Diagnosis and treatment of bladder endometriosis: state of the art

Endometriosis and Vesico-Sphincteral Disorders

Objectives

The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function).

Materials and methods

We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms, and surgery.

Results

The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction.

Conclusion

A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.

World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: II. Clinical and covariate phenotype data collection in endometriosis research

OBJECTIVE

To harmonize the collection of nonsurgical clinical and epidemiologic data relevant to endometriosis research, allowing large-scale collaboration.

DESIGN

An international collaboration involving 34 clinical/academic centers and three industry collaborators from 16 countries on five continents.

SETTING

In 2013, two workshops followed by global consultation, bringing together 54 leaders in endometriosis research.

PATIENTS

None.

INTERVENTION(S)

Development of a self-administered endometriosis patient questionnaire (EPQ), based on [1] systematic comparison of questionnaires from eight centers that collect data from endometriosis cases (and controls/comparison women) on a medium to large scale (publication on >100 cases); [2] literature evidence; and [3] several global consultation rounds.

MAIN OUTCOME MEASURE(S)

Standard recommended and minimum required questionnaires to capture detailed clinical and covariate data.

RESULT(S)

The standard recommended (EPHect EPQ-S) and minimum required (EPHect EPQ-M) questionnaires contain questions on pelvic pain, subfertility and menstrual/reproductive history, hormone/medication use, medical history, and personal information.

CONCLUSION(S)

The EPQ captures the basic set of patient characteristics and exposures considered by the WERF EPHect Working Group to be most critical for the advancement of endometriosis research, but is also relevant to other female conditions with similar risk factors and/or symptomatology. The instruments will be reviewed based on feedback from investigators, and-after a first review after 1 year-triannually through systematic follow-up surveys. Updated versions will be made available through http://endometriosisfoundation.org/ephect.

Bladder endometriosis and endocervicosis: presentation of 2 cases with endoscopic management and review of literature

Urinary tract endometriosis and endocervicosis are an uncommon pathologic finding, with a common embryological origin. We present 2 cases of female patients with bladder mass. The first one was a finding of a nodular formation in the bladder during study of a nonviable foetus and the second was an incidental finding of a neoformation in the fundus of the bladder during the realization of an ultrasound. In both cases, we performed a surgical management with transurethral resection. Histopathological examination revealed a bladder endometrioma in the first case and endocervicosis with associated endometriosis in the second.

Employing Laparoscopic Surgery for Endometriosis

Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis.

Bladder endometriosis: characterization by magnetic resonance imaging and the value of documenting ureteral involvement

OBJECTIVES

To characterize bladder endometriosis by MRI and assess aspects of ureteral involvement.

STUDY DESIGN

From 2007 to 2013, bladder endometriosis was diagnosed, surgically treated and histopathologically verified in 18 patients (mean age 31.7±4.6 years) retrospectively enrolled under a published MRI protocol at our hospital's Endometriosis Center. Preoperatively, to diagnose disease spread, cystoscopy was performed and MRI in the following sequences: T2-TSE and T1-SE with and without fat saturation in the sagittal and transversal planes after rectovaginal opacification. Nine patients additionally underwent a diffusion-weighted sequence, including calculation of the apparent diffusion coefficient (ADC). By consensus, two experienced radiologists, without prior knowledge of the surgical or cystoscopic findings, retrospectively characterized bladder endometriosis on the MRI scans, also determining anatomic position, size, sequence-dependent features and incidence of hemorrhages, and calculating ADC. The scans were also investigated to determine if MRI could detect ureteral involvement intercurrent with bladder endometriosis.

RESULTS

Endometriosis localizations were bladder roof, n=1 (5.6%) and back wall, n=17 (94.4%). Mean lesion size was 3.65±1.5ml. Lesions exhibited a lower signal intensity in T2- than in T1-weighted images. High-signal-intensity spots showed an occurrence of 72.2% in fat-suppressed T1-weighted and 61.1% in T2-weighted sequences. Mean ADC was 1251.6±220.9mm(2)/s. By MRI, it was not possible to differentiate wall layers and hence infiltration depth. The bladder endometriosis of two women showed direct involvement with the right ureter. Furthermore, one woman had endometriosis of the left distal ureter in addition to bladder endometriosis. All cases of ureteral involvement were detected by MRI.

CONCLUSIONS

Characteristic MRI features of bladder endometriosis were found to be low signal intensity in T2-weighted and high-signal-intensity spots in T1- and T2-weighted sequences. Standard-sequence MRI was capable of detecting ureteral involvement, but not bladder wall infiltration depth.

Full-thickness endometriosis of the bladder: report of 31 cases

OBJECTIVE

To draw attention to the rare condition of endometriosis in the bladder. This is correlated with symptoms not normally connected to endometriosis and therefore often remains underdiagnosed for years.

DESIGN AND SETTING

Retrospective study in a university teaching hospital, one of two referral centres in Denmark for surgical treatment of stage III and IV endometriosis.

POPULATION

Thirty-one women with deep infiltrating bladder endometriosis.

METHODS

All women presenting in the Department of Obstetrics and Gynaecology with deep infiltrating bladder endometriosis between March 2002 and March 2011. We included only patients with symptomatic full-thickness bladder detrusor endometriosis and mucosal involvement. All patients had had bladder symptoms for two to seven years.

MAIN OUTCOME MEASURES

Symptoms after surgery and recurrence rate.

RESULTS

The main preoperative symptom was urinary frequency. All patients had significant relief of symptoms after operation, and none had recurrence of the bladder endometriosis judged by ultrasound or reported symptoms. Twenty-six (87%) patients had endometriosis in another location as well. Eight had nodules in the recto-vaginal septum. Complete surgical excision of all associated endometriotic lesions was carried out during the same surgical procedure. During the mean follow-up period of 59 months no long-term complications were diagnosed.

CONCLUSION

Bladder endometriosis should be considered in patients who present with irritative urological symptoms with aggravation during menstruation or in patients with a history of endometriosis. When patients have symptoms we recommend surgical treatment in cases where medical treatment fails.