Bladder Endometriosis

It is recommended to read the ‘Overview’ page prior. The anatomy of the urinary system and general overview of endometriosis among each organ is discussed before disease specific to each organ is detailed further on their respective pages.

The bladder is the most common urinary organ affected. Lesions may be isolated or singular/multiple with concurrent endometriosis in other regions.

As noted in the ‘Overview’ page, 30% of those with endometriosis of the bladder do not report symptoms. (1,2) The average diameter of endometriosis lesions at time of identification is 1-2cm. (1)

Endometriosis of the bladder commonly causes problems with urine storage or excretion. Lesions reduce the bladder’s ability to expand. As a result, increased frequency and urgency to void smaller volumes is common. This is oft related to lesions found in the dome and body of the bladder. For lesions lower down toward the urethra (parametrium), lesions may grow, swell and restrict urine outflow. This can lead to less urine passed from the body and higher residuals left within the bladder. As a side-effect, retained urine promotes bacteria growth. This increases the probability of recurrent urinary tract infections. Lesions in the parametrium may also lead to unintentional leakage of urine (incontinence). (3)

Symptoms (1):

Bladder:

Increased frequency and urgency (commonly reported @ 70%)
Pain with urination (dysuria)
Pain directly above the pubic bones
Recurrent urinary tract infections (infrequently reported)
Blood in the urine (20-35% report hematuria. 40% of these occurs @ menses)

General:

Painful Menstruation (dysmennorhea)
Painful Intimacy (penetration) (dyspareunia)

Differential Diagnosis Bladder Endometriosis versus:

A variety of conditions which affect the bladder can present similarly. (1,4) Based upon history and clinical exam, a variety of tests may be completed to determine the cause(s) of concern. These include, but are not limited to:

Overactive Bladder
Bladder Carcinoma
Interstitial Cystitis
Chronic Urethral Syndrome

Examination and Adjunct Tests:

If you present your concerns to a gynecologist, a bimanual examination is important to determine location of any tenderness, nodules or thickening(s) and visual abnormalities. A urine sample should be given to determine bacteria count and presence of any blood products: invisible (micro) or visible (macro) and white blood cells.

Imaging:

The use of Transvaginal Ultrasound (TVUS) has been a long-standing reliable imaging system to detect and differentiate endometriosis lesions from other abnormalities specific to the urinary system. A recent investigation of 207 subjects to determine accuracy of preoperative TVUS use to detect bladder endometriosis was 93% sensitive (7% of bladder lesions found at surgery were NOT detected with TVUS preoperative imaging) and 99% specific (1% of abnormalitie(s) detected was no endometriosis, but another finding) in detection of bladder lesions. (5) In 207 subjects, 50 UTE lesions were found with TVUS; 30/50 involved the bladder and 23/50 developed various degrees of hydronephrosis (indicating a degree of obstruction to urine flow through the ureter). Note: A separate trans-abdominal ultrasound imaging must be performed to visualize the kidney and upper ureter(s).

Although the distal ureter and bladder are not routine and comprehensively scanned in routine TVUS use, it is suggested that:

“Ultrasound should be part of all diagnostic evaluations for urinary endometriosis despite lack of urinary symptoms, especially if deep infiltrating endometriosis is present” (6) – Pateman K (2015)

TVUS is inexpensive, easy to administer and can often be completed in the same visit without contraindications. Although MRI is sensitive and specific to detect endometriosis lesions in this area, it is significantly more expensive.

Medical Management:

The natural progression of endometriosis is fibrosis. The older the disease, the greater it’s fibrotic content. As discussed above, progressive fibrosis and lesion location reduces the bladders flexibility. The bladder becomes more rigid. This leads to reduced volume of urine storage and long-term urinary frequency. Imagine the loss of sleep at night? Fibrosis reduces the ability to regulate urine release and impair urine flow rates. Incontinence is not enjoyable. Hormone therapy doesn’t resolve progressive fibrosis. Fibrosis plays a significant role in long-term bladder dysfunction.

“The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation (but we also know that endometriosis lesions can create their own estrogen), with no effect on the scarring caused by the tissue” (1) – Maccagnano, C et al. (2012)

It is important to recall that 30% cases are asymptomatic and the 70% who are symptomatic, lesion size average 1-2 cm. This is significant to understand lesion impact before medical management is even considered.

To determine the efficacy of medical management of those with Deep Infiltrating Endometriosis, a database review of 70 original and 4 review articles from 1996 to 2011 was completed. The subgroup of those with concurrent UTE had a disease recurrence rate of 56%. (1) The authors concluded that surgical excision is appropriate and that:

“Medical management appears to have a high recurrence rate after cessation, and is often considered a palliative modality for the treatment of bladder endometriosis”(1) – Maccagnano C et al. (2012)

Surgical Management:

A few techniques to assess and remove endometriosis lesions of the bladder have evolved over the years.

To visualize the interior of the bladder, a cystoscopy is performed. A small camera is inserted through the urethra. This approach can only detected lesions which are full-thickness (grown through all layers of the bladder wall). A procedure known as Transurethral resection has been used to remove lesions which have penetrated the bladder wall completely. This was an attempt to avoid transabdominal surgery. However, recurrence of disease has been reported more frequent with transurethral approach to resection due to incomplete lesion removal unless combined with laparoscopic partial cystectomy which allows visualization of the external surface of the bladder and remove any residual partial-thickness disease which cannot be visualized through the transurethral scope. (1,9,10)

Bladder Endometriosis Citations

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