Endometriosis is a benign medical disorder characterized by the formation of glands and uterine tissues outside the uterus[2]. Despite the common occurrence of endometriosis, its impact on the urinary tract is a rare phenomenon. Urinary tract involvement can manifest in various locations, with statistics indicating that the majority occurs in the bladder, up to 85%[2]. This is usually attributed to fluctuations in hormone levels such as estrogen and progesterone, which can lead to primary or secondary infertility issues due to endometriosis[6]. This could explain the secondary infertility in our patient, who underwent diagnostic laparoscopy and adhesiolysis as part of an infertility assessment seven years ago.
Despite doubts surrounding the hypothesis of uterine tissue implantation as a result of surgical interventions, there is an observed increase in cases of endometriosis in the bladder, especially among women who have undergone pelvic surgeries, particularly cesarean sections[3]. This was evident in our patient who had a cesarean section five years ago and underwent ( Intracytoplasmic Sperm Injetion ) ICSI tube baby. In a previous study, Donnez and colleagues analyzed a series of cases and found that 4 out of 17 patients had undergone previous cesarean sections[1]. The clinical presentation of patients with bladder endometriosis (BE) varies significantly based on the size and location of the lesion. Common symptoms include increased urinary frequency, bladder pain, and difficulty urinating. Difficulty urinating has been observed in 21–69% of BE patients. The presence of blood in the urine during menstruation occurs in 20–25% of cases due to the effect on the mucosal layer. It is important to note that BE rarely penetrates the mucosal layer, making the presence of blood in the urine a rare occurrence[7].This rarity is what makes our case unique, as the patient presented to us with symptoms including the presence of blood in the urine. In a study conducted by Vercellini and colleagues, they observed bladder abnormalities in only two out of 40 women, noting that these two women did not experience any symptoms. The absence of periodic symptoms for pelvic uterine abnormalities may be related to the use of Mirena[1]. In the case of our patient, a 37-year-old married woman with a child, she has been suffering from recurrent urinary tract infections for a year, experiencing burning during urination and pelvic pain for three years. She had a history of bloody urine during menstruation two years ago, difficulty in sexual intercourse, along with the complaint of bloody discharge at the beginning of urination unrelated to menstruation. Based on these symptoms, a differential diagnosis was made:
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Uterine mass fibroid,Atypical bladder mass,Uterine bladder fistula, Bladder endometriosis, Sarcoma and Foreign body. Studies have shown that the assessment of urinary bladder deformities relies on the use of techniques such as uroscopy, magnetic resonance imaging. The research emphasizes the role of cystoscopy in diagnosing these deformities and even the possibility of taking samples for confirmation[1]. In our patient, upon conducting some laboratory tests, the following findings were observed:
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Urine analysis: the field is filled with red blood cells, Creatinine: 1 and INR: 2.5.
Upon requesting an ultrasound imaging for our patient, it was found that both kidneys are normal, but a 3 cm mass was noted on the posterior wall of the bladder.
Cystoscopy Report without Injection: An irregular solid mass on the upper posterior wall of the bladder triangle near the ureteric orifices without biopsy. Computed Tomography Report: A 3 cm mass on the posterior wall of the bladder extending towards the uterus suggesting origin from the bladder or a uterine wall mass protruding into the bladder. Additionally, a 5 cm ovarian cyst was observed on the left side. A bladder cystoscopy was requested for further evaluation, but the family refused this procedure. However, the patient mentioned that she underwent a bladder cystoscopy two years ago which was normal. Magnetic resonance imaging stands out as an effective method for evaluating endometriosis in the bladder. It distinguishes tissues with precision and offers advanced imaging capabilities, thereby providing a clearer visualization of the bladder wall layers compared to ultrasound imaging techniques. The features of bladder endometriosis in magnetic resonance imaging typically manifest as a low-density signal on T2-weighted images, and a medium-density signal on T1-weighted images, with the appearance of high-density signal spots at the interface between the T2 and T1 timings. According to research conducted by Medeiros and colleagues, pelvic magnetic resonance imaging shows a sensitivity of up to 0.6 (95% CI: 0.48–0.77) and an accuracy of 0.98 (95% CI: 0.96–0.99) in detecting cases of bladder endometriosis[2]. In our patient, she underwent MRI with sagittal, coronal, and axial sequences in T1 and T2 timings before injection, sagittal, coronal, and axial sequences in T1 after pelvic injection, followed by imaging with a closed 1.5 Tesla MRI machine. The findings were as follows: Scarring from a previous caesarean section was observed on the lower anterior wall of the uterus with thinning of the uterine wall. Thickening of the posterior bladder wall with decreased signal on T2 timing and several small high-signal cavities on T2 timing, measuring 16x23 mm, was noted. Also observed was thickening of the posterior uterine wall near the cervical region without explicit masses.
In this context, the discussion should revolve around treatment options, where medical therapy is considered the primary choice due to its safety and effectiveness. Hormonal therapies are the cornerstone in the treatment strategy, playing a crucial role in the treatment plan[7]. Using hormonal treatments along with oral contraceptives helps alleviate symptoms, although it is not considered a definitive cure[3]. It is important to note that medical literature advises resorting to hormonal therapy as a first step in cases where the condition is mild, and the patient does not have severe symptoms, especially if the patient desires future pregnancy[6]. Surgical treatment is considered necessary when medical treatment fails[3], as was the case with our patient who was treated with oral contraceptives (Dimsylate) but did not respond to the treatment.
When it comes to surgical treatment, our patient underwent a surgical procedure involving a vertical incision reaching the bladder, followed by a longitudinal incision in the bladder and suspension suture. There was no observed direct connection between the uterus and the bladder, but a solid, movable mass was noted on the posterior wall of the bladder. The mass was cautiously dissected, completely excised, sent to the pathology lab, and the posterior wall of the bladder was closed in two layers[8].
In conclusion, bladder endometriosis is a rare condition, usually accompanying other forms of endometriosis in the abdominal area. This underscores the importance of collaborating with a specialized team of physicians to ensure comprehensive excision of endometriosis and achieve thorough and effective care.