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Bladder Detrusor Endometriosis: Clinical and Pathogenetic Implications
Val. 165,8446.
1996 Printed in U S A
BLADDER DETRUSOR ENDOMETRIOSIS: CLINICAL AND PATHOGENETIC IMPLICATIONS PAOLO VERCELLINI, MICHELE MESCHTA, OLGA DE GIORGI, STEFANIA PANMZA, ILENIA CORTESI AND PIER GIORGIO CROSIGNANI From the Clinica Ostetrica e Ginecologica "Luigi Mangingalli," University of Milano. Milnm, Italy
ABSTRACT
Purpose: We examined the pathogenesis of vesical endometriosis, identified the diagnostic signs and defined a successful management strategy. Materials and Methods: The records of 8 patients with bladder detrusor endometriosis were reviewed. Results: Two distinct forms of the condition appear to exist, that is spontaneous and postcesarean. In the former case the bladder lesion is a manifestationof a generalized pelvic disease, whereas &r iatrogenic dissemination growth of ectopic endometrium is usually limited to the bladder wall. The catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. Cystoscopy with biopsy was diagnostic in 3 cases. Ultrasonography revealed an endo-luminal vegetation and ruled out an anterior uterine leiomyoma, whereas magnetic resonance imaging did not add relevant information. Partial cystedomy appears to cure the urinary disturbances. Conclusions: We suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures. KEYWOW: endometriosis, bladder, menstruation About 1%of women with endometriosis have urinary tract lesions, of which 84% involve the bladder.' Vesical endometrio& may present with variable symptoms and subtle onset, &n mimickingrecurrent cystitis. Prompt recognition of the condition ia important to avoid prolonged morbidity and erroneous therapies, and to limit further involvement of the bladder wall. We reviewed the cases of vesical endometriosis observed in the last decade at a university hospital endometrioeis referral center to shed light on the pathogenesis of the condition, identi@the diagnostic signs and define a successful management stzategy. MATERIALS AND METHODS
We reviewed the records of patients who underwent clinical evaluation for endometriosis at our department of obstetrics and gynecology from 1985 to 1994 to identify cases with veeical lesions. Women were included in the study if they underwent abdomino-pelvic surgical exploration at either lapamtomy or lapamscopy, there was a sufficiently analytical description of the operation with particular reference to bladder involvement (only full thickness detrusor lesions were considered, excluding small subperitoneal nodules of the anterior cul-de-sac), there was histological confirmation of veeical endometriosis (endometrial glands and stroma), and they were available for followup examination. Eight women were identified who met the inclusion criteria. Mean patient age plus or minus standard deviation at diagnosis was 30 2 4 years (range 23 to 34).We excluded 1postmenop a d patient who underwent surgery for ovarian carcinoma with an incidental finding of an asymptomatic and inactive endometriotic bladder nodule, and 1 woman with a highly suggestive diagnosis of bladder endometriosis who decided to undergo surgery elsewhere and was lost to followup. RESULTS
Mean time from onset of urinary symptoms to diagnosis of bladder endometriosis in the 8 patients was 16 t 5 months Accepted for publication May 5,1995.
(range 7 to 28). Several bladder symptoms were reported, mainly frequency, urgency and pain at micturition with vesical tenesmus of varying severity, all of which were limited to the menstrual period. Only 1patient reported gross hematuria. In all cases anticholinergic drugs were used before referral to us and repeated treatments with antibiotics were prescribed despite negative urine cultures. Two women were treated with benzodiazepines on a long-term basis. All women had 1or more pain symptoms typical of endometrie sis (dysmenorrhea, deep dyspareunia and inter-menstrual pelvic pain). At vaginal examination a painful nodule was palpated above the anterior fornix contiguous with the anterior uterine wall in 7 patients. Other physical findings suggestive of pelvic endometriosis were noted in 6 patients (posterior fornix nodularity and tenderness in all 6,and a fixed ovarian cyst in 3). All patients underwent ultrasound (fig. 1,A), 5 underwent magnetic resonance imaging (MRI) (fig. 1, B ) and 1 underwent computerized tomography. All investigations revealed an endo-luminal vegetation on the posterior bladder wall above the trigonal area. Excretory urography in 6 patients demonstrated vesical filling defects and no ureteral involvement. Cystoscopy demonstrated an endo-luminal mass of the posterior bladder wall or dome in all cases but the typical bluish endometriotic nodules were observed in only 2 cases. The urothelium did not appear ulcerated and biopsy was diagnostic in 3 instances. After the diagnosis of endometriosis, all patients received medical therapy specific for the disease (progestogens, dana201, gestrinone or gonadotropin-releasinghormone agonists), which proved effective in relieving urological and gyneeologi d symptoms with no significant differences between treatment schedules. However, symptoms reappeared when the drugs were stepped. Six patients underwent laparotomy at our department and 2 underwent laparoscopy elsewhere. The 2 women with a previous cesarean section had no other remarkable sign of pelvic endometriosis,whereas the other 6 had diffuse endometriotic lesions located in the pouch of Douglas with infiltration of subperitoneal tissue and involve 84
BJADDER DETRUSOR ENDOMETRIOSIS
a5
FIG.1. A, transabdominal median longitudinal ultrasound scan of lvis with 3.5 MHz. probe. H rechogenic endo-luminal conical vegetation with small transsonic formations is seen in posterior wall oKladder (arrow, intravesical enrmetrioma. B , bladder. U,uterus). B,MRI of pelvis. Axial T2-weighted scan (TR2.0, TE 90) reveals endovesical vegetation (arrow) with low and intermediate intensity areas. Anterior profile of cervix ( C )is unimpaired.
FIG.2. A, intraoperative photograph of same case as in figure 1.Margins of incision on bladder dome are opened to demonstrate presence en. Nodule com of of full thickness endometriotic nodule (arrow) of sterior wall projectin into vesical lumen. B, operative s small bluish endometriotic cysts (arrow) embeddegn dense fibrotic tissueaas been excised h m bladder w a U . E e r urothelium C e n o t ulcerated.
FIG.3. Histological preparation of bladder detrusor endometie sis. Endometrial glands and stroma, and endometriotic cyst (C)lie in dense connective tissue matrix with scanty smooth muscle cells under vesical transitional (U)epithelium. H & E, reduced from X10.
ment of the anterior rectal and posterior vaginal walls in 4. In the 6 patients who underwent laparotomy bladder detrusor endometriotic lesions were easily excised by incision of the bladder dome (fig. 2,A) and enucleation of the nodule (fig. 2, B ) , which in no instance involved the ureteral meatus. In all cases histological examination demonstrated detrusor muscle endometriosis with endometrial glands and stroma lying in a dense connective tissue matrix with sparse smooth muscle fibers under the vesical transitional epithelium (fig. 3). Postoperatively 2 of the 4 women desiring children became pregnant and delivered a t term, and no urological symptoms recurred in the entire study group during a mean followup of 47 2 38 months (range 9 to 114). Two patients who underwent previous laparoscopy and who refused partial cystectomy are now asymptomatic on depot progestin therapy. DISCUSSION
According to our experience the 2 distinct forms of bladder detrusor endometriosis, spontaneous and iatrogenic, have
clearly different pathogenesis and clinical implications. In the former case the vesical lesion represents only 1 site of a more generalized disease. In the 6 women without a previous cesarean section other ovarian, peritoneal and vaginal implants were observed, with a manifest tendency toward extensive involvement of the pelvic viscera and infiltration of the subperitoneal structures. This finding suggests that in most instances extraperitoneal endometriosis derives from endo-peritoneal disease.2 On the other hand, in the 2 patients with a previous cesarean section the pelvis was virtually free of endometriosis. It is conceivable that in these 2 women the bladder lesion could have been caused by intraoperative dissemination of endometrial cells or a suboptimal surgical technique for closure of the low transverse uterine incision.3-6 From a clinical standpoint, the most reliable diagnostic signs were still history and physical examination, with particular reference to the catamenial onset or worsening of bladder symptoms (frequency, urgency, dysuria or tenesmus), coexistence with dysmenorrhea, and presence of an antero-uterine painful nodule and pelvic signs suggestive of endometnosis.' Hematuria was observed only in 1 case, which is not surprising since endometriosis rarely infiltrates and ulcerates the mucosal layer of hollow viscera like the bladder and rect~sigmoid.7Consequently, cystoscopy may not reveal the true nature of the lesion because the typical endometriotic bluish nodules are visible in only a minority of patients and biopsy may be nonspecific. However, in our opinion cystmcopy should always be performed to rule out epithelial cancer or other nonendometriotic tumors. Ultrasound scans performed with a full bladder, although nondiagnostic, revealed the endo-luminal nature of the lesion and identified a cleavage plane between the detruaor nodule and the uterine wall, excluding an anterior leiomyoma.8 In this regard, MRI did not provide M e r e n t or more precise information than ultrasound scans, and we would not recommend its routine performance. Excretory urography ie useful
86
BLADDER DETRUSOR ENDOMETRIOSIS
mainly to demonstrate any ureteral strictures and hydroureteronephrosis, and to schedule the o p e r a t i ~ n . ~ All anti-endometriosis medical therapies prescribed were highly successful temporarily but recurrence of symptoms was the rule a t drug withdrawal. However, a preoperative course of medical therapy may be helpful to support the diagnosis in doubtful cases. We performed laparotomy to excise the bladder lesion in accordance with Sircus et al, who recommended a transperitoneal abdominal approach.’ Because of the full thickness nature of the nodule we would not select transurethral resection, which, if complete, has a high risk of bladder perforation and, if partial, would result in a short-term recurrence.s In fact, the only postoperative relapse in our series was observed in a woman who underwent cystoscopic resection before referral to us. A laparoscopic approach is an interesting alternative in expert hands. lo CONCLUSIONS
We confirm that bladder detrusor endometriotic nodules can be managed successfully with a conservative operation for pelvic endometriosis. Because the nodule originates in the bladder dome, the intramural portion of the ureters usually is not affected. In our experience the urinary symptoms are definitively cured aRer intervention, whereas relief from dysmenorrhea and dyspareunia, and the reproductive prognosis are associated with severity of the genital lesions, which is coexistent in cases of spontaneous bladder endometriosis but absent or of marginal importance in patients with post-cesarean nodules. Given the frequently prolonged diagnostic
delay with related morbidity and erroneous treatments, we suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures. REFERENCES
1. Shook, T.E. and Nyberg, L. M.: Endometriosis of the urinary tract. Urology, 31: 1, 1988. 2. Brosens, I. A.,Puttemans, P., Deprest, J . and Rombauts, L.: The endometriosis cycle and its derailments. Hum. Reprod., 9:770, 1994. 3. Arap N e b , W.,Lopes, R. N., Cury, M., Montelatto, N. I. and Arap, S.: Vesical endometriosis. Urology, 24: 271,1984. 4. Aldridge, K.W.,Burns, J. R. and Singh, B.: Vesical endometriosis: a review and 2 case reports. J. Urol., 134:539, 1985. 5. Foster, R. S., Rink, R. C. and Mulcahy, J . J.: Vesical endometriosis: medical or surgical treatment. Urology, 29 64,1987. 6. Buka, N.J.: Vesical endometriosis afler cesarean section. h e r . J. Obst. Gynec., 158 1117, 1988. 7. Sircua, S.I., Sant, G. R. and Ucci, A. A., Jr.: Bladder detrusor endometriosis mimicking interstitial cystitis. Urology, 32 339, 1988. 8. Kumar, R.,Haque, A. K and Cohen, M. S.: Endometriosis of the urinary bladder: demonstration by sonography. J . Clin. Ultrasound, 12 363, 1984. 9. Schwartzwald, D.,Mooppan, U. M., Ohm, H. K. and Kim, H.: Endometriosis of bladder. Urology, 39 219, 1992. 10. Nezhat, C. R.and Nezhat, F. R.: Laparoscopic segmental bladder resection for endometriosis: a report of two cases. Obst. Gynec., 81:882,1993.
1996 Printed in U S A
BLADDER DETRUSOR ENDOMETRIOSIS: CLINICAL AND PATHOGENETIC IMPLICATIONS PAOLO VERCELLINI, MICHELE MESCHTA, OLGA DE GIORGI, STEFANIA PANMZA, ILENIA CORTESI AND PIER GIORGIO CROSIGNANI From the Clinica Ostetrica e Ginecologica "Luigi Mangingalli," University of Milano. Milnm, Italy
ABSTRACT
Purpose: We examined the pathogenesis of vesical endometriosis, identified the diagnostic signs and defined a successful management strategy. Materials and Methods: The records of 8 patients with bladder detrusor endometriosis were reviewed. Results: Two distinct forms of the condition appear to exist, that is spontaneous and postcesarean. In the former case the bladder lesion is a manifestationof a generalized pelvic disease, whereas &r iatrogenic dissemination growth of ectopic endometrium is usually limited to the bladder wall. The catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. Cystoscopy with biopsy was diagnostic in 3 cases. Ultrasonography revealed an endo-luminal vegetation and ruled out an anterior uterine leiomyoma, whereas magnetic resonance imaging did not add relevant information. Partial cystedomy appears to cure the urinary disturbances. Conclusions: We suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures. KEYWOW: endometriosis, bladder, menstruation About 1%of women with endometriosis have urinary tract lesions, of which 84% involve the bladder.' Vesical endometrio& may present with variable symptoms and subtle onset, &n mimickingrecurrent cystitis. Prompt recognition of the condition ia important to avoid prolonged morbidity and erroneous therapies, and to limit further involvement of the bladder wall. We reviewed the cases of vesical endometriosis observed in the last decade at a university hospital endometrioeis referral center to shed light on the pathogenesis of the condition, identi@the diagnostic signs and define a successful management stzategy. MATERIALS AND METHODS
We reviewed the records of patients who underwent clinical evaluation for endometriosis at our department of obstetrics and gynecology from 1985 to 1994 to identify cases with veeical lesions. Women were included in the study if they underwent abdomino-pelvic surgical exploration at either lapamtomy or lapamscopy, there was a sufficiently analytical description of the operation with particular reference to bladder involvement (only full thickness detrusor lesions were considered, excluding small subperitoneal nodules of the anterior cul-de-sac), there was histological confirmation of veeical endometriosis (endometrial glands and stroma), and they were available for followup examination. Eight women were identified who met the inclusion criteria. Mean patient age plus or minus standard deviation at diagnosis was 30 2 4 years (range 23 to 34).We excluded 1postmenop a d patient who underwent surgery for ovarian carcinoma with an incidental finding of an asymptomatic and inactive endometriotic bladder nodule, and 1 woman with a highly suggestive diagnosis of bladder endometriosis who decided to undergo surgery elsewhere and was lost to followup. RESULTS
Mean time from onset of urinary symptoms to diagnosis of bladder endometriosis in the 8 patients was 16 t 5 months Accepted for publication May 5,1995.
(range 7 to 28). Several bladder symptoms were reported, mainly frequency, urgency and pain at micturition with vesical tenesmus of varying severity, all of which were limited to the menstrual period. Only 1patient reported gross hematuria. In all cases anticholinergic drugs were used before referral to us and repeated treatments with antibiotics were prescribed despite negative urine cultures. Two women were treated with benzodiazepines on a long-term basis. All women had 1or more pain symptoms typical of endometrie sis (dysmenorrhea, deep dyspareunia and inter-menstrual pelvic pain). At vaginal examination a painful nodule was palpated above the anterior fornix contiguous with the anterior uterine wall in 7 patients. Other physical findings suggestive of pelvic endometriosis were noted in 6 patients (posterior fornix nodularity and tenderness in all 6,and a fixed ovarian cyst in 3). All patients underwent ultrasound (fig. 1,A), 5 underwent magnetic resonance imaging (MRI) (fig. 1, B ) and 1 underwent computerized tomography. All investigations revealed an endo-luminal vegetation on the posterior bladder wall above the trigonal area. Excretory urography in 6 patients demonstrated vesical filling defects and no ureteral involvement. Cystoscopy demonstrated an endo-luminal mass of the posterior bladder wall or dome in all cases but the typical bluish endometriotic nodules were observed in only 2 cases. The urothelium did not appear ulcerated and biopsy was diagnostic in 3 instances. After the diagnosis of endometriosis, all patients received medical therapy specific for the disease (progestogens, dana201, gestrinone or gonadotropin-releasinghormone agonists), which proved effective in relieving urological and gyneeologi d symptoms with no significant differences between treatment schedules. However, symptoms reappeared when the drugs were stepped. Six patients underwent laparotomy at our department and 2 underwent laparoscopy elsewhere. The 2 women with a previous cesarean section had no other remarkable sign of pelvic endometriosis,whereas the other 6 had diffuse endometriotic lesions located in the pouch of Douglas with infiltration of subperitoneal tissue and involve 84
BJADDER DETRUSOR ENDOMETRIOSIS
a5
FIG.1. A, transabdominal median longitudinal ultrasound scan of lvis with 3.5 MHz. probe. H rechogenic endo-luminal conical vegetation with small transsonic formations is seen in posterior wall oKladder (arrow, intravesical enrmetrioma. B , bladder. U,uterus). B,MRI of pelvis. Axial T2-weighted scan (TR2.0, TE 90) reveals endovesical vegetation (arrow) with low and intermediate intensity areas. Anterior profile of cervix ( C )is unimpaired.
FIG.2. A, intraoperative photograph of same case as in figure 1.Margins of incision on bladder dome are opened to demonstrate presence en. Nodule com of of full thickness endometriotic nodule (arrow) of sterior wall projectin into vesical lumen. B, operative s small bluish endometriotic cysts (arrow) embeddegn dense fibrotic tissueaas been excised h m bladder w a U . E e r urothelium C e n o t ulcerated.
FIG.3. Histological preparation of bladder detrusor endometie sis. Endometrial glands and stroma, and endometriotic cyst (C)lie in dense connective tissue matrix with scanty smooth muscle cells under vesical transitional (U)epithelium. H & E, reduced from X10.
ment of the anterior rectal and posterior vaginal walls in 4. In the 6 patients who underwent laparotomy bladder detrusor endometriotic lesions were easily excised by incision of the bladder dome (fig. 2,A) and enucleation of the nodule (fig. 2, B ) , which in no instance involved the ureteral meatus. In all cases histological examination demonstrated detrusor muscle endometriosis with endometrial glands and stroma lying in a dense connective tissue matrix with sparse smooth muscle fibers under the vesical transitional epithelium (fig. 3). Postoperatively 2 of the 4 women desiring children became pregnant and delivered a t term, and no urological symptoms recurred in the entire study group during a mean followup of 47 2 38 months (range 9 to 114). Two patients who underwent previous laparoscopy and who refused partial cystectomy are now asymptomatic on depot progestin therapy. DISCUSSION
According to our experience the 2 distinct forms of bladder detrusor endometriosis, spontaneous and iatrogenic, have
clearly different pathogenesis and clinical implications. In the former case the vesical lesion represents only 1 site of a more generalized disease. In the 6 women without a previous cesarean section other ovarian, peritoneal and vaginal implants were observed, with a manifest tendency toward extensive involvement of the pelvic viscera and infiltration of the subperitoneal structures. This finding suggests that in most instances extraperitoneal endometriosis derives from endo-peritoneal disease.2 On the other hand, in the 2 patients with a previous cesarean section the pelvis was virtually free of endometriosis. It is conceivable that in these 2 women the bladder lesion could have been caused by intraoperative dissemination of endometrial cells or a suboptimal surgical technique for closure of the low transverse uterine incision.3-6 From a clinical standpoint, the most reliable diagnostic signs were still history and physical examination, with particular reference to the catamenial onset or worsening of bladder symptoms (frequency, urgency, dysuria or tenesmus), coexistence with dysmenorrhea, and presence of an antero-uterine painful nodule and pelvic signs suggestive of endometnosis.' Hematuria was observed only in 1 case, which is not surprising since endometriosis rarely infiltrates and ulcerates the mucosal layer of hollow viscera like the bladder and rect~sigmoid.7Consequently, cystoscopy may not reveal the true nature of the lesion because the typical endometriotic bluish nodules are visible in only a minority of patients and biopsy may be nonspecific. However, in our opinion cystmcopy should always be performed to rule out epithelial cancer or other nonendometriotic tumors. Ultrasound scans performed with a full bladder, although nondiagnostic, revealed the endo-luminal nature of the lesion and identified a cleavage plane between the detruaor nodule and the uterine wall, excluding an anterior leiomyoma.8 In this regard, MRI did not provide M e r e n t or more precise information than ultrasound scans, and we would not recommend its routine performance. Excretory urography ie useful
86
BLADDER DETRUSOR ENDOMETRIOSIS
mainly to demonstrate any ureteral strictures and hydroureteronephrosis, and to schedule the o p e r a t i ~ n . ~ All anti-endometriosis medical therapies prescribed were highly successful temporarily but recurrence of symptoms was the rule a t drug withdrawal. However, a preoperative course of medical therapy may be helpful to support the diagnosis in doubtful cases. We performed laparotomy to excise the bladder lesion in accordance with Sircus et al, who recommended a transperitoneal abdominal approach.’ Because of the full thickness nature of the nodule we would not select transurethral resection, which, if complete, has a high risk of bladder perforation and, if partial, would result in a short-term recurrence.s In fact, the only postoperative relapse in our series was observed in a woman who underwent cystoscopic resection before referral to us. A laparoscopic approach is an interesting alternative in expert hands. lo CONCLUSIONS
We confirm that bladder detrusor endometriotic nodules can be managed successfully with a conservative operation for pelvic endometriosis. Because the nodule originates in the bladder dome, the intramural portion of the ureters usually is not affected. In our experience the urinary symptoms are definitively cured aRer intervention, whereas relief from dysmenorrhea and dyspareunia, and the reproductive prognosis are associated with severity of the genital lesions, which is coexistent in cases of spontaneous bladder endometriosis but absent or of marginal importance in patients with post-cesarean nodules. Given the frequently prolonged diagnostic
delay with related morbidity and erroneous treatments, we suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures. REFERENCES
1. Shook, T.E. and Nyberg, L. M.: Endometriosis of the urinary tract. Urology, 31: 1, 1988. 2. Brosens, I. A.,Puttemans, P., Deprest, J . and Rombauts, L.: The endometriosis cycle and its derailments. Hum. Reprod., 9:770, 1994. 3. Arap N e b , W.,Lopes, R. N., Cury, M., Montelatto, N. I. and Arap, S.: Vesical endometriosis. Urology, 24: 271,1984. 4. Aldridge, K.W.,Burns, J. R. and Singh, B.: Vesical endometriosis: a review and 2 case reports. J. Urol., 134:539, 1985. 5. Foster, R. S., Rink, R. C. and Mulcahy, J . J.: Vesical endometriosis: medical or surgical treatment. Urology, 29 64,1987. 6. Buka, N.J.: Vesical endometriosis afler cesarean section. h e r . J. Obst. Gynec., 158 1117, 1988. 7. Sircua, S.I., Sant, G. R. and Ucci, A. A., Jr.: Bladder detrusor endometriosis mimicking interstitial cystitis. Urology, 32 339, 1988. 8. Kumar, R.,Haque, A. K and Cohen, M. S.: Endometriosis of the urinary bladder: demonstration by sonography. J . Clin. Ultrasound, 12 363, 1984. 9. Schwartzwald, D.,Mooppan, U. M., Ohm, H. K. and Kim, H.: Endometriosis of bladder. Urology, 39 219, 1992. 10. Nezhat, C. R.and Nezhat, F. R.: Laparoscopic segmental bladder resection for endometriosis: a report of two cases. Obst. Gynec., 81:882,1993.