**5. Summery**


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**6. References** 


#### **6. References**

42 Endometriosis - Basic Concepts and Current Research Trends

• Endometriosis of the urinary tract is predominantly found in the bladder, accounting for 70% to 80% of the cases. The ureter may be involved in *15% to 20%* of the urinary tract cases and *the left side* is more often affected**.** *Bilateral ureteral* disease has been

• Ureteral involvement may be either *intrinsic or extrinsic*. Eighty percent of ureteral endometriosis is extrinsic and most commonly involves the *distal ureter*. Differentiation between these two forms of ureteral endometriosis has histologic and pathogenetic

• Because a large percentage of ureteral endometriosis can result in silent loss of renal function due to asymptomatic obstruction*,* all patients with pelvic endometriosis

• Classic symptoms and signs of urinary tract endometriosis include cyclical flank pain, dysuria, urgency, urinary tract infection, and hematuria. As a rule, we can say that

• The exact location and volume of the ureteral disease can be defined through retrograde ureteropyelography, CT or MRI , which can be valuable for planning treatment. • The diagnosis of ureteral endometriosis requires a high index of suspicion and is aided by clinicians' awareness of the condition. Definite diagnosis can be reached through

• Treatment of ureteral endometriosis has several goals including preservation of renal function, management of the main disease process, maintenance of the patient's fertility, and relief of the patient's symptoms. If renal function is normal and there is minimal to mild hydronephrosis with no functional obstruction as determined by radionuclide renal scanning, hormone therapy may be prescribed otherwise, surgery is

• Since most lesions are located in the distal ureter, ureteral resection is usually combined with *ureteroneocystostomy* but, when the endometriotic lesion is in the middle or upper third of the ureter, *end ureteroureterostomy* should be done after resection of lesions. • Bladder endometriosis is defined as the presence of endometrial glands and stroma *through detrusor muscle*. The ureteral openings are usually not involved by the vesical

• Bladder endometriosis causes nonspecific urinary symptoms, including urinary frequency, urgency, dysuria, or urinary retention . Occurrence of these symptoms

• Treatment of vesical endometriosis is indicated only if there is any symptoms or resulted in hydronephrosis. First line treatment is *medical therapy*. Surgery must be reserved for cases in whom medical therapy have failed or is contraindicated, who wish

• If the inferior border of the endometriotic lesion is less than 2 cm away from the interureteric ridge, then *ureteral catheters* should be inserted at the beginning of the

• Removal of endometriotic nodules at the bladder *dome* may not require any dissection but, in the face of nodules involving the *posterior or inferior* aspects, the bladder must be dissected from the uterus just enough below the inferior margin of the nodule in order

• 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

during menses is suggestive. *Cyclic hematuria is uncommon but characteristic*.

to avoid chronic medical treatment, or who have hydronephrosis.

importance, but has little impact on clinical management.

*intrinsic endometriosis is more symptomatic* than extrinsic disease.

should undergo the *upper urinary tract imaging*.

direct visualization and biopsy of implants.

lesions so, hydronephrosis is rare.

to achieve complete resection.

may prevent recurrence.

indicated.

procedure.

reported in up to 23% of cases.


Urinary Tract Endometriosis 45

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6.


**3** 

*P. R. China* 

**Diagnosis and Treatment of** 

*Dept. of O/G of Peking Union Medical College Hospital,* 

Endometriosis is the extrauterine occurrence of endometrial glands and stroma, most often involving the ovaries or dependent visceral peritoneal surfaces. This tissue responds to the

Endometriosis is most commonly a disease of women in the second half of their reproductive life, between 30 and 45 years, and tends to regress at the menopause or even before. As a significant gynecological problem, endometriosis occurs in 7%–10% of the general population and up to 50% of premenopausal women (Wheeler, 1989). It is found in 20%–50% (mean 38%) of infertile women (Rawson, 1991; Strathy, 1982; Verkauf, 1987), and in 71%–87% of those with chronic pelvic pain (Carter, 1994; Koninckx et al., 1991; Ling, 1999). Endometriosis is responsible for 20% of all gynecologic operations and is the single leading nonobstetric cause (.5%) of hospitalization for women age 15–44 years. Although benign, endometriosis is progressive, tends to recur, may be locally invasive, may have widespread disseminated foci (rare), and may exist in pelvic lymph nodes (30%) (Martin &

Endometriosis is commonest in the pelvis. It is very occasionally found in bizarre sites such as the pleura, umbilicus, Caesarean section scars, perineam or vagina, diaphragm, arm, leg or kidney, but these cases are rare. The following statistical data shows the order of frequency: ovaries (30%), uterosacral and large ligaments (18–24%), fallopian tubes (20%), pelvic peritoneum, pouch of Douglas and gastrointestinal tract. Extraperitoneal locations include cervix (0.5%), vagina and rectovaginal septum, round ligament and inguinal hernia sac (0.3–0.6%), navel (1%), abdominal scars after gynecological surgery (1.5%) and cesarean section (0.5%). Endometriosis rarely affects extra-abdominal organs such as the lungs,

Perineal endometriosis (PEM) is the presence of endometrial tissues in the perineal sites. It has been published in obstetric and gynecologic literature since 1949. A retrospective study in Peking Union Medical College Hospital shows 17263 women received surgical treatment for endometriosis between Jan 1992 and Apr 2011. Of them, 64 women (3.7‰) were with PEM. Of these 64 women, cases of PEM with anal sphincter involvement were 31 (1.8‰).

urinary system, skin and central nervous system (Bergqvist, 1993; Lin et al., 2006).

That is, in nearly half of women with PEM, the lesions erode into anal sphincter.

hormone variations in the cycle similar to eutopic endometrium.

**1. Introduction** 

Pernoll, 2001).

**1.1 Introduction and epidemiology** 

**Perineal Endometriosis** 

Lan Zhu, Na Chen and Jinghe Lang

*Chinese Academy of Medical Science, Beijing,* 


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