Endometriosis of the Urinary Bladder and Ureter: A Review and Update of the Literature

Abstract

Endometriosis of the urinary bladder and / or ureter are diseases that may occur alone or in association with endometriosis elsewhere in the pelvis or other sites of the body in women between the 2nd decades of life and the fifth decades of their lives typically in women who are menstruating but endometriosis of urinary bladder may occur / present in post-menopausal women on very rare occasions or in women with a past history of treatment for endometriosis elsewhere. Endometriosis of the urinary bladder and / or endometriosis of the ureter are uncommon diseases which tend to be reported sporadically globally. Endometriosis of the urinary bladder and / or ureter may be asymptomatic in some patients but other cases of endometriosis of the urinary bladder / and or ureter tend to present with non-specific symptoms including: suprapubic pain, urinary frequency and urgency, loin pain, dyspareunia, dysmenorrhoea, cyclical dysuria, and other non-specific symptoms including loin pain and infertility. A high-index of suspicion is required in order to diagnose the disease early with utilization of (a) various radiology imaging including ultrasound scan of pelvis and urinary tract, computed tomography scan of pelvis and urinary tract, or magnetic resonance imaging (MRI scan of pelvis and renal tract, (b) laparoscopy and biopsy of the endometriosis lesion for histopathology examination including immunohistochemistry studies of the specimen, (c) cystoscopy examination for further assessment. Diagnosis of endometriosis of the urinary bladder and / or ureter tends to be confirmed by pathology examination finding of endometrial glands and stroma in the excised or biopsy specimen and immunohistochemistry staining studies tend to exhibit the following features: (a) the endometrial stromal cells of endometriosis tend to stain positively upon immunohistochemistry staining for CD 10; (b) the glandular component of endometriosis does exhibit positive nuclear staining for p63; (c) the glandular component of endometriosis also stains positively for: CK7, ER oestrogen receptor, PR progesterone receptor; (d) endometriosis specimens also usually stain positively for: CA125. Treatment for endometriosis of bladder and or ureter could be conservative with inclusion of hormonal treatment, pain relief, and medications to reduce urinary bladder symptoms and this tends to be effective in many cases but recurrences tend to be higher in most cases in comparison with surgical treatment. Some of the surgical treatment for endometriosis of urinary bladder includes partial cystectomy ensuring completed excision of the endometriosis lesion or submucosal excision of the urinary bladder endometriosis lesion but leaving an intact urinary bladder mucosa. Surgical treatment of endometriosis of the ureter tend to involve (a) complete excision of the endometriosis segment of the ureter and end-to end ureteric anastomosis, or excision of the endometriotic ureter segment with either Boari-flap ureteric anastomosis to the urinary bladder or Psoas hitch anastomosis. Complication may occur following various treatment options adopted for the disease of the ureter and urinary bladder including recurrence, urinary urgency and urge incontinence, urinary stress incontinence, ureteric stenosis / stricture, vesico-ureteric reflux and these complications need to be treated and a long-period of follow-up would be required in order to also diagnose the late complications of the disease. Surgical excision surgery in the developed countries tend to be undertaken by the laparoscopic technique but in the developing countries that do not have facilities for laparoscopic surgery the open technique would tend to be adopted for all surgical treatment options of the disease.