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Postmenopausal vesical endometriosis
POSTMENOPAUSAL BERT VORSTMAN, CHARLES VICTOR
VESICAL ENDOMETRIOSIS
F.R.A.C.S.
LYNNE, M.D. A. POLITANO,
M.D.
From the Department of Urology, University of Miami School of Medicine, Miami, Florida
ABSTRACT-Vesical endometriosis in a postmenopausal patient is reported. An abdominal hysterectomy had been performed twenty-four years previously, and exogenous estrogens had not been adminktered. The patient was treated surgically with a partial cystectomy.
Endometriosis of the genitourinary tract is a rare clinical occurrence. 1,2 Vesical endometriosis was first reported by Judd in 1921.2a A review by Fein and Horton in 19663 indicated that vesical endometriosis occurs in about 2 per cent of all types of endometriosis reported. The occurrence of vesical endometriosis in the male has been documented following prolonged estrogen treatment for prostatic carcinoma.4,5 We believe this is the first report of endometriosis of the bladder in a postmenopausal female patient not taking exogenous hormones. Case Report A sixty-four-year-old married, black woman with a two-month history of painless hematuria was seen at Jackson Memorial Hospital. She had suffered a similar episode seven years previously. The patient also admitted to symptoms of stress incontinence and suprapubic discomfort. There were no other urologic symptoms. Her systems review was unremarkable. The patient was gravida 1 para 0. She had a past medical history of paroxysmal atria1 tachycardia, mitral valve prolapse, and chronic paranoid schizophrenia. Past surgical history included an appendectomy at the age of eighteen and a transabdominal hysterectomy for “fibroids” at the age of forty-one. Previous pathologic disease could not be confirmed.
540
Currently, she was taking propranolol40 mg qid, thioridazine 25 mg bid, trihexyphenidyl25 mg bid, and hydrochlorothiazide 50 mg daily. At no time did she take any hormone preparations. Physical examination was remarkable for a tarditive dyskinesia and an old lower midline abdominal scar. Some suprapubic discomfort was noted on deep palpation, The external genitalia were unremarkable. A vaginal examination revealed a cystocele. Her vital signs were normal, and results of routine laboratory tests were within normal limits. Her urine was uninfected. A carbon dioxide cystometrogram was normal. Cystoscopic examination (outpatient) under local anesthesia prior to admission confirmed the cystocele and a postvoid residual of 80 cc. In addition, a nodular lesion on the upper right posterior bladder wall was seen. Bimanual examination confirmed a small, slightly tender, mobile, mass palpable in the posterior bladder wall. The patient had a positive Marshall’s test. An excretory urogram revealed a filling defect in the posterior-superior aspect of the bladder, but was otherwise unremarkable. She was admitted to the hospital, and a transurethral biopsy of this lesion was reported as endometriosis of the bladder. The patient underwent a partial cystectomy. A nodule of endometriosis extending from the
UROLOGY
/
NOVEMBER
1983
/
VOLUME XXII, NUMBER 5
right ovary to and through the contiguous bladder wall was excised; left oophorectomy and Marshal-Marchetti operation were done. Postoperatively, her postvoid residual was about 125 ml, but this was significantly decreased by stopping her propranolol and thioridazine, and substituting metroprolol. Pathologic examination revealed extensive endometrial glandular structures in a cellular and vascular stroma involving the bladder wall and right ovary. The left ovary was similarly involved. They were otherwise atrophic with no evidence of activity. Comment Endometriosis means ectopic endometrial tissue, and though it may involve any part of the upper urinary system, it is most commonly found in the pelvis .6 The pathogenesis behind this ectopic endometriosis has not been determined, but the theories have been broadly classified into 3 groups: embryonic, metaplastic, and migratory.’ Within these groups, however, we have a multitude of theories with possibly the best explanation being provided by the migratory theory. There appear to be no obvious predisposing factors toward the development of endometriosis. However, Abeshouse and Abeshouse,’ in their review of genitourinary involvement by endometriosis, found that 39 of their 56 cases had had previous pelvic surgery. No particular type of surgery manifested a tendency for endometriosis to develop, but they emphasized the value of using a cautious surgical technique in the pelvis to prevent dissemination of endometrial tissue. Vesical endometriosis occurs in about 2 per cent of all cases of endometriosis, commonly in the posterior bladder wall, and usually in women in the twenty to forty-year-old group.3 In postmenopausal women, 1 case has been reported in a patient taking exogenous estrogens.’ There are no classic features to vesical endometriosis, but about 80 per cent will have a sense of pressure in the suprapubic area, usually relieved by voiding .2 Other symptomatology commonly elicited are pelvic pain, dysmenorrhea, dyspareunia, and irregular vaginal bleeding.8 Cyclical flank pain from hydronephrosis also may indicate ureteral involvement,Q About 75 per cent will admit to irritative symptoms such as frequency, urgency, and burning, and according to Fein and Horton3 a quarter of the patients will have gross hematuria with cyclical
UROLOGY
i
NOVEMBER
1983
/
symptomatology in relation to their menses. Relevant physical findings in about half the women will be a palpable pelvic mass on bimanual examination.3 Radiologic investigation such as excretory urography and cystography may reveal a filling defect. CT may be useful in delineating the extent of the bladder and/or pelvic lesion. Cystoscopically, endometriosis usually is seen as a nodule with one or more bluish bullae beneath the mucosa.‘O They are most frequently found on the posterior wall or base of the bladder, and their appearance varies with the hormonal phase of the menstrual cycle.” Abeshouse and Abeshouse’ have reviewed the cystoscopic findings and summarized the appearances as follows: (1) premenstrually, the elevated vesical mucous membrane may show congestion and edema, giving a fold-like appearance. Cyst-like structures may be discernable through the mucosa. (2) During menstruation, there may be congested swelling with bluish black cystic areas; actual bleeding and sloughing may be observed. (3) Postmenstruation, congestion and edema may be less marked with bluish black cysts losing color intensity. (4) Intermenstrually, considerable decrease in congestion may occur. There may be a few blueblack cysts, and the mucosa may have a diffuse and irregular, spotty, yellowish red coloration. Pregnancy may lead to a temporary abatement and improvement of cystoscopic appearance. Biopsies are recommended, but previous studies have seldom shown these to be diagnostic.3 Other pathologic entities in the differential diagnosis would include benign tumors such as angiomas and malignancies, primary or secondary, of the bladder. According to Novak’s textbook, there is considerable variation in endometrial histology.12 The essential criterion is the presence of endometrial tissue in the wall of the cyst, preferably stromal as well as glandular.12 The endometrial lining of the cyst cavities may disappear because of desquamation and a lining of reactive connective tissue may be obvious. Pseudoxanthoma cells are usually present. Malignant vesical endometriosis has not been documented.i3 Treatment is, in the first instance, preventative in that pelvic surgery is performed carefully to prevent spillage of endometrial tissue. Definitive treatment of vesical endometriosis must be individualized after consideration of age, marital status, possible future pregnancies, severity of symptoms, and associated disease.’
VOLUME XXII, NUMBER 5
541
Nonsurgical treatment modalities include hormonal therapy and radiotherapy to arrest ovarian activity. Endometriosis undergoes regression during amenorrhea of menopause and improves in the latter part of pregnancy. Various hormone manipulations in the treatment of endometriosis have been described.14 These include pseudopregnancy induced with various estrogenprogesterone preparations, the use of androgens, the induction of hyperhormonal amenorrhea with estrogens, the induction of a pseudomenopause through ovarian suppression, and hypoestrogenic amenorrhea with use of danazol. Radiotherapy to the ovaries has in general given poor results, either in combination with other therapy or alonea Surgery is performed in those with severe disease or in those with an associated surgical condition. This may be conservative to excise all endometrial-bearing tissue preserving uterus and ovaries or definitive surgery with resection of endometriosis and ovaries and uterus.14 Partial cystectomy is best performed through a transperitoneal approach since it affords adequate exploration of the pelvis.8 Transurethral fulguration has no place in the treatment of vesical endometriosis since the disease extends through the bladder wallee Endometriosis in the postmenopausal woman is uncommon, and it is important to rule out ovarian cancer. A workup in this instance would include obtaining plasma estradiol levels (raised in functioning ovarian tissue) and follicle-stimulating hormone levels (< 40 IU with
542
functioning ovarian tissue). Definitive treatment then would be excision of the ovaries and surgery for any other associated conditions. F’.O.Box 016217 Miami, Florida 33101 (DR. LYNNE) References 1. Stewart WW, and Ireland GW: Vesical endometriosis in a postmenopausal woman, J Urol 118: 480 (1977). 2. Skor AB. Warren MM. and Mueller EO: Endometriosis of bladder, Urology 9: 689 (1977). 2a. Judd ES: Adenomyomata presenting as tumor of the bladder, Surg Clin North Am 1: 1271 (1921). 3. Fein RL, and Horton BF: Vesical endometriosis, a case report and review of the literature, J Urol 95: 45 (1966). 4. Oliker AJ, and Harris AE: Endometriosis of the bladder in the male patient, ibid. 106: 858 (1971). 5. Pinkert TC. Catlow CE. and Straus R: Endometriosis of the urinary bladder in a man with prostatic carcinoma, Cancer 43: d 1562 (1979). 6. O’Connor VJ, and Greenhill JP: Endometriosis of the bladder and ureter, Surg Gynecol Obstet 80: 113 (1945). 7. Abeshouse BS. and Abeshouse G: Endometriosis of the urinary tract: a review of the literature and a report of 4 cases of vesical endometriosis, J Int Co11 Surg 34: 43 (1960). 8. Ranney B: Endometriosis, III.-complete operations, Am J Obstet Gvnecol 109: 1137 (1971). 9. Ball TL, and Platt MA: Urologic complications of endometriosis, ibid. 84: 1516 (1962). 10. Lichtenheld FR, McCauley RT, and Staples PP: Endometriosis involving the urinary tract, a collective review, Obstet Gynecol 17: 762 (1961). 11. Iwano JH, and Ewing GE: Endometriosis of the bladder, J Urol 166: 614 (1968). 12. Jones GS, and Jones HW: Novak’s Textbook of Gynecology, ed 10, Baltimore, Williams and Wilkins Co, chap 25,1981, p 478. 13. Stanley KE, Utz DC, and Dockerty MB: Clinically significant endometriosis of the urinary tract, Surg Gynecol Obstet 120: 491 (1965). 14. Dmowski WP: Current concepts in the management of endometriosis, Obstet Gynecol Ann 10: 279 (1981).
UROLOGY
/ NOVEMBER
1983
/ VOLUME
XXII, NUMBER
5
VESICAL ENDOMETRIOSIS
F.R.A.C.S.
LYNNE, M.D. A. POLITANO,
M.D.
From the Department of Urology, University of Miami School of Medicine, Miami, Florida
ABSTRACT-Vesical endometriosis in a postmenopausal patient is reported. An abdominal hysterectomy had been performed twenty-four years previously, and exogenous estrogens had not been adminktered. The patient was treated surgically with a partial cystectomy.
Endometriosis of the genitourinary tract is a rare clinical occurrence. 1,2 Vesical endometriosis was first reported by Judd in 1921.2a A review by Fein and Horton in 19663 indicated that vesical endometriosis occurs in about 2 per cent of all types of endometriosis reported. The occurrence of vesical endometriosis in the male has been documented following prolonged estrogen treatment for prostatic carcinoma.4,5 We believe this is the first report of endometriosis of the bladder in a postmenopausal female patient not taking exogenous hormones. Case Report A sixty-four-year-old married, black woman with a two-month history of painless hematuria was seen at Jackson Memorial Hospital. She had suffered a similar episode seven years previously. The patient also admitted to symptoms of stress incontinence and suprapubic discomfort. There were no other urologic symptoms. Her systems review was unremarkable. The patient was gravida 1 para 0. She had a past medical history of paroxysmal atria1 tachycardia, mitral valve prolapse, and chronic paranoid schizophrenia. Past surgical history included an appendectomy at the age of eighteen and a transabdominal hysterectomy for “fibroids” at the age of forty-one. Previous pathologic disease could not be confirmed.
540
Currently, she was taking propranolol40 mg qid, thioridazine 25 mg bid, trihexyphenidyl25 mg bid, and hydrochlorothiazide 50 mg daily. At no time did she take any hormone preparations. Physical examination was remarkable for a tarditive dyskinesia and an old lower midline abdominal scar. Some suprapubic discomfort was noted on deep palpation, The external genitalia were unremarkable. A vaginal examination revealed a cystocele. Her vital signs were normal, and results of routine laboratory tests were within normal limits. Her urine was uninfected. A carbon dioxide cystometrogram was normal. Cystoscopic examination (outpatient) under local anesthesia prior to admission confirmed the cystocele and a postvoid residual of 80 cc. In addition, a nodular lesion on the upper right posterior bladder wall was seen. Bimanual examination confirmed a small, slightly tender, mobile, mass palpable in the posterior bladder wall. The patient had a positive Marshall’s test. An excretory urogram revealed a filling defect in the posterior-superior aspect of the bladder, but was otherwise unremarkable. She was admitted to the hospital, and a transurethral biopsy of this lesion was reported as endometriosis of the bladder. The patient underwent a partial cystectomy. A nodule of endometriosis extending from the
UROLOGY
/
NOVEMBER
1983
/
VOLUME XXII, NUMBER 5
right ovary to and through the contiguous bladder wall was excised; left oophorectomy and Marshal-Marchetti operation were done. Postoperatively, her postvoid residual was about 125 ml, but this was significantly decreased by stopping her propranolol and thioridazine, and substituting metroprolol. Pathologic examination revealed extensive endometrial glandular structures in a cellular and vascular stroma involving the bladder wall and right ovary. The left ovary was similarly involved. They were otherwise atrophic with no evidence of activity. Comment Endometriosis means ectopic endometrial tissue, and though it may involve any part of the upper urinary system, it is most commonly found in the pelvis .6 The pathogenesis behind this ectopic endometriosis has not been determined, but the theories have been broadly classified into 3 groups: embryonic, metaplastic, and migratory.’ Within these groups, however, we have a multitude of theories with possibly the best explanation being provided by the migratory theory. There appear to be no obvious predisposing factors toward the development of endometriosis. However, Abeshouse and Abeshouse,’ in their review of genitourinary involvement by endometriosis, found that 39 of their 56 cases had had previous pelvic surgery. No particular type of surgery manifested a tendency for endometriosis to develop, but they emphasized the value of using a cautious surgical technique in the pelvis to prevent dissemination of endometrial tissue. Vesical endometriosis occurs in about 2 per cent of all cases of endometriosis, commonly in the posterior bladder wall, and usually in women in the twenty to forty-year-old group.3 In postmenopausal women, 1 case has been reported in a patient taking exogenous estrogens.’ There are no classic features to vesical endometriosis, but about 80 per cent will have a sense of pressure in the suprapubic area, usually relieved by voiding .2 Other symptomatology commonly elicited are pelvic pain, dysmenorrhea, dyspareunia, and irregular vaginal bleeding.8 Cyclical flank pain from hydronephrosis also may indicate ureteral involvement,Q About 75 per cent will admit to irritative symptoms such as frequency, urgency, and burning, and according to Fein and Horton3 a quarter of the patients will have gross hematuria with cyclical
UROLOGY
i
NOVEMBER
1983
/
symptomatology in relation to their menses. Relevant physical findings in about half the women will be a palpable pelvic mass on bimanual examination.3 Radiologic investigation such as excretory urography and cystography may reveal a filling defect. CT may be useful in delineating the extent of the bladder and/or pelvic lesion. Cystoscopically, endometriosis usually is seen as a nodule with one or more bluish bullae beneath the mucosa.‘O They are most frequently found on the posterior wall or base of the bladder, and their appearance varies with the hormonal phase of the menstrual cycle.” Abeshouse and Abeshouse’ have reviewed the cystoscopic findings and summarized the appearances as follows: (1) premenstrually, the elevated vesical mucous membrane may show congestion and edema, giving a fold-like appearance. Cyst-like structures may be discernable through the mucosa. (2) During menstruation, there may be congested swelling with bluish black cystic areas; actual bleeding and sloughing may be observed. (3) Postmenstruation, congestion and edema may be less marked with bluish black cysts losing color intensity. (4) Intermenstrually, considerable decrease in congestion may occur. There may be a few blueblack cysts, and the mucosa may have a diffuse and irregular, spotty, yellowish red coloration. Pregnancy may lead to a temporary abatement and improvement of cystoscopic appearance. Biopsies are recommended, but previous studies have seldom shown these to be diagnostic.3 Other pathologic entities in the differential diagnosis would include benign tumors such as angiomas and malignancies, primary or secondary, of the bladder. According to Novak’s textbook, there is considerable variation in endometrial histology.12 The essential criterion is the presence of endometrial tissue in the wall of the cyst, preferably stromal as well as glandular.12 The endometrial lining of the cyst cavities may disappear because of desquamation and a lining of reactive connective tissue may be obvious. Pseudoxanthoma cells are usually present. Malignant vesical endometriosis has not been documented.i3 Treatment is, in the first instance, preventative in that pelvic surgery is performed carefully to prevent spillage of endometrial tissue. Definitive treatment of vesical endometriosis must be individualized after consideration of age, marital status, possible future pregnancies, severity of symptoms, and associated disease.’
VOLUME XXII, NUMBER 5
541
Nonsurgical treatment modalities include hormonal therapy and radiotherapy to arrest ovarian activity. Endometriosis undergoes regression during amenorrhea of menopause and improves in the latter part of pregnancy. Various hormone manipulations in the treatment of endometriosis have been described.14 These include pseudopregnancy induced with various estrogenprogesterone preparations, the use of androgens, the induction of hyperhormonal amenorrhea with estrogens, the induction of a pseudomenopause through ovarian suppression, and hypoestrogenic amenorrhea with use of danazol. Radiotherapy to the ovaries has in general given poor results, either in combination with other therapy or alonea Surgery is performed in those with severe disease or in those with an associated surgical condition. This may be conservative to excise all endometrial-bearing tissue preserving uterus and ovaries or definitive surgery with resection of endometriosis and ovaries and uterus.14 Partial cystectomy is best performed through a transperitoneal approach since it affords adequate exploration of the pelvis.8 Transurethral fulguration has no place in the treatment of vesical endometriosis since the disease extends through the bladder wallee Endometriosis in the postmenopausal woman is uncommon, and it is important to rule out ovarian cancer. A workup in this instance would include obtaining plasma estradiol levels (raised in functioning ovarian tissue) and follicle-stimulating hormone levels (< 40 IU with
542
functioning ovarian tissue). Definitive treatment then would be excision of the ovaries and surgery for any other associated conditions. F’.O.Box 016217 Miami, Florida 33101 (DR. LYNNE) References 1. Stewart WW, and Ireland GW: Vesical endometriosis in a postmenopausal woman, J Urol 118: 480 (1977). 2. Skor AB. Warren MM. and Mueller EO: Endometriosis of bladder, Urology 9: 689 (1977). 2a. Judd ES: Adenomyomata presenting as tumor of the bladder, Surg Clin North Am 1: 1271 (1921). 3. Fein RL, and Horton BF: Vesical endometriosis, a case report and review of the literature, J Urol 95: 45 (1966). 4. Oliker AJ, and Harris AE: Endometriosis of the bladder in the male patient, ibid. 106: 858 (1971). 5. Pinkert TC. Catlow CE. and Straus R: Endometriosis of the urinary bladder in a man with prostatic carcinoma, Cancer 43: d 1562 (1979). 6. O’Connor VJ, and Greenhill JP: Endometriosis of the bladder and ureter, Surg Gynecol Obstet 80: 113 (1945). 7. Abeshouse BS. and Abeshouse G: Endometriosis of the urinary tract: a review of the literature and a report of 4 cases of vesical endometriosis, J Int Co11 Surg 34: 43 (1960). 8. Ranney B: Endometriosis, III.-complete operations, Am J Obstet Gvnecol 109: 1137 (1971). 9. Ball TL, and Platt MA: Urologic complications of endometriosis, ibid. 84: 1516 (1962). 10. Lichtenheld FR, McCauley RT, and Staples PP: Endometriosis involving the urinary tract, a collective review, Obstet Gynecol 17: 762 (1961). 11. Iwano JH, and Ewing GE: Endometriosis of the bladder, J Urol 166: 614 (1968). 12. Jones GS, and Jones HW: Novak’s Textbook of Gynecology, ed 10, Baltimore, Williams and Wilkins Co, chap 25,1981, p 478. 13. Stanley KE, Utz DC, and Dockerty MB: Clinically significant endometriosis of the urinary tract, Surg Gynecol Obstet 120: 491 (1965). 14. Dmowski WP: Current concepts in the management of endometriosis, Obstet Gynecol Ann 10: 279 (1981).
UROLOGY
/ NOVEMBER
1983
/ VOLUME
XXII, NUMBER
5