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Urogynaecology
Update on Urinary Tract Endometriosis
a report by
Claudio Simeone
1,2
and Alessandro Antonelli
2
1. Department of Urology, University of Brescia; 2. Department of Urology, Civic Hospital, Brescia
Endometriosis is defined as the presence of active (i.e. responsive to functionality. This affects the choice of diagnostic and therapeutic approach,
hormone stimulation) endometrial tissue outside the uterine cavity. Three which in both conditions should aim to relieve the symptoms and preserve
pathogenic theories have been suggested to explain the presence of active renal function within acceptable morbidity levels. Treatment is still
endometrium in ectopic sites: the embryonic theory postulates its controversial and based on expert opinions because the rarity of this
development from embryonic remnants of the Wolffian or Müllerian condition makes randomised studies almost unfeasible.
ducts; the metaplastic theory postulates the transformation of tissues
originating from the celomic mesothelium in endometrial tissue if Bladder involvement should be regarded as a typical feature of deeply
stimulated by hormonal or inflammatory factors; and the migratory or infiltrating endometriosis, a particular form of endometriosis that penetrates
metastatic theory postulates the migration of endometrial cells through >5mm under the peritoneal surface,
9
since only the cases in which the
lymphatic or blood flow and their diffusion through retrograde detrusor is colonised are clinically significant. In contrast, superficial
menstruation from the tubes into the peritoneal cavity, by direct extension endometriosis of the supravesical peritoneum is usually only an
from the uterine wall by contiguity or after surgical procedures that open intraoperative finding with no clinical impact. The presenting symptoms of
the uterine cavity (i.e. Caesarean section). There is some experimental bladder endometriosis are lower urinary tract symptoms (LUTS: frequency,
proof of the migration/metastatic theory.
1,2
tenesmus, painful micturition) and haematuria, but these characteristics can
vary considerably depending on the size and location of the lesion. They
Endometriosis generally affects pre-menopausal women and is one of the are often confused with symptoms of urinary tract infections, which are
main causes of hospitalisation in female patients between 15 and 44 years extremely frequent in young women, as a mean delay to correct diagnosis
of age,
3
with a prevalence of around 10%,
4,5
although reported figures vary of up to four to five years confirms.
10
Diagnostic doubts should arise
widely depending on the population under study. It has also been reported based on the common evidence that symptoms are exacerbated in the
rarely in post-menopausal women receiving substitutive oestrogenic pre-menstrual period and in cases of positive medical history for
hormone treatment or affected by ovarian or adrenal tumours with endometriosis or pelvic surgery. In such cases, cystoscopy is highly advisable,
increased secretion of endogenous oestrogens. Recent clinical data suggest especially during the menstrual period, because evidence of a bluish
that low parity and heavy menstrual cycles are risk factors; however, submucosal polycyclic lesion located in the trigone, posterior wall or dome
previous hormone therapies, gynaecological surgery or Caesarean section is pathognomonic. A biopsy is required only for doubtful cases. Before
must also be taken into account as possible risk factors, supporting the explorative laparoscopy, pelvic transvaginal ultrasonography, computed
menstrual reflux aetiopathogenetic hypothesis.
5
The disease is characterised tomography (CT) or nuclear magnetic resonance (NMR) is advisable because
by high local aggressiveness and risk of recurrence and requires both surgical
and hormonal treatment, which is mainly based on luteinising-hormone-
Claudio Simeone is an Associate Professor of Urology at the
releasing hormone (LHRH) analogues, danazol or oestroprogestins.
University of Brescia, and teaches nationally at both
Therefore, although biologically benign, endometriosis may be viewed as a undergraduate and post-graduate level. He also practises in
true neoplastic process that can invade and damage all of the pelvic
female urology and complex lower urinary tract and pelvic
floor reconstruction in the Department of Urology of the Civic
structures, and exceptionally can also migrate outside the pelvis to the skin
Hospital in Brescia. Professor Simeone’s research interests are
or the lungs.
6
Moreover, it must be noted that the malignant degeneration
experimental and clinical receptor pharmacology, specifically
urogenital medicine and urinary tract involvement in
of endometriosis in endometriocarcinoma is well recognised.
gynaecological disease. He has lectured extensively and
authored or co-authored numerous journal articles on these topics. He is a member of various
Although endometriosis can spread in almost any site, and despite the
international scientific societies and is on the Editorial Board of several urological journals.
Professor Simeone received his MD from the University of Milan before training in general
gradual increase in the number of diagnoses over the last few years
surgery. He registered as a urologist in 1982, and is certified by the European Board of Urology.
following the diffusion of explorative laparoscopy, urinary tract involvement
E: csimeone@liberto.it
is still uncommon (1–5% of all cases of endometriosis) and mainly concerns
the bladder and ureter according to a 8:1 ratio.
7,8
There is only anecdotal
Alessandro Antonelli is a staff member in the Department of
Urology of the Civic Hospital in Brescia, with a specific interest
evidence of kidney or urethral endometriosis. The involvement of the urinary
in laparoscopic surgery. His research fields mainly concern
tract shares many features with gynaecological presentations but, at the renal oncology and female urology, and he is the author or
same time, it has its own peculiar clinical and therapeutic characteristics and
co-author of many papers on these topics published in national
and international journals. Dr Antonelli is a member of the
requires dedicated urological management.
Italian Society of Urology (SIU) and the European Association
of Urology (EAU). He received his MD in 1999 from the
University of Brescia and registered as a urologist in 2004.
Bladder and ureteral endometriosis are distinct clinical entities in terms of
aetiopathogenesis, symptomatology and possible consequences for renal
© TOUCH BRIEFINGS 2008 113