In urinary tract endometriosis the treatment methods vary according to the signs, hydronephrosis and obstruction of the urinary tract. Medical treatment can be successful in reducing the pain. Among the medical treatments, progesterone-based regimens, oestrogen-progesterone therapy or gonadotropin-releasing hormone analogues are used.
Medical treatment shrinks the existing lesions but does not remove them. As a result it is often treated with surgery. With laparoscopic or robotic surgery the lesion on the bladder or the ureter involved by endometriosis is removed in these patients, and the tissues are repaired after the incision. With this method the lesions can be eliminated.
The most important point in the surgical treatment of endometriosis of the urinary system is that a urologist experienced in these matters takes part in the surgical team. Under the moderation of the endometriosis surgeon and together with the urologist, all endometriosis lesions in the urinary system can be removed completely and the surgery can be completed without harming the organs and with minimal complications.
The management of the disease by these two branches together provides a very important advantage both in managing the complications that can be encountered after surgery and in the follow-up of these patients.
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