**4. Lower tract involvement**

#### **4.1 Urethral endometriosis**

Since urethral endometriosis is rarely encountered the clinical guidelines and literature are briefe. Eendometriosis have been described within urethral diverticula. urethral endometriosis do not involve the urethral meatus.

#### **4.2 Bladder endometriosis**

Bladder endometriosis is defined as the presence of endometrial glands and stroma at detrusor muscle.

#### **4.2.1 Clinical manifestations**

Bladder endometriosis causes nonspecific urinary symptoms, including urinary frequency, urgency, dysuria, or urinary retention. Occurrence of these symptoms during menses is suggestive. Cyclic hematuria is uncommon but characteristic. The ureteral openings are usually not involved by the vesical lesions so, hydronephrosis is rare.

into the bladder is performed. When the endometriotic lesion is in the middle or upper third of the ureter, end ureteroureterostomy should be done after resection of lesions.

Whether to proceed with resection of an endometriotic segment of the ureter or aggressive ureterolysis and stenting is a subjective decision based upon intraoperative visual with no definite criteria to predict normal postoperative ureteral function. In presence of stenosis and significant hydronephrosis, most surgeons have found that the risk of recurrence is lower after ureteral resection and ureteroneocystostomy rather than aggressive ureterolysis and stent insertion. In the case of surface ovarian endometriotic lesions or an endometrioma ipsilateral oophorectomy should be performed as needed. Bilateral oophorectomy is

In the cases incidentally discovered at time of laparoscopy or laparotomy, if ureteral

Complications of these surgeries include general complications the same as other abdominal laparoscopy or laparotomy and specific complications to this procedure such as ureteral

The rates of recurrence for each type of surgical procedures are included in Table.3. Complications are few and most common of them is ureteral fistula. Ureterolysis alone is associated with higher rates of both recurrence and complications compared with

Since urethral endometriosis is rarely encountered the clinical guidelines and literature are briefe. Eendometriosis have been described within urethral diverticula. urethral

Bladder endometriosis is defined as the presence of endometrial glands and stroma at

Bladder endometriosis causes nonspecific urinary symptoms, including urinary frequency, urgency, dysuria, or urinary retention. Occurrence of these symptoms during menses is suggestive. Cyclic hematuria is uncommon but characteristic. The ureteral openings are

usually not involved by the vesical lesions so, hydronephrosis is rare.

Table 3. The rates of recurrence for each type of surgical procedures for ureteral

performed in some women to prevent recurrence of endometriosis.

adhesions are present, ureterolysis should be performed.

ureteroneocystostomy and Ureteroureteral anastomosis

endometriosis do not involve the urethral meatus.

Ureteroneocystostomy 3 percent Ureterolysis alone 8 percent Ureteroureteral anastomosis 11 percent

fistula.

endometriosis.

**4. Lower tract involvement 4.1 Urethral endometriosis** 

**4.2 Bladder endometriosis** 

**4.2.1 Clinical manifestations** 

detrusor muscle.

Some women with bladder endometriosis are asymptomatic and present with an incidental finding of a bladder nodule on pelvic imaging or as a result of pelvic surgery. Some patients are asymptomatic for the first few years and will only realize that they have the disease when it is already in its serious stage, manifesting more severe symptoms.

The most common complaint of women that have bladder endometriosis is pain in the abdominal or pelvic area. The degree of pain can be mild to severe or acute to subacute. Usually, this pain will be more intense during monthly period. Many women suffer from endometriosis silently because they feel that the pain is just the normal pain of premenstrual syndrome. However, if the premenstrual pain in a woman hampers her normal activities she is suspected to has endometriosis.

Women with bladder endometriosis also experience various urinary problems. It is common to feel a burning sensation during voiding. Since the cause of your urinary problems is endometrium cells in the bladder wall, antibiotics will not cure or alleviate the symptoms.

#### **4.2.2 Diagnosis**

The gold standard for diagnosis of bladder endometriosis is biopsy and histologic confirmation of visualized lesions during cystoscopy or laparoscopy.

Symptoms compatible with bladder endometriosis, specially togetherwith known endometriosis at other sites or characteristic symptoms such as pelvic pain, dysmenorrhea, dyspareunia and infertility, and finding of a bladder nodule on ultrasound suggest vesical endometriosis and further evaluation is needed.

The differential diagnosis of bladder endometriosis includes urinary tract infection, interstitial cystitis, and a bladder stone or neoplasm. So, proper tests and examinations must be done based on patient's clinical presentation to rule out these conditions. In more than 70% of cases the presenting symptoms of bladder endometriosis are identical to those of interstitial cystitis. Therefore, endometriosis should always be considered in the patient referred for frequency, urgency and pain with no documented infection.

Pelvic and renal sonography may show a bladder nodule or hydronephrosis, although, endometriosis is often not visualized on imaging studies. Endometriosis itself and its surgical treatments are capable of VVF formation. Nevertheless, endometriosis of the bladder must be differentiated from VVF because both of them may present with cyclic hematuria.

In the case of a bladder nodule, cystoscopy and biopsy is performed to rule out malignancy and confirm diagnosis. The distance of the lesion from the ureteral openings is important since, removal of the lesions adjuscent to ureteral orifices may requires ureteral surgery, as well. Magnetic resonance imaging may be useful to detect Lesions that are not visible with cystoscopy. If there is hydronephrosis , radiologic evaluation of the same ureter is required.

#### **4.2.3 Management**

Bladder endometriosis, if left unmanaged, may lead to more severe urinary problems in the future such as urinary obstruction or incontinence. However, treatment of vesical endometriosis is indicated only if there is any symptoms or resulted in hydronephrosis. First

Urinary Tract Endometriosis 41

For lesions at the vesical base, where the bladder is apposed to the uterus, resection of a 0.5 to 1 cm deep portion of the myometrium contiguous with the endometriotic nodule may

At the end of the procedure, the bladder is filled to confirm that the closure is watertight

The removal of bladder endometriosis is contraindicated in pregnant women as well during cesarean section, because high endometrial blood flow can result in massive hemorrhagia. General complications are the same as other laparoscopic or cystoscopic procesures. Special complications include vesicovaginal hematoma and vesicovaginal fistula. Ureter–fallopian tube fistula has also been reported as a consequence of laparoscopic fulguration of

The overall outcome of surgical treatment for bladder endometriosis has been good and

• Endometriosis is defined as the presence of functional endometrial tissue in an ectopic site (*outside of the uterus*). Endometriosis is a common, benign, chronic, *estrogen-*

• Although endometriosis is usually confined to the ovaries, uterosacral ligaments, and cul-de-sac, it has been documented in almost every organ system in the body. • Because ovarian function is necessary for the development and maintenance endometrial implants, endometriosis has been reported only in the *reproductive age* and so, is normally not seen before age 15 or after menopause. Endometriosis is most

• The prevalence of endometriosis in specific categories of patients has been reported (Table.1), but the prevalence in the general population is not definitely known because a majority of patients are asymptomatic. It is estimated that affect *10% to 20%* of women

• Endometriosis can be associated with many distressing and debilitating symptoms *may be asymptomatic*, and incidentally discovered at laparoscopy or exploratory surgery. • Endometriotic lesions of the urinary tract are present in *1 to 2 percent* of women with endometriosis and often *coexists with* disease at other sites of the body. Actually,

• The pathogenesis of endometriosis has not been definitively established but predominant hypotheses are *the implantation theory, lymphatics and blood vessels dissemination, and coelomic metaplasia. Genetic* factors and altered humoral and cell-

• The endometrial tissue in the endometriotic lesions acts just like the normal ones in the uterus, *responding to cyclical hormone* levels, growing and bleeding at certain times of the cycle, causing the surrounding tissues to become inflamed. This *inflammation* causes *fibrosis*, leading to *adhesions* that produce pain and other complications such as

• Since renal and urethral endometriosis is rarely encountered, they are briefely

complications or need for reoperations had been low.

*dependent* disorder with a *relapsing/remitting* nature.

common in women between the ages of *25 and 35*.

endometriosis *is multifocal* in most patients.

mediated *immunity* may also *play a role in endometriosis.* 

mentioned in the clinical guidelines and literatures.

and the bladder catheter is left in place for 7 to 10 days to prevent fistula formation.

prevent recurrence.

endometriosis.

**5. Summery** 

of reproductive age**.** 

infertility.

line treatment is medical therapy, since this approach avoids the risk of surgical complications. Medical therapy must be continued until menopause is not effective in all cases. Surgery must be reserved for cases in whom medical therapy have failed or is contraindicated, who wish to avoid chronic medical treatment, or who have hydronephrosis.
