**2. Ethiology and pathogenesis**

The classic definition of endometriosis is as the presence of endometrial glands and stroma at extrauterine sites. These ectopic endometrial implants are usually located in the pelvis, but can occur nearly anywhere in the body. It can be associated with many distressing and debilitating symptoms or may be asymptomatic, and incidentally discovered at laparoscopy or exploratory surgery.

have cyclic hematuria at times of menstruation. Some patients give a history of gynecologic

Women of reproductive age(overall) 10 to 20 percent

indication 1 percent Women undergoing tubal sterilization 1 to 7 percent Following laparoscopy to determine the cause of pelvic pain 12 to 32 percent Women undergoing laparoscopy for infertility 9 to 50 percent Women undergoing laparoscopy without infertility 6.7 percent

pelvic pain or dysmenorrheal 50 percent

Table 1. The prevalence of endometriosis in women groups of reproductive age.

It can be associated with many distressing and debilitating symptoms may be asymptomatic, and incidentally discovered at laparoscopy or exploratory surgery. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas. Endometriotic lesions of the urinary tract are present in 1 to 4 percent of women with endometriosis and often coexists with disease at

Although ureteral and bladder endometriosis both occur in the urinary tract, they do not frequently coexist and their clinical presentation and management are different. Bladder endometriosis often mimicks recurrent cystitis, but rarely results in severe sequelae. Ureteral endometriosis is often asymptomatic, but can lead to silent loss of renal function. Renal and

Overall unclear but may occur in 1 -4% of all cases of

Kidney 4 percent of all urinary tract involvements Urethra 2 percent of all urinary tract involvements

The optimal way to diagnose endometriosis is by direct visualization and biopsy of the

The classic definition of endometriosis is as the presence of endometrial glands and stroma at extrauterine sites. These ectopic endometrial implants are usually located in the pelvis, but can occur nearly anywhere in the body. It can be associated with many distressing and debilitating symptoms or may be asymptomatic, and incidentally discovered at laparoscopy

Bladder 70 – 80 percent of all urinary tract

Ureter 15 – 20 percent of all urinary tract

endometriosis

involvements

involvements

surgeries such as hysterectomy many years ago.

other sites of the body.

Women with a history of major surgery for any gynecologic

Teenagers undergoing laparoscopy for evaluation of chronic

urethral involvements are rare and only as case reports.

Table 2. The prevalence of endometriosis in urinary tract.

implant(s) anywhere through the body.

**2. Ethiology and pathogenesis** 

or exploratory surgery.

The pathogenesis of endometriosis has not been definitively established but predominant hypotheses are as follows:


Genetic factors probably influence an individual's susceptibility to endometriosis. The possibility of a familial tendency for endometriosis has been recognized for several decades. If a woman has endometriosis, a first-degree relative has a 7 percent likelihood of developing the disorder as compared with 1 percent in unrelated persons. Concordance in twins has also been observed.

There is evidence for altered humoral and cell-mediated immunity in the pathogenesis of endometriosis such as Deficient cellular immunity, improper Natural killer cell activity and increased concentration of leukocytes and macrophages in the peritoneal cavity and ectopic endometrium. These variations in immune system may result in an inability to recognize the presence of endometrial tissue in abnormal locations, decreased cytotoxicity to autologous ectopic endometrium and finally, secretion of cytokines and growth factors by leukocytes and macrophages into the peritoneal fluid of women with endometriosis.

One hypothesis is that secretion of various cytokines by inflammatory cells into the peritoneal cavity leads to proliferation of implants and recruitment of capillaries. Oxidative stress may be another component of the inflammatory reaction. Thus, the immune system may play a role in determining who will develop endometriosis, as well as the extent and clinical manifestation of the disease.

It is said that these women had higher rates of autoimmune inflammatory diseases, hypothyroidism, fibromyalgia, chronic fatigue syndrome, allergies and asthma, compared with the general female population so, it could provide support for the theory of altered immune system in women with endometriosis.

Vesical endometriosis is said that may be due to bladder adenomyosis or an extension of adenomyosis from the uterus into the bladder or because of imperfect closure of the uterus during a cesarean delivery.

The risk of endometriosis developing into a cancerous lesion is very low(1 - 2.5%) and the same as normal endometrium and ovaries.

Endometriosis is a common, benign, chronic, estrogen-dependent disorder with a relapsing/remitting nature. The endometrial tissue acts just like the normal ones in the uterus, responding to cyclical hormone levels, growing and bleeding at certain times of the cycle. If the tissue is in the ovaries, then bleeding of it results in accumulation of blood,

Urinary Tract Endometriosis 35

endometriosis. In the younger patients and in order to preserve fertility, endometriosis should be resected but with preservation of ovarian function and strict periodic surveillance

Since renal endometriosis is rarely encountered, it is briefely mentioned in the clinical

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. Bilateral disease has been reported in up to 23% of cases. The left side is more often affected, which may be because the sigmoid colon prevents the regurgitated endometrial cells to be

Ureteral involvement may be either intrinsic or extrinsic. If endometrial glands and stroma are within the lamina propria, tunica muscularis, or ureteral lumen it is said Intrinsic endometriosis and if they are localized within periureteral tissue extrinsic endometriosis ensues. 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 importance, but has little impact on clinical management since the precise location of the lesion cannot be determined preoperatively. Moreover, both

Silent loss of renal function has been reported in 25% to 43% of patients with ureteral endometriosis, which may result in total loss of function of the affected kidney. Historically, up to one third of kidneys affected by ureteral endometriosis were lost. So, *it has been* recommended to take image of the upper urinary tract in all patients with pelvic

Gynecologic laparoscopy for treatment of endometriosis is responsible for a large percentage of ureteral injuries. The reasons for this may be as follows: (1) endometrioma can involve the ureter either extrinsically or intrinsically; (2 adhesions from endometriosis makes ureteral visualization difficult; and (3) the disease can deviate the ureters medially

In addition, the most commonly affected portions of the ureter are the distal third, followed by the middle third. Involvement of the proximal ureter is rare. Thus, the most frequent sites of ureteral endometriosis are below the level of tubal efflux. The lesions of the distal ureter usually coexist with posterior pouch endometriosis, as the lesions of the middle third of the

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 intrinsic

intrinsic and extrinsic forms of the disease may result in ureteral stenosis.

of urinary tract.

**3. Upper tract involvement** 

**3.1 Renal endometriosis** 

guidelines and literatures.

**3.2 Ureteral endometriosis** 

cleared by the peritoneal fluid on the left side.

endometriosis with ultrasonography or IVU.

ureter may be together with involvement of the ovary.

resulting in abnormal anatomy.

**3.2.1 Clinical manifestations** 

named chocolate cysts. During menstruation, the ectopic tissue bleeds, causing the surrounding tissues to become inflamed. This inflammation causes fibrosis, leading to adhesions that produce pain and other complications such as infertility. Inflammation that happens at the site of the endometrial tissue results in and adhesions in the abdomen and pelvis. These can lead to a frozen pelvis and other complications such as infertility. It can be associated with many distressing and debilitating symptoms, such as pelvic pain, severe dysmenorrhea, dyspareunia and infertility, or it may be asymptomatic, and incidentally discovered at laparoscopy or exploratory surgeries.

Active endometriosis usually occurs between ages 30 and 40, but may be seen before age 20. Severe symptoms of endometriosis may have an abrupt onset or develop over many years. This disorder usually becomes progressively severe during the menstrual years but after menopause, it tends to subside.

The most common sites of endometriosis are respectively the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments. Other less commonly involved regions include the vagina, cervix, rectovaginal septum, cecum, ileum, inguinal canals, abdominal or perineal scars, urinary bladder, ureters, and umbilicus. Rarely, endometriosis has been reported in the breast, pancreas, liver, gallbladder, kidney, urethra, extremities, vertebrae, bone, peripheral nerves, lung, diaphragm, central nervous system, and even in the prostate. Endometriosis is multifocal in most patients. The disease is staged according to site and severity of involvements.

Diagnosis of urinary tract endometriosis requires a careful history and thorough physical examination. High index of suspician to all symptomatic women with a history of caesarian delivary or other gynaecological surgery gives a clue to the diagnosis.

Ultrasonography is the initial step of investigation to detect the vesical endoluminal mass or upper urinary tract dilatation. On ultrasound examination, the lesions usually appears as hypoechoic, vascular, and solid masses, although cystic changes can be present . The lesions have no definite margines and may appear to infiltrate adjacent tissues. IVU is still very much useful to detect the integrity of the upper tract and ureter. MRI is better than computed tomography for identifying hemorrhage and soft tissue planes. Fine needle aspiration will yield chocolate-colored fluid.

Cystoscopy and laparoscopy together with biopsy are fundamental to the assessment of urinary tract endometriosis specially before operation. Wide local excision is performed either for confirmation diagnosis or as treatment.

Optimal management requires a team of specialists including gynaecologists, colorectal surgeons and urologists, working together to thoroughly assess the risks and benefits of treatments and to determine the optimal care.

Treatment varies according to the severity and site of involvement of each case. Hormonal therapy with danazole does have a definite roll in regressing the lesion but in cases with urinary tract involvement, surgical treatment is a better option because the condition may lead to kidney loss up to 25%.

Aggressive surgical removal of ectopic tissues, relief of urinary obstruction and castration with or without hysterectomy is the recommended surgical treatment for urinary tract

named chocolate cysts. During menstruation, the ectopic tissue bleeds, causing the surrounding tissues to become inflamed. This inflammation causes fibrosis, leading to adhesions that produce pain and other complications such as infertility. Inflammation that happens at the site of the endometrial tissue results in and adhesions in the abdomen and pelvis. These can lead to a frozen pelvis and other complications such as infertility. It can be associated with many distressing and debilitating symptoms, such as pelvic pain, severe dysmenorrhea, dyspareunia and infertility, or it may be asymptomatic, and incidentally

Active endometriosis usually occurs between ages 30 and 40, but may be seen before age 20. Severe symptoms of endometriosis may have an abrupt onset or develop over many years. This disorder usually becomes progressively severe during the menstrual years but after

The most common sites of endometriosis are respectively the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments. Other less commonly involved regions include the vagina, cervix, rectovaginal septum, cecum, ileum, inguinal canals, abdominal or perineal scars, urinary bladder, ureters, and umbilicus. Rarely, endometriosis has been reported in the breast, pancreas, liver, gallbladder, kidney, urethra, extremities, vertebrae, bone, peripheral nerves, lung, diaphragm, central nervous system, and even in the prostate. Endometriosis is multifocal in most patients. The disease is staged according to site and

Diagnosis of urinary tract endometriosis requires a careful history and thorough physical examination. High index of suspician to all symptomatic women with a history of caesarian

Ultrasonography is the initial step of investigation to detect the vesical endoluminal mass or upper urinary tract dilatation. On ultrasound examination, the lesions usually appears as hypoechoic, vascular, and solid masses, although cystic changes can be present . The lesions have no definite margines and may appear to infiltrate adjacent tissues. IVU is still very much useful to detect the integrity of the upper tract and ureter. MRI is better than computed tomography for identifying hemorrhage and soft tissue planes. Fine needle

Cystoscopy and laparoscopy together with biopsy are fundamental to the assessment of urinary tract endometriosis specially before operation. Wide local excision is performed

Optimal management requires a team of specialists including gynaecologists, colorectal surgeons and urologists, working together to thoroughly assess the risks and benefits of

Treatment varies according to the severity and site of involvement of each case. Hormonal therapy with danazole does have a definite roll in regressing the lesion but in cases with urinary tract involvement, surgical treatment is a better option because the condition may

Aggressive surgical removal of ectopic tissues, relief of urinary obstruction and castration with or without hysterectomy is the recommended surgical treatment for urinary tract

delivary or other gynaecological surgery gives a clue to the diagnosis.

discovered at laparoscopy or exploratory surgeries.

menopause, it tends to subside.

severity of involvements.

aspiration will yield chocolate-colored fluid.

either for confirmation diagnosis or as treatment.

treatments and to determine the optimal care.

lead to kidney loss up to 25%.

endometriosis. In the younger patients and in order to preserve fertility, endometriosis should be resected but with preservation of ovarian function and strict periodic surveillance of urinary tract.
