{"paper_id":"470bdbbc-b597-4299-9947-8ef14828fb4d","body_text":"Vol.:(0123456789)\nInternational Urogynecology Journal \nhttps://doi.org/10.1007/s00192-026-06804-3\nCLINICAL OPINION\nAre We Missing the Bladder? Reflections on Endometriosis and IC/BPS\nGiovanni Di Favero1,2 · Felix Zeppernick1 · Magdalena Zeppernick1 · Tatiana Pfiffer2 · Thilo Schwandner2 · \nIvo Meinhold‑Heerlein1\nReceived: 13 February 2026 / Accepted: 19 June 2026 \n© The Author(s) 2026\nAbstract\nEndometriosis and interstitial cystitis/bladder pain syndrome (IC/BPS) frequently coexist in women with chronic pelvic pain, \nyet overlapping symptoms and non-standardized diagnostic pathways often delay recognition of dual pathology. We propose \nthat a structured surgical approach combining laparoscopy and diagnostic cystoscopy may improve identification and clinical \ncharacterization of this overlap. On the basis of prospective surgical experience in women with suspected endometriosis and \nconcomitant bladder symptoms, optical assessment enables phenotypic differentiation of bladder-centric and non–bladder-\ncentric IC/BPS. When cystoscopic features are present, initiation of a standardized bladder-directed therapeutic strategy \nalongside endometriosis treatment may enhance symptom control and reduce persistent pain. Systematic evaluation during \na single surgical setting has the potential to increase diagnostic precision, minimize incomplete interventions, and support \nindividualized, mechanism-based management. This opinion highlights the importance of integrated diagnostic algorithms \nand multidisciplinary care models to address the complex interplay between endometriosis and IC/BPS.\nKeywords Endometriosis · Interstitial cystitis · Chronic pelvic pain\nEndometriosis is a benign, estrogen-dependent, and het-\nerogeneous gynecological disorder characterized by the \npresence of endometrial-like tissue outside the uterine \ncavity, resulting in a persistent inflammatory response [1 ]. \nThis condition affects approximately 10–15% of women of \nreproductive age and is associated with a wide spectrum of \nclinical manifestations [2]. Common symptoms include dys-\nmenorrhea, dyspareunia, and abdominal pain, while some \npatients may also experience dyschezia, dysuria, and urinary \nfrequency [3, 4]. These symptoms often result in a signifi-\ncant reduction in quality of life. Disease extent and sever -\nity are described using several classification systems, most \ncommonly the Revised American Society for Reproductive \nMedicine (rASRM) score and the #Enzian classification [5, \n6]. While the rASRM system provides a general assessment \nof superficial endometriosis, the #Enzian classification is \nbetter suited for staging deep infiltrating and more severe \nforms of the disease [7].\nRecently, phenotype-based classification systems have \nbeen proposed, offering a more comprehensive framework \nby integrating lesion morphology and anatomical involve-\nment [8]. Four principal phenotypes of endometriosis may \noccur independently or concurrently: superficial peritoneal \nendometriosis, ovarian endometriosis, uterine endometrio-\nsis (adenomyosis), and deep endometriosis (DE) [9 ]. Deep \nendometriosis is characterized by nodular lesions infiltrat-\ning beneath the peritoneal surface (> 3 mm) or penetrating \nthe muscular layer of pelvic or visceral organs, frequently \ninducing fibrotic reactions and distortion of normal anatomy \n[10]. This subtype is considered a severe form of the disease, \naffecting approximately 20% of women with pelvic endome-\ntriosis and often involving pelvic organs extensively, leading \nto significant morbidity [10].\nTo address the critical 8-to-10-year diagnostic latency, \nthe current European Society of Human Reproduction and \nEmbriology (ESHRE – 2022) and American Society Repro-\nductive Medicine (ASRM—2024) guidelines has moved \nHandling Editor: Rok Šumak\nEditor in Chief: Kaven Baessler\n * Giovanni Di Favero \n gdifavero@hotmail.com\n1 Department Gynecology and Obstetrics, Justus-Liebig \nUniversity, University Hospital Giessen-Marburg (UKGM), \nCampus Giessen, Giessen, Germany\n2 Department Gynecology and Obstetrics, Asklepios Hospital \nLich, Justus-Liebig University, Baumgarten 32, 35394 Lich, \nGermany\n\n International Urogynecology Journal\nfrom a surgery-dependent model to a multimodal clinical \nframework that integrates structured screening question-\nnaires, physical exam, and high-resolution imaging (ultra-\nsonography/magnet ressonance imaging) for noninvasive \nprediction of the disease [11, 12]. This concept intends to \nfacilitate initiation of empirical treatment, while reserving \nlaparoscopy with histological verification (traditionally the \ndefinitive gold standard) for complex or imaging-negative \ncases. More recently, the development and progressive \nimplementation of microRNA signatures, together with \nthe use of targeted questionnaires, have shown promise in \nexpediting diagnosis [13, 14]. Earlier identification enables \ntimely therapeutic intervention, which may not only slow \nlesion progression but also help prevent pain centralization \nand chronification. First-line management of endometriosis \nconsists of medical therapy with combined oral contracep-\ntives or progestin-based treatments [12]. In cases of treat-\nment failure, surgical intervention is considered as second-\nline therapy, with the extent of surgical radicality tailored to \nthe patient’s symptoms and reproductive desires.\nDespite extensive research, the exact pathophysiology \nof endometriosis remains incompletely understood and is \nconsidered multifactorial, involving genetic, immunologi-\ncal, hormonal, and environmental influences [ 15]. Several \ntheories have been proposed to explain the development of \nendometriosis. Retrograde menstruation remains the most \nwidely accepted hypothesis, although it fails to account for \ncases in non-menstruating individuals. Alternative mecha-\nnisms include vascular and lymphatic dissemination, which \nsuggest systemic spread of endometrial cells, and coelomic \nmetaplasia, whereby peritoneal cells transform into endome-\ntrial-like tissue [16]. Genetic and epigenetic factors further \nmodulate disease susceptibility and progression.\nAt the molecular level, endometriosis progression is \ndriven by dysregulated pathways involved in cellular adhe-\nsion, invasion, and resistance to apoptosis [17]. Elevated \nlocal estradiol production and progesterone resistance, often \nmediated by epigenetic modifications, promote lesion sur -\nvival and proliferation [18, 19]. Inflammation and immune \ndysfunction are central to endometriosis pathogenesis. Acti-\nvated peritoneal macrophages secrete excessive proinflam-\nmatory cytokines, while reduced natural killer cell activity \nimpairs immune-mediated clearance of ectopic endometrial \ncells [20, 21]. Moreover, recurrent microbleeding from the \nlesions contribute to tissue damage, perpetuating chronic \ninflammation, fibrosis, and pain [22]. Consequently, endo-\nmetriosis is associated with chronic pelvic pain (CPP) in up \nto 80% of affected women [23].\nChronic pelvic pain (CPP) is a common and debilitating \ncondition affecting approximately 6–25% of women of all \nages worldwide, with reported prevalence varying depend-\ning on the definition applied [24, 25]. To date, no univer -\nsally accepted definition or diagnostic criterion for CPP has \nbeen established. The American College of Obstetricians \nand Gynecologists (ACOG), in collaboration with the ReVI-\nTAlize initiative, describes as non-cyclic lower abdominal \npain persisting for at least 6 months, which may be constant \nor intermittent and can be exacerbated by menstruation or \nsexual intercourse [ 26]. CPP is associated with significant \nimpairments in quality of life, reduced work productivity, \nand increased healthcare utilization [25]. A recent system-\natic review estimated the annual economic costs of CPP to \nbe approximately USD 2.8 billion [27]. From a clinical per-\nspective, CPP accounts for nearly 10% of gynecological con-\nsultations, approximately 12% of hysterectomies, and more \nthan 40% of diagnostic laparoscopies [26, 28].\nAlthough the pain is localized to the pelvic region, its \nperception is ultimately mediated by central nervous sys-\ntem (CNS) processing [29]. Endometriosis shares multiple \nclinical and pathophysiological features with chronic pelvic \npain. Women with these conditions often exhibit alterations \nin brain structure and function, consistent with central sen-\nsitization and dysfunctional pain processing mechanisms. In \nendometriosis-associated pain, persistent peripheral inflam-\nmation and nociceptive input can further drive central sen-\nsitization, contributing to pain persistence even after lesion \nresection or hormonal suppression. Therefore, early and \naccurate diagnosis, followed by timely initiation of therapy, \nis critical to interrupt these processes and potentially pre -\nvent pain chronification and long-term CNS alterations [30]. \nNevertheless, delayed diagnosis remains a major challenge \nin the management of both CPP and endometriosis, with \nup to 50% of affected women remaining without a defini-\ntive diagnosis even after years of symptoms [31]. Despite \nits high prevalence and substantial socioeconomic impact, \nCPP has been described by the World Health Organization \n(WHO) as a “neglected reproductive health morbidity” [25]. \nThis designation reflects persistent deficiencies in healthcare \nsystems, prioritization, and resource allocation across differ-\nent regions of the world [31].\nIn the context of chronic pelvic pain (CPP), the presence \nof a prior diagnosis of endometriosis should not preclude \ncomprehensive evaluation for additional or overlapping eti-\nologies. The differential diagnosis spans multiple medical \nspecialties, including gastrointestinal, gynecologic, urologic, \nmusculoskeletal, and psychiatric or psychosomatic disorders \n[32]. Management of CPP is extremely challenging due to \nthe wide range of nonspecific symptoms and numerous pos-\nsible underlying conditions, including depression—affect-\ning up to 50% of patients—and anxiety [25]. Despite the \nfrequent use of invasive diagnostic procedures, patients with \nCPP are often treated empirically for presumed diagnoses, \nwhich frequently results in poor response [31]. As a result \nof their frustration with these suboptimal outcomes, many \npatients consult multiple healthcare providers and undergo \nrepeated medical and surgical interventions [32].\n\nInternational Urogynecology Journal \nPelvic pain of bladder origin has received increasing \nrecognition since the initial descriptions of interstitial cys-\ntitis (IC) in 1887 and painful bladder syndrome (PBS) in \n1957 [33]. These conditions are defined by the American \nUrological Association (AUA) and the International Con-\ntinence Society (ICS) as chronic disorders characterized \nby pain, pressure, or discomfort perceived to originate \nfrom the urinary bladder, accompanied by lower urinary \ntract symptoms, such as dysuria, nocturia, frequency, and \nurgency, persisting for more than 6 weeks in the absence of \ninfection or another identifiable cause [34, 35]. In contrast, \nthe European Society for the Study of Interstitial Cystitis \ndefines the condition based on the presence of at least one \nurinary symptom in combination with characteristic cys-\ntoscopic findings [36]. Although it was once considered a \nrare condition, more recent studies indicate a prevalence of \n2.7% to 6.5% among women, with peak incidence occurring \nbetween 40 and 60 years of age [33, 34]. While interstitial \ncystitis (IC) traditionally refers to cases with characteristic \nbladder findings, such as Hunner’s lesions identified on cys-\ntoscopy, bladder pain syndrome (BPS) represents a broader, \nsymptom-based diagnosis that includes patients experienc-\ning bladder-associated pain in the absence of these specific \ncystoscopic features [37].\nCystoscopy may contribute to the diagnostic evaluation of \nselected patients with suspected IC/BPS by enabling direct \nvisualization of characteristic bladder findings. However, \ncystoscopic abnormalities should be interpreted cautiously, \nparticularly glomerulations, which are increasingly recog-\nnized as nonspecific findings that may also occur in other \npelvic pain conditions or even after instrumentation itself. \nThe most clinically relevant cystoscopic features include \nHunner’s lesions, areas of mucosal erythema, edema, and, \nless specifically, glomerulations. Increasing evidence indi-\ncates that IC/BPS is a heterogeneous condition, encompass-\ning distinct subtypes that differ in underlying pathophysiol-\nogy, clinical presentation, and response to treatment. On the \nbasis of cystoscopic findings, two IC/BPS sub-phenotypes \nhave been described.\n• Patients with Hunner’s lesions are classified as having \na bladder-centric IC/BPS phenotype, accounting for \napproximately 20% of cases. This subtype is character -\nized by chronic inflammatory changes, including mast \ncell and lymphocyte infiltration, and typically presents \nwith focal bladder pain and visible mucosal lesions on \ncystoscopy. Patients often demonstrate significant symp-\ntom improvement following lesion-directed therapies \nsuch as fulguration, resection, or intralesional steroid \ninjection.\n• Patients without Hunner’s lesions are classified as having \na non–bladder-centric IC/BPS phenotype, accounting for \napproximately 80% of cases. This subtype is more com-\nmonly associated with systemic pain disorders, including \nfibromyalgia, endometriosis, depression, irritable bowel \nsyndrome, vulvodynia, dyspareunia, and migraine. It is \nthought to involve heightened nociception and central \nsensitization rather than localized bladder inflamma-\ntion. Multimodal pain management is essential. Treat-\nment options include oral pharmacotherapy—such as \npentosan polysulfate sodium, hydroxyzine, amitriptyline, \nand pregabalin—with or without adjunctive intravesical \ntherapies, including hyaluronic acid. Particular emphasis \nis placed on neuromodulatory approaches (e.g., antide-\npressants and antiepileptics), as well as non-pharmaco-\nlogical interventions such as transcutaneous electrical \nnerve stimulation (TENS), meditation, and structured \nphysiotherapy with pelvic floor rehabilitation.\nNotably, Chung et al. were among the first investigators \nto describe the association between interstitial cystitis/blad-\nder pain syndrome (IC/BPS) and endometriosis [38]. This \nobservation led Chung to coin the term “evil twin syndrome” \nto denote the coexistence of these two conditions. These \npatients are significantly more likely to carry a non-blad-\nder centric IC/BPS phenotype as well as several comorbid, \nsystemic pain diagnoses [39]. Evidence from the literature \nsuggests that this association is particularly pronounced in \nwomen with chronic pelvic pain. Reported prevalence rates \nof coexistence range from 15.5% to 78.3%, reflecting sub-\nstantial heterogeneity in the individual prevalence of each \ncondition across studies [31]. This variability is largely \nattributable to differences in diagnostic criteria, the absence \nof standardized definitions for IC/BPS, and selection biases \ninherent in study populations. Similarly, the true prevalence \nof endometriosis remains uncertain due to underdiagnosis, \ndiagnostic delays, and variability in surgical and histopatho-\nlogical assessment. Consequently, precise epidemiological \ndata on the coexistence of these conditions remain inconsist-\nent, hindering accurate prevalence estimates and delaying \nthe development of integrated management strategies. This \ngap underscores the need for well-designed prospective stud-\nies to clarify their true association and clinical impact.\nInterstitial cystitis/bladder pain syndrome (IC/BPS), \nmuch like endometriosis, is characterized by a substantial \ndiagnostic delay [39]. Driscoll et al. reported a median \nsymptom duration of 5 years prior to diagnosis, with many \npatients initially presenting with isolated symptoms that \ngradually evolve into a more complex clinical picture [40]. \nThis delay has important consequences. Women are fre-\nquently subjected to serial medical and surgical interven-\ntions, sometimes including hysterectomy, with limited ben-\nefit for persistent pain. In many cases, what is interpreted as \nrefractory endometriosis may, in fact, reflect unrecognized \nIC/BPS. The presence of endometriosis should not exclude \nthe possibility of concomitant bladder pathology.\n\n International Urogynecology Journal\nIn our opinion, concomitant diagnostic cystoscopy during \nendometriosis surgery should not be considered routine for \nall patients. Rather, cystoscopy may be particularly valuable \nin selected clinical scenarios, including refractory lower uri-\nnary tract symptoms in the absence of infection, unexplained \nhematuria, or radiological suspicion of bladder infiltration \nor involvement. In these situations, cystoscopy may help \nidentify coexisting IC/BPS, characterize bladder pheno-\ntypes, and detect bladder-penetrating endometriotic lesions, \nthereby supporting individualized, mechanism-based man-\nagement. Direct visualization and histological confirmation \nof endometriosis, together with objective cystoscopic assess-\nment of IC/BPS phenotypes, offer an opportunity to better \ncharacterize overlapping pain mechanisms. Distinguishing \nbladder-centric from non–bladder-centric phenotypes may \nbe relevant for guiding individualized therapy, although cur-\nrent evidence suggests that most patients with concomitant \nendometriosis and IC/BPS belong to the non–bladder-centric \nphenotype associated with systemic pain amplification and \ncentral sensitization. Routine bladder biopsies are unlikely to \nbe necessary and should be reserved for selected cases with \nsuspicious findings. Moreover, clinicians must recognize \nthat pelvic surgery itself may influence bladder physiology, \nrequiring careful interpretation of postoperative symptoms.\nThe clinical implications are substantial. Failure to iden-\ntify coexisting bladder pathology or IC/BPS in appropriately \nselected women undergoing surgery for endometriosis may \ncontribute to persistent postoperative pain, repeated inter -\nventions, and escalating therapeutic frustration. Recognizing \ncoexistence earlier could prevent unnecessary procedures \nand support a shift toward mechanism-based, multidiscipli-\nnary care.\nAlthough prospective data remain limited and universally \naccepted diagnostic criteria for IC/BPS are still evolving, the \ncurrently available evidence does not support routine cystos-\ncopy with hydrodistension in all surgical cases of endome-\ntriosis. Rather, they highlight the urgent need for integrated \ndiagnostic algorithms and collaborative care models. Ulti-\nmately, improving recognition of the endometriosis–IC/BPS \noverlap is not merely a diagnostic refinement—it is a neces-\nsary step toward reducing pain chronification, minimizing \navoidable interventions, and improving long-term quality of \nlife for women with chronic pelvic pain.\nFuture prospective studies are needed to determine \nwhether selective intraoperative cystoscopy changes long-\nterm outcomes, improves pain control, or modifies thera-\npeutic strategies in women with overlapping endometriosis \nand IC/BPS phenotypes. Until stronger evidence becomes \navailable, a phenotype-driven and multidisciplinary \napproach appears more appropriate than universal cysto-\nscopic screening.\nAuthor’s Contribution GF, FZ, MZ: Manuscript design and writing.\nTP, TS: Literature search and manuscript review.\nIM-H: Manuscript review.\nFunding Open Access funding enabled and organized by Projekt \nDEAL.\nDeclarations \nConflicts of Interest None.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article’s Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a \ncopy of this licence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\n 1. International Working Group of AAGL, ESGE, ESHRE and WES, \nTomassetti C, Johnson NP, Petrozza J, Abrao MS, Einarsson JI, \net al. An international terminology for endometriosis, 2021. Hum \nReprod Open. 2021;2021(4):hoab029.\n 2. Xu S, Zhang Y, Ye P, Huang Q, Wang Y, Zhang Y, et al. Global, \nregional, and national burden of endometriosis among women \nof childbearing age from 1990 to 2021: a cross-sectional anal-\nysis from the 2021 global burden of disease study. Int J Surg. \n1990;111(9):5927–40.\n 3. - ACOG Committee on Practice Bulletins. 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