**4.2.3.1 Medical treatment**

Hormonal therapy is reasonable and effective management for bladder endometriosis and because it preserves fertility, is especially attractive to younger women. While medical therapy is effective for pain relief, symptoms often recur once treatment is completed.

Medical therapy of symptomatic bladder endometriosis is the same as for other sites of the disease. Oral contraceptives, progestins, and gonadotropin releasing hormone agonists all have been reported to improve symptoms and regress the lesions.

A tolerable and safe medication should be chosen. Oral contraceptive on the usual cyclic regimen may be efficient. Although, If perimenstrual symptoms do not resolve with a cyclic regimen, it should be substituted by a continuous regimen. Low dose progestin is also effective and safe.

#### **4.2.3.2 Surgeries**

Definitive treatment of bladder endometriosis is surgical removal of the lesions. Surgery is indicated if fertility is a major goal, where symptoms fail to respond to medical therapies, or where ureteric obstruction has been confirmed. Untreated ureteric obstruction may lead to irreversible kidney damage.

 If the lesion deeply infiltrates the bladder wall then, a full thickness resection and subcequent repair of the bladder wall is needed, which can be done laparoscopically. Although, in the case of partial thickness involvements one can only resect the lesions without opening the bladder wall.

In the face of the complicated conditions there may be the need for more advanced procedures which should be performed via laparotomy and only by more experient surgeons (table.4).


Table 4. The complicated bladder endometrioses.

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 procedure.

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 to achieve complete resection. The lesions is then excised with cold scissors or electrosurgery and the bladder is closed with two layers of transverse sutures.

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

Hormonal therapy is reasonable and effective management for bladder endometriosis and because it preserves fertility, is especially attractive to younger women. While medical therapy is effective for pain relief, symptoms often recur once treatment is completed.

Medical therapy of symptomatic bladder endometriosis is the same as for other sites of the disease. Oral contraceptives, progestins, and gonadotropin releasing hormone agonists all

A tolerable and safe medication should be chosen. Oral contraceptive on the usual cyclic regimen may be efficient. Although, If perimenstrual symptoms do not resolve with a cyclic regimen, it should be substituted by a continuous regimen. Low dose progestin is also

Definitive treatment of bladder endometriosis is surgical removal of the lesions. Surgery is indicated if fertility is a major goal, where symptoms fail to respond to medical therapies, or where ureteric obstruction has been confirmed. Untreated ureteric obstruction may lead to

 If the lesion deeply infiltrates the bladder wall then, a full thickness resection and subcequent repair of the bladder wall is needed, which can be done laparoscopically. Although, in the case of partial thickness involvements one can only resect the lesions

In the face of the complicated conditions there may be the need for more advanced procedures which should be performed via laparotomy and only by more experient

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 to achieve complete resection. The lesions is then excised with cold scissors or electrosurgery

1 Any possiblility for endometriosis of the ureter such as hydronephrosis.

2 The lesion is less than 2 cm away from the inter-ureteric ridge.

3 Another bladder lesion has been recently resected.

and the bladder is closed with two layers of transverse sutures.

Table 4. The complicated bladder endometrioses.

have been reported to improve symptoms and regress the lesions.

hydronephrosis.

effective and safe. **4.2.3.2 Surgeries** 

surgeons (table.4).

procedure.

irreversible kidney damage.

without opening the bladder wall.

**4.2.3.1 Medical treatment** 

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 prevent recurrence.

At the end of the procedure, the bladder is filled to confirm that the closure is watertight and the bladder catheter is left in place for 7 to 10 days to prevent fistula formation.

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 endometriosis.

The overall outcome of surgical treatment for bladder endometriosis has been good and complications or need for reoperations had been low.
