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Endometriosis of the bladder and ureter

Nicola Berlanda, MD
Paolo Vercellini, MD
Luigi Fedele, MD
Section Editor
Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG


Endometriosis is defined as endometrial glands and stroma at extrauterine sites. These ectopic endometrial implants are typically located in the pelvis but can occur throughout the body. Urinary tract endometriosis refers to endometriotic implants of the bladder, ureter, kidney, and urethra. In women with urinary tract endometriosis, the bladder and ureter are most commonly affected.

This topic will review the clinical presentation, diagnosis, and management of endometriosis of the bladder and ureter. General principles of the treatment of endometriosis, as well as endometriosis of the rectovaginal septum, bowel, and thorax, are presented separately.

(See "Endometriosis: Pathogenesis, clinical features, and diagnosis".)

(See "Endometriosis: Treatment of pelvic pain".)

(See "Endometriosis: Surgical management of pelvic pain".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 19, 2017.
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  1. Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000; 74:1175.
  2. Fedele L, Piazzola E, Raffaelli R, Bianchi S. Bladder endometriosis: deep infiltrating endometriosis or adenomyosis? Fertil Steril 1998; 69:972.
  3. Buka NJ. Vesical endometriosis after cesarean section. Am J Obstet Gynecol 1988; 158:1117.
  4. Cruz Guerra NA, Linares Quevedo A, Cuesta Roca C, et al. [Bladder endometriosis in a patient with cesarean history]. Arch Esp Urol 2002; 55:194.
  5. Vercellini P, Frontino G, Pisacreta A, et al. The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002; 187:538.
  6. Tosti C, Pinzauti S, Santulli P, et al. Pathogenetic Mechanisms of Deep Infiltrating Endometriosis. Reprod Sci 2015; 22:1053.
  7. Berlanda N, Vercellini P, Carmignani L, et al. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009; 64:830.
  8. Bosev D, Nicoll LM, Bhagan L, et al. Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol 2009; 182:2748.
  9. Vercellini P, Pisacreta A, Pesole A, et al. Is ureteral endometriosis an asymmetric disease? BJOG 2000; 107:559.
  10. Vercellini P, Eskenazi B, Consonni D, et al. Oral contraceptives and risk of endometriosis: a systematic review and meta-analysis. Hum Reprod Update 2011; 17:159.
  11. Seracchioli R, Mabrouk M, Montanari G, et al. Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril 2010; 94:856.
  12. Donnez J, Brosens I. Definition of ureteral endometriosis? Fertil Steril 1997; 68:178.
  13. Gabriel B, Nassif J, Trompoukis P, et al. Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 2011; 78:1269.
  14. Schneider A, Touloupidis S, Papatsoris AG, et al. Endometriosis of the urinary tract in women of reproductive age. Int J Urol 2006; 13:902.
  15. Maccagnano C, Pellucchi F, Rocchini L, et al. Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature. Urol Int 2013; 91:1.
  16. Muñoz JL, Jiménez JS, Tejerizo A, et al. Rectosigmoid deep infiltrating endometriosis and ureteral involvement with loss of renal function. Eur J Obstet Gynecol Reprod Biol 2012; 162:121.
  17. Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 2002; 77:32.
  18. Setälä M, Kössi J, Silventoinen S, Mäkinen J. The impact of deep disease on surgical treatment of endometriosis. Eur J Obstet Gynecol Reprod Biol 2011; 158:289.
  19. Knabben L, Imboden S, Fellmann B, et al. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril 2015; 103:147.
  20. ABESHOUSE BS, ABESHOUSE G. Endometriosis of the urinary tract: a review of the literature and a report of four cases of vesical endometriosis. J Int Coll Surg 1960; 34:43.
  21. Yohannes P. Ureteral endometriosis. J Urol 2003; 170:20.
  22. Dénes FT, Pompeo AC, Montelatto NI, Lopes RN. Ureteral endometriosis. Int Urol Nephrol 1980; 12:205.
  23. Kovoor E, Nassif J, Miranda-Mendoza I, Wattiez A. Endometriosis of bladder: outcomes after laparoscopic surgery. J Minim Invasive Gynecol 2010; 17:600.
  24. Sinaii N, Plumb K, Cotton L, et al. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil Steril 2008; 89:538.
  25. Hickey M, Ballard K, Farquhar C. Endometriosis. BMJ 2014; 348:g1752.
  26. Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol 2014; 10:261.
  27. Leone Roberti Maggiore U, Ferrero S, Salvatore S. Urinary incontinence and bladder endometriosis: conservative management. Int Urogynecol J 2015; 26:159.
  29. Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000; 163:1814.
  30. Guerriero S, Condous G, van den Bosch T, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol 2016; 48:318.
  31. Bennett GL, Slywotzky CM, Cantera M, Hecht EM. Unusual manifestations and complications of endometriosis--spectrum of imaging findings: pictorial review. AJR Am J Roentgenol 2010; 194:WS34.
  32. Goncalves MO, Dias JA Jr, Podgaec S, et al. Transvaginal ultrasound for diagnosis of deeply infiltrating endometriosis. Int J Gynaecol Obstet 2009; 104:156.
  33. Exacoustos C, Malzoni M, Di Giovanni A, et al. Ultrasound mapping system for the surgical management of deep infiltrating endometriosis. Fertil Steril 2014; 102:143.
  34. Guerriero S, Ajossa S, Gerada M, et al. Diagnostic value of transvaginal 'tenderness-guided' ultrasonography for the prediction of location of deep endometriosis. Hum Reprod 2008; 23:2452.
  35. Reid S, Lu C, Casikar I, et al. Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign. Ultrasound Obstet Gynecol 2013; 41:685.
  36. Berlanda N, Somigliana E, Frattaruolo MP, et al. Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician? Eur J Obstet Gynecol Reprod Biol 2017; 209:67.
  37. Chapron C, Bourret A, Chopin N, et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Hum Reprod 2010; 25:884.
  38. Chamié LP, Blasbalg R, Gonçalves MO, et al. Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis. Int J Gynaecol Obstet 2009; 106:198.
  39. Grasso RF, Di Giacomo V, Sedati P, et al. Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography. Abdom Imaging 2010; 35:716.
  40. Busard MP, Mijatovic V, van Kuijk C, et al. Magnetic resonance imaging in the evaluation of (deep infiltrating) endometriosis: the value of diffusion-weighted imaging. J Magn Reson Imaging 2010; 32:1003.
  41. Nezhat CH, Malik S, Osias J, et al. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002; 78:872.
  42. Vercellini P, Somigliana E, Consonni D, et al. Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction. Hum Reprod 2012; 27:3450.
  43. Fedele L, Bianchi S, Montefusco S, et al. A gonadotropin-releasing hormone agonist versus a continuous oral contraceptive pill in the treatment of bladder endometriosis. Fertil Steril 2008; 90:183.
  44. Leone Roberti Maggiore U, Ferrero S, Candiani M, et al. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. Eur Urol 2017; 71:790.
  45. Chapron C, Dubuisson JB. Laparoscopic management of bladder endometriosis. Acta Obstet Gynecol Scand 1999; 78:887.
  46. Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002; 29:625.
  47. Antonelli A, Simeone C, Zani D, et al. Clinical aspects and surgical treatment of urinary tract endometriosis: our experience with 31 cases. Eur Urol 2006; 49:1093.
  48. Pastor-Navarro H, Giménez-Bachs JM, Donate-Moreno MJ, et al. Update on the diagnosis and treatment of bladder endometriosis. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:949.
  49. Lousquy R, Borghese B, Chapron C. [Deep bladder endometriosis: how do I...to perform a laparoscopic partial cystectomy?]. Gynecol Obstet Fertil 2010; 38:697.
  50. Seracchioli R, Mannini D, Colombo FM, et al. Cystoscopy-assisted laparoscopic resection of extramucosal bladder endometriosis. J Endourol 2002; 16:663.
  51. Sener A, Chew BH, Duvdevani M, et al. Combined transurethral and laparoscopic partial cystectomy and robot-assisted bladder repair for the treatment of bladder endometrioma. J Minim Invasive Gynecol 2006; 13:245.
  52. Pang ST, Chao A, Wang CJ, et al. Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis. Fertil Steril 2008; 90:2014.e1.
  53. Nerli RB, Reddy M, Koura AC, et al. Cystoscopy-assisted laparoscopic partial cystectomy. J Endourol 2008; 22:83.
  54. Fedele L, Bianchi S, Zanconato G, et al. Long-term follow-up after conservative surgery for bladder endometriosis. Fertil Steril 2005; 83:1729.
  55. Reisenauer C. Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center. Arch Gynecol Obstet 2015; 292:245.
  56. Schonman R, Dotan Z, Weintraub AY, et al. Deep endometriosis inflicting the bladder: long-term outcomes of surgical management. Arch Gynecol Obstet 2013; 288:1323.
  57. Seracchioli R, Raimondo D, Di Donato N, et al. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod 2015; 30:833.
  58. Choi JI, Yoo JG, Kim SJ, et al. Acute Renal Failure due to Obstructive Uropathy Secondary to Ureteral Endometriosis. Case Rep Obstet Gynecol 2015; 2015:761348.
  59. Arrieta Bretón S, López Carrasco A, Hernández Gutiérrez A, et al. Complete loss of unilateral renal function secondary to endometriosis: a report of three cases. Eur J Obstet Gynecol Reprod Biol 2013; 171:132.
  60. Spinelli A, Contri S, Savino A, et al. Unexpected hypertension associated to silent renal failure in a "healthy" young woman. Intern Emerg Med 2014; 9:115.
  61. Freire MJ, Dinis PJ, Medeiros R, et al. Deep Infiltrating Endometriosis-Urinary Tract Involvement and Predictive Factors for Major Surgery. Urology 2017; 108:65.
  62. Pateman K, Holland TK, Knez J, et al. Should a detailed ultrasound examination of the complete urinary tract be routinely performed in women with suspected pelvic endometriosis? Hum Reprod 2015; 30:2802.
  63. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993; 23:478.
  64. Carmignani L, Vercellini P, Spinelli M, et al. Pelvic endometriosis and hydroureteronephrosis. Fertil Steril 2010; 93:1741.
  65. Shokeir AA, Provoost AP, Nijman RJ. Recoverability of renal function after relief of chronic partial upper urinary tract obstruction. BJU Int 1999; 83:11.
  66. Chapron C, Chiodo I, Leconte M, et al. Severe ureteral endometriosis: the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions. Fertil Steril 2010; 93:2115.
  67. Rivlin ME, Krueger RP, Wiser WL. Danazol in the management of ureteral obstruction secondary to endometriosis. Fertil Steril 1985; 44:274.
  68. Matsuura K, Kawasaki N, Oka M, et al. Treatment with danazol of ureteral obstruction caused by endometriosis. Acta Obstet Gynecol Scand 1985; 64:339.
  69. Gantt PA, Hunt JB, McDonough PG. Progestin reversal of ureteral endometriosis. Obstet Gynecol 1981; 57:665.
  70. Maccagnano C, Pellucchi F, Rocchini L, et al. Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int 2012; 89:249.
  71. Vercellini P, Crosignani PG, Somigliana E, et al. Medical treatment for rectovaginal endometriosis: what is the evidence? Hum Reprod 2009; 24:2504.
  72. Seracchioli R, Mabrouk M, Manuzzi L, et al. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 2008; 15:435.
  73. Ghezzi F, Cromi A, Bergamini V, et al. Outcome of laparoscopic ureterolysis for ureteral endometriosis. Fertil Steril 2006; 86:418.
  74. Mereu L, Gagliardi ML, Clarizia R, et al. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis. Fertil Steril 2010; 93:46.
  75. Carmignani L, Ronchetti A, Amicarelli F, et al. Bladder psoas hitch in hydronephrosis due to pelvic endometriosis: outcome of urodynamic parameters. Fertil Steril 2009; 92:35.
  76. Pérez-Utrilla Pérez M, Aguilera Bazán A, Alonso Dorrego JM, et al. Urinary tract endometriosis: clinical, diagnostic, and therapeutic aspects. Urology 2009; 73:47.
  77. Nezhat C, Nezhat F, Nezhat CH, et al. Urinary tract endometriosis treated by laparoscopy. Fertil Steril 1996; 66:920.
  78. Frenna V, Santos L, Ohana E, et al. Laparoscopic management of ureteral endometriosis: our experience. J Minim Invasive Gynecol 2007; 14:169.
  79. Seracchioli R, Manuzzi L, Mabrouk M, et al. A multidisciplinary, minimally invasive approach for complicated deep infiltrating endometriosis. Fertil Steril 2010; 93:1007.e1.
  80. Isac W, Kaouk J, Altunrende F, et al. Robot-assisted ureteroneocystostomy: technique and comparative outcomes. J Endourol 2013; 27:318.
  81. Scioscia M, Molon A, Grosso G, Minelli L. Laparoscopic management of ureteral endometriosis. Curr Opin Obstet Gynecol 2009; 21:325.
  82. Ahn M, Loughlin KR. Psoas hitch ureteral reimplantation in adults--analysis of a modified technique and timing of repair. Urology 2001; 58:184.
  83. Fedele L, Bianchi S, Zanconato G, et al. Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004; 191:1539.
  84. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988; 72:82.
  85. Kobayashi E, Nagase T, Fujiwara K, et al. Total laparoscopic hysterectomy in 1253 patients using an early ureteral identification technique. J Obstet Gynaecol Res 2012; 38:1194.
  86. Magrina JF, Kho RM, Weaver AL, et al. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008; 109:86.
  87. Vercellini P, Meschia M, De Giorgi O, et al. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol 1996; 155:84.
  88. Vercellini P, Aimi G, Amicarelli F, et al. Treatment of endometriosis associated with pain. In: Reconstructive and Reproductive Surgery in Gynecology, 1st ed, Gomel V, Brill AI (Eds), CRC Press, London 2010.