{"paper_id":"b66559c1-162c-4140-b01c-51dbc62e5a7d","body_text":"RESEARCH Open Access\n© The Author(s) 2025. Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 \nInternational License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you \ngive appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the \nlicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the \nmaterial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or \nexceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  \nv e c  o m m  o n s .  o r  g / l  i c e  n s e s  / b  y - n c - n d / 4 . 0 /.\nChen et al. BMC Women's Health           (2025) 25:91 \nhttps://doi.org/10.1186/s12905-025-03579-5\nBMC Women's Health\n†Xuanmin Chen, Qiaojian Zou and Tingting Zhao contributed equally \nto this work.\n*Correspondence:\nYinglei Mo\nmoyl@mail.sysu.edu.cn\nJinfeng Huang\nhjinf@mail.sysu.edu.cn\nJiebing Chen\nchenjieb@mail.sysu.edu.cn\n1Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun \nYat-sen University, Guangzhou, China\n2Outpatient Department, First Affiliated Hospital of Sun Yat-sen University, \nGuangzhou, China\n3Hangzhou Center for Disease Control and Prevention, Hangzhou, China\n4Nursing Department, First Affiliated Hospital of Sun Yat-sen University, \nGuangzhou, China\n5Department of Radiotherapy, First Affiliated Hospital of Sun Yat-sen \nUniversity, Guangzhou, China\n6Guangdong Provincial Clinical Research Center for Obstetrical and \nGynecological Diseases, Guangzhou, China\nAbstract\nBackground Urinary tract endometriosis (UTE) is a special type of endometriosis affecting the urinary system, yet the \nphysical and mental health of UTE patients remain unexplored.\nMethods We enrolled 92 women with UTE and another 234 with deep infiltrating endometriosis from the First \nAffiliated Hospital of Sun Yat-sen University. Personal information was collected via paper questionnaires. Health-\nrelated quality of life, including physical and mental health, was measured by physical component summary scale \n(PCS) and mental component summary scale (MCS) of the 12-item Short Form Health Survey (SF-12). Multiple linear \nregression analysis was conducted to identify factors influencing physical and mental health.\nResults Patients in the UTE group had a higher creatinine level and detection rate of urinary leukocyte, erythrocyte \nand protein. The PCS score was lower in the UTE group, while the MCS was similar between two groups. Multiple \nlinear regression analysis shown that patients using painkillers had lower PCS scores, while those aware of urologic \nabnormalities before surgery or with a history of more than two miscarriages had lower MCS scores.\nConclusions Our study explores the quality of life in UTE patients and identifies influencing factors. Individualized \nand targeted care should be added to clinical practice to prevent negative outcomes for UTE patients.\nKeywords Urinary tract endometriosis, Health-related quality of life, Physical health, Mental health, SF-12\nAssociation of urinary tract endometriosis \nwith physical and mental health: a cross-\nsectional study\nXuanmin Chen1,2,6†, Qiaojian Zou1,6†, Tingting Zhao3†, Guimei He1,6, Xiaohui Wang1,6, Yinglei Mo4*, Jinfeng Huang5* \nand Jiebing Chen1,6*\n\nPage 2 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nBackground\nEndometriosis is a frequent estrogen-dependent benign \ntumor affecting over 10% of women of reproductive age \n[1]. Deep infiltrating endometriosis (DIE) is the most \nsevere form, characterized by lesions that infiltrate the \nperitoneum beyond 5  mm. DIE can affect various ana -\ntomical sites, including the uterosacral ligament, recto -\nvaginal septum, bladder, ureter, and colon-rectum [ 2]. \nAmong them, DIE involving the urinary system includ -\ning the urethra, bladder, ureters, or kidney is called uri -\nnary tract endometriosis (UTE). The most common form \nof UTE is bladder endometriosis (70–85% of cases), fol -\nlowed by ureteral endometriosis (9–23%), while urethra \nand kidney endometriosis are very rare [ 3, 4]. It is esti -\nmated that 0.3–12% of women with endometriosis suffer \nfrom UTE, and one-third of them remain asymptomatic \nor experience only mild discomfort [ 5]. Symptoms of \nUTE include such as dysuria, urinary urgency and fre -\nquency, painful micturition, burning sensation in the ure-\nthra or discomfort in the retropubic area. Without proper \ndiagnosis and treatment, these patients would eventually \ndevelop hydronephrosis, hydroureter, and even kidney \nfunction loss [6, 7]. Currently, surgical treatment is often \nrecommended, especially in cases with urinary function \nimpairment [8].\nEndometriosis, particularly DIE and UTE, can lead to \ndysmenorrhea, dyspareunia, intolerable chronic pelvic \npain, urinary tract symptoms, and infertility, significantly \naffecting patients’ health-related quality of life (HQoL) \nand damaging their physical and mental health [ 9, 10]. \nIncreasing research has highlighted the impact of endo -\nmetriosis on quality of life, mood disorders, and sexual \nfunction [11, 12]. Many studies indicates that pain asso -\nciated with endometriosis is the main factor of those \nnegative outcomes [ 13]. Chronic pain can seriously dis -\nrupt daily life and work, sleep quality, sexual satisfaction, \nand physical and mental health [ 14– 16]. This long-term \nimpairment can contribute to mood disorders such as \nanxiety, depression, and even suicidal tendencies [ 17]. \nResearch has shown that more invasive surgical pro -\ncedures in UTE cases are associated with higher rate of \nsevere postoperative complications, which may further \naffect their quality of life [ 18]. However, the impact on \nquality of life of UTE still remains unclear, underscoring \nthe necessity of great attention to their physical and men-\ntal health.\nIn this study, we assessed the quality of life in UTE \npatients, including both physical and mental health, and \ndiscovered their potential influence factors, thus enhanc -\ning their quality of life and providing valuable evidence \nand guidance for clinical and nursing work.\nMethods\nStudy design and participants\nA total of 326 participants were enrolled from July 2020 \nto December 2023 at the First Affiliated Hospital of Sun \nYat-sen University, Guangzhou, China. Inclusion cri -\nteria were: aged 18 or above, underwent laparoscopic \nsurgery in our hospital and were diagnosed with DIE by \nat least two pathologists, able to read the questionnaire \nand voluntarily participate in this survey, and no history \nof other mental disorders. Exclusion criteria were: diag -\nnosis of any psychiatric disorders or long-term use of \nantipsychotic medications, and refusal to cooperate with \nfollow-up or withdrawal from this survey. Based on oper-\native findings and pathological results, 92 patients were \ndivided into the UTE group, while 234 DIE patients were \ndivided into the control group.\nSurgical intervention\nAll 326 participants in this study underwent laparoscopic \nsurgery. The primary surgical goal for DIE patients was \nto excise as much of the lesion as possible, relieve dys -\nmenorrhea, prevent recurrence, and preserve fertility \nfor those desiring pregnancy. For UTE patients, an addi -\ntional focus was to alleviate urologic abnormalities, par -\nticularly urinary obstruction caused by endometriosis [ 5, \n8]. Depending on the UTE lesions observed during sur -\ngery, surgeons might perform ureterolysis, ureterectomy \nwith end-to-end anastomosis or ureteroneocystostomy \nfor lesion removal. Partial cystectomy was commonly \nperformed for bladder endometriosis [ 19]. Ureteral stent \nimplantation was usually done preoperatively to relieve \nobstruction or intraoperatively to prevent postoperative \ncomplications.\nData collection\nAll researchers, including gynaecological doctors and \nnurses, received training on data collection before this \nstudy. The name, age, body weight, height, educational \nexperience, family monthly income, reproduction his -\ntory, fertility requirements, condition of dysmenorrhea \nand painkillers, and other basic information were col -\nlected via paper questionnaires within one week before \nsurgery. Body mass index (BMI) was calculated as weight \ndivided by height squared. Blood and urine test results \nwere also collected within this period. Before surgery, \nparticipants underwent abdominal type B ultrasonic \nexamination or magnetic resonance imaging (MRI) to \nassess urologic abnormalities such as hydronephrosis, \nureter obstruction, stricture, dilation, hydroureter, or \nother pathological changes. All data was reviewed by at \nleast two researchers.\n\nPage 3 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nMain outcome measures\nIn this study, we measured the HQoL of participants \nby the 12-item Short Form Health Survey (SF-12). The \nSF-12, which derived from the 36-item Short-Form \nHealth Survey (SF-36) in 1996, includes 12 items involv -\ning physical functioning, role physical, bodily pain, gen -\neral health, vitality, social functioning, role emotional and \nmental health [ 20]. In China, the SF-12 has been shown \nto perform similarly to the SF-36 [ 21]. The physical com-\nponent summary scale (PCS) and mental component \nsummary scale (MCS) are calculated by the score of 12 \nitems and reflect the physical and mental health, respec -\ntively. Higher PCS and MCS scores indicate better HQoL. \nThe SF-12 was collected within one week before surgery \nby well-trained gynaecological doctors or nurses.\nStatistical analysis\nStatistical analysis was performed by Statistical Package \nfor the Social Sciences (SPSS) 23.0. Continuous variables \nwere described using means and standard deviations, \nwhile categorical variables were described by constitu -\nent ratios. Comparisons of continuous and unordered \ncategorical variables were conducted by an indepen -\ndent sample t-test and rank-sum test, while binary vari -\nables and ordered categorical variables were compared \nusing chi-square test. Univariate analysis and multiple \nlinear regression analysis were used to identify factors \nassociated with mental or physical health and UTE. A \nP-value < 0.05 was considered statistically significant.\nResults\nAnalysis of baseline data between two groups\nBaseline data were compared between 92 UTE patients \nand 234 DIE patients in the control group. As shown in \nTable 1, the incidence of complication was higher t s in \nUTE group, but no significant difference was found in \nother baseline information. For SF-12 scores, the PCS \nwas significantly lower in the UTE group ( P < 0.05), while \nthe MCS was similar between two groups.\nWe also compared the laboratory tests between the two \ngroups. As shown in Table  2, the UTE group had higher \ncreatinine level as well as a greater detection rate of uri -\nnary leukocyte, erythrocyte and protein ( P < 0.05). Addi-\ntionally, patients in the UTE group were more likely to \nhave urologic abnormalities, including hydronephrosis \nand ureter lesions, and had a higher incidence of ureteral \nstent implantation before surgery.\nAll 92 patients in the UTE group underwent laparo -\nscopic surgery. Most underwent ureterolysis (55.43%) \nor ureterectomy with end-to-end anastomosis (29.35%), \nwhile a small portion received ureteroneocystostomy or \npartial cystectomy (Table 3). Additionally, 70.65% of UTE \npatients received ureteral stent implantation on one or \nboth sides of ureter to promote wound healing or prevent \npostoperative complications.\nInfluence factors of PCS and MCS in UTE group\nTo identify the factors affecting physical and mental \nhealth in UTE patients, we conducted a univariate anal -\nysis of PCS and MCS for 92 patients. Our results sug -\ngested that the need for painkillers significantly impacted \nPCS, while miscarriage times, the need for painkillers, \npresence of urine occult blood and detection of urologic \nabnormalities before surgery were significant factors \nof MCS in the UTE group (Table  4 and Supplementary \nTable 1).\nWe further conducted multiple linear regression analy-\nsis to investigate the influence factors of PCS and MCS \nin UTE group. As shown in Tables  5 and 6, that UTE \npatients requiring painkillers had lower PCS scores, \nand those with more than two times of miscarriage or \nurologic abnormalities before surgery had lower MCS, \nreflecting worse physical or mental health, respectively.\nDiscussion\nArion investigated 275 endometriosis patients and \nfound that bladder pain was linked to poorer sleep qual -\nity and overall quality of life [ 22]. Pontis demonstrated \nthat surgery improved the quality of life for 16 patients \nwith bladder endometriosis [ 23], but yet now, few stud -\nies have focused on the quality of life in UTE patients. \nTo explore this further, we enrolled 92 women with UTE \nand 234 women with DIE in our study. Compared to the \ncontrol group, UTE patients had higher creatinine lev -\nels and elevated detection rates of urinary leukocyte, \nerythrocyte and protein. Besides, UTE patients shown a \nhigher rate of hydronephrosis and ureter abnormalities, \nlikely due to UTE’s impact on bladder and ureter, caus -\ning urinary obstruction and even renal function damage. \nElevated creatinine and abnormal urine tests are com -\nmon accompanying symptoms of UTE. Similarly, because \nof the higher incidence of ureteral abnormalities, UTE \npatients in our study also had a higher rate of ureteral \nstent implantation before surgery, consistent with previ -\nous research [7, 24].\nTo further investigate the HQoL of UTE patients, we \nanalyzed the PCS and MCS of SF-12 among those candi -\ndates, respectively. Our data show that UTE patients had \nlower PCS scores compared to the control group, indicat-\ning poorer physical health. We also found that the need \nfor painkillers was an influential factor of physical health \nin UTE patients. Those requiring painkillers had lower \nPCS scores, which may be related to their more severe \nphysical symptoms. Facchin’s research also suggested \nthat pain from endometriosis severely affects physical \nhealth, which aligns with our findings [ 25]. Management \nof pain in endometriosis remains a significant challenge. \n\nPage 4 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nVariables UTE group\nMean ± SD / N (%)\nControl Group\nMean ± SD / N (%)\nt or χ2 P-value\nAge (year) 35.90 ± 6.77 36.65 ± 6.52 0.926 0.355\nBMI (kg/m2) 21.99 ± 3.48 21.26 ± 2.93 -1.911 0.057\nEducation experience (year) 14.25 ± 3.06 14.13 ± 3.77 -0.276 0.783\nNationality\n Han 88(95.65%) 222(94.87%) 0.000 0.993\n Other nationality 4(4.35%) 12(5.13%)\nResidence\n Rural 25(27.17%) 66(28.21%) 0.002 0.960\n Urban 67(72.83%) 168(71.79%)\nEmployment situation\n Employed 77(83.70%) 202(86.32%) 0.188 0.665\n Unemployed 15(16.30%) 32(13.68%)\nFamily monthly income\n < 10,000 yuan 46(50.00%) 89(38.03%) 4.890 0.180\n 10,000–19,999 yuan 25(27.17%) 66(28.21%)\n20,000–29,999 yuan 8(8.70%) 31(13.25%)\n ≥ 30,000 yuan 13(14.13%) 48(20.51%)\nCaring from family\n Cared 84(91.30%) 215(91.88%) 0.000 1.000\n Not cared or living alone 8(8.70%) 19(8.12%)\nMarriage and childbearing\n Married with children 52(56.52%) 134(57.26%) 0.442 0.932\n Married but childless 20(21.74%) 47(20.09%)\n Unmarried and childless 17(18.48%) 45(19.23%)\n Divorced 2(2.17%) 8(3.42%)\nPregnancy times\n 0 34(36.96%) 82(35.04%) 0.191 0.662\n 1 21(22.83%) 73(31.20%)\n ≥ 2 37(40.22%) 79(33.76%)\nMiscarriage times\n 0 61(66.30%) 170(72.65%) 1.414 0.234\n 1 18(19.57%) 40(17.09%)\n ≥ 2 13(14.13%) 24(10.26%)\nCesarean times\n 0 67(72.83%) 157(67.09%) 1.001 0.317\n 1 19(20.65%) 58(24.79%)\n ≥ 2 6(6.52%) 19(8.12%)\nChildren number\n 0 42(45.65%) 94(40.17%) 0.504 0.478\n 1 32(34.78%) 93(39.74%)\n ≥ 2 18(19.57%) 47(20.09%)\nNeed for fertility\n Yes 48(52.17%) 104(44.44%) 1.290 0.256\n No 44(47.83%) 130(55.56%)\nTime until diagnosis (month) 25.11 ± 33.14 35.38 ± 49.72 1.826 0.069\nDysmenorrhea\n Yes 75(81.52%) 194(82.91%) 0.018 0.893\n No 17(18.48%) 40(17.09%)\nNeed for painkillers\n Yes 44(47.83%) 122(52.14%) 0.333 0.564\n No 48(52.17%) 112(47.86%)\nDyspareunia\nTable 1 Comparison of personal characteristics between two groups\n\nPage 5 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nEndometriosis-associated pain, including dysmenor -\nrhea, chronic pelvic pain, dyspareunia and tenesmus, is \nthe most common and influential symptom and affects \n70-80% of patients [ 26]. However, due to the misconcep -\ntions about endometriosis, patients often receive insuf -\nficient understanding and support from friends, family \nmembers, and even their husbands, who often believe \nthat pain during menstruation is normal and manage -\nable and that women should be able to face it alone [ 27]. \nTherefore, patients with endometriosis often lack suffi -\ncient understanding and support from others. Through \ninteractions with participants, we noticed that most \nwomen with dysmenorrhea experienced significant dis -\nruptions to their daily lives. While some relied on pain -\nkillers like nonsteroidal anti-inflammatory drugs, either \norally or through injection, many chose to endure the \npain due to concerns about side effects such as gastroin -\ntestinal reactions, cardiovascular effects, nephrotoxicity, \nand risk of addiction [ 28– 30]. With prolonged painkiller \nuse, some patients may develop drug resistance and \ndiminish the effectiveness of pain relief. In our study, \n47.83% of UTE patients required painkillers, but only \n26.09% found them effective. Long-term, severe pain \ncan significantly impact patients’ physical health, mental \nhealth and quality of life.\nConfusingly, our results show that UTE patients have \nlower PCS scores compared to other DIE patients with -\nout urinary system involvement in the control group, but \nthere has been no significant difference in MCS scores. \nWe speculate this may be due to DIE patients usually \nhaving a long duration of suffering pain and illness and \ncontinuously impacting their mental health, to the extent \nwhere no difference in MCS can be found between UTE \nand DIE patients. Another possible reason is that while \nthe PCS is more directly influenced by physiological \nfactors, MCS may also correlate with other influences, \nsuch as family or social factors. To further explore this, \nwe conducted a multiple linear regression analysis of \nMCS scores in 92 UTE patients. Our analysis found that \nmiscarriage times and the detection of urologic abnor -\nmalities before surgery were the influential factors of \nMCS. Preoperative imaging examinations such as type B \nultrasound and MRI are meaningful for detecting renal \nand ureteral lesions, which are important for diagnos -\ning UTE [ 31, 32]. Early diagnosis of UTE can optimize \npatient management, improve preoperative counsel -\ning, and facilitate better surgical planning. In our study, \nall participants underwent abdominal imaging exami -\nnations before surgery. Among the 92 UTE patients, \n53 were found to have urologic abnormalities by type B \nultrasound or MRI, including 49 with ureter lesions and \n45 with hydronephrosis. Interestingly, we observed a \nsignificant correlation between the detection of urologic \nabnormalities and MCS in UTE patients. UTE primar -\nily affects the urethra, bladder, ureters, or kidney, lead -\ning to urinary tract obstruction or renal dysfunction. In \nour study, UTE patients exhibited higher creatinine levels \nand a greater detection rate of urinary leukocyte, eryth -\nrocyte and protein than the DIE group, and they also had \na higher incidence of hydronephrosis, consistent with \nprevious studies [33]. However, only the detection of uro-\nlogic abnormalities significantly impacted their mental \nVariables UTE group\nMean ± SD / N (%)\nControl Group\nMean ± SD / N (%)\nt or χ2 P-value\n Yes 37(40.22%) 85(36.32%) 1.577 0.455\n No 46(50.00%) 133(56.84%)\n Asexual 9(9.78%) 16(6.84%)\nAccompany with adenomyosis\n Yes 41(44.67%) 114(48.72%) 0.305 0.581\n No 51(55.43%) 120(51.28%)\nAccompany with ovarian endometriosis\n Yes 52(56.52%) 142(60.68%) 0.368 0.544\n No 40(43.48%) 91(38.89%)\nRecurrent endometriosis\n Yes 24(26.09%) 56(23.93%) 0.070 0.792\n No 68(73.91%) 178(76.07%)\nComplications a\n Yes 33(35.89%) 47(20.09%) 8.053 0.005*\n No 59(64.13%) 187(79.91%)\nSF-12 score\n PCS 38.54 ± 8.54 41.64 ± 9.58 2.703 0.007*\n MCS 43.62 ± 10.96 42.19 ± 11.37 -1.033 0.302\na Complications refer to existing diseases of another system, including but not limited to hypertension, diabetes mellitus and thyroid dysfunction. * Statistically \nsignificant. BMI, body mass index\nTable 1 (continued) \n\nPage 6 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nhealth. Our data shown that UTE patients with explicitly \nurologic abnormalities before surgery had significantly \nlower MCS scores than those without abnormalities \n(41.26 ± 11.29 vs. 46.81 ± 9.74, P = 0.016), while their PCS \nshown no difference (38.16 ± 8.06 vs. 39.04 ± 9.25, \nP = 0.629). We speculate that this may be due to the \nTable 2 Comparison of clinical examinations between two \ngroups before surgery\nVariables UTE group\nMean ± SD / \nN (%)\nControl \nGroup\nMean ± SD / \nN (%)\nt / χ2 P-value\nHemoglobin 114.51 ± 19.00 115.75 ± 15.60 0.605 0.546\nCreatinine 67.57 ± 28.44 57.41 ± 11.95 -4.542 < 0.001*\nAMH\n Normal 63(68.48%) 162(69.23%) 0.000 1.000\n Abnormal 12(13.04%) 31(13.25%)\nCA-125\n Normal 22(23.91%) 63(26.92%) 0.229 0.632\n Abnormal 70(76.09%) 168(71.79%)\nUrinary leukocyte\n Negative 60(65.22%) 182(77.78%) 4.810 0.028*\n Positive 32(34.78%) 52(22.22%)\nUrinary \nerythrocyte\n Negative 62(67.39%) 205(87.61%) 16.868 < 0.001*\n Positive 30(32.61%) 29(12.39%)\nUrinary protein\n Negative 79(85.87%) 224(95.73%) 8.339 0.004*\n Positive 13(14.13%) 10(4.27%)\nUrine occult blood\n Negative 44(47.83%) 138(58.97%) 2.891 0.089\n Positive 48(52.17%) 96(41.03%)\nUreteral stent im-\nplantation before \nsurgery\n No 76(82.61%) 231(98.72%) 28.357 < 0.001*\n Yes 16(17.39%) 3(1.28%)\nUrologic abnor-\nmalities before \nsurgery a\n No 39(42.39%) 215(91.88%) 91.134 < 0.001*\n Yes 53(57.61%) 19(8.12%)\na Urologic abnormalities refer to unilateral or bilateral hydronephrosis or the \nobstruction, stricture, dilation, hydroureter, or other pathological changes of \none or both sides of the ureters, detected by type B ultrasonic examination \nand MRI before surgery and ultimately confirmed during surgery. * Statistically \nsignificant. AMH, anti-Müllerian hormone\nTable 3 Surgical procedure of 92 patients in UTE group\nSurgical procedure n (%)\nUreterolysis 51 (55.43%)\nUreterectomy with end-to-end anastomosis 27 (29.35%)\nUreteroneocystostomy 16 (17.39%)\nPartial cystectomy 8 (8.70%)\nUreteral stent implantation 65 (70.65%)\nTable 4 Univariate analysis of SF-12 scores in UTE group\nVariables PCS P-value MCS P-value\nMiscarriage \ntimes\n 0 38.85 ± 7.79 0.140 44.72 ± 10.30 0.042*\n 1 41.33 ± 10.75 44.77 ± 11.66\n ≥ 2 33.21 ± 6.60 36.83 ± 11.36\nNeed for \npainkillers\n Yes 35.62 ± 8.37 0.001* 40.94 ± 11.65 0.024*\n No 41.21 ± 7.87 46.06 ± 9.77\nUrine occult \nblood\n Negative 39.67 ± 8.35 0.226 46.32 ± 9.87 0.023*\n Positive 37.50 ± 8.68 41.14 ± 11.41\nUrologic \nabnormali-\nties before \nsurgery\n No 37.57 ± 10.76 0.742 46.81 ± 9.74 0.013*\n Yes 36.85 ± 9.61 41.26 ± 11.29\n* Statistically significant\nTable 5 Multiple linear regression analysis of PCS in UTE group\nVariables β 95% CI t P-value\nBMI -0.388 -0.870 ~ 0.094 -1.599 0.113\nNeed for painkillers\n No (Reference)\n Yes -5.721 -9.062~-2.381 -3.403 0.001*\nIntercept 49.809 38.885 ~ 60.733 9.060 < 0.001*\n* Statistically significant. β, standardized regression coefficient. 95% CI, 95% \nconfidence interval. BMI, body mass index\nTable 6 Multiple linear regression analysis of MCS in UTE group\nVariables β 95% CI t P-value\nBMI -0.461 -1.078 ~ 0.155 -1.487 0.141\nTime until diagnosis \n(month)\n0.059 -0.007 ~ 0.124 1.785 0.078\nMiscarriage times\n 0 (Reference)\n 1 0.146 -5.273 ~ 5.566 0.054 0.957\n ≥ 2 -9.300 -15.592~-3.007 -2.938 0.004*\nUrine occult blood\n Negative \n(Reference)\n Positive -3.499 -8.005 ~ 1.008 -1.544 0.126\nUrologic abnormali-\nties before surgery\n No (Reference)\n Yes -5.562 -10.189~-0.935 -2.390 0.019*\nIntercept 58.597 44.549 ~ 72.646 8.293 < 0.001*\n* Statistically significant. β, standardized regression coefficient. 95% CI, 95% \nconfidence interval. BMI, body mass index\n\nPage 7 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nmisunderstanding and fear of urologic abnormalities. The \nearly symptoms of UTE, such as painful micturition, dys -\nuria, urinary urgency and frequency, are often nonspe -\ncific and can easily be mistaken for symptoms of urinary \ntract infections. This can lead to delayed diagnosis and \ntreatment, resulting in ureteral lesions, hydronephro -\nsis and loss of kidney function [ 34– 36]. Many patients \nin our study expressed confusion, puzzlement, and even \npanic about why their dysmenorrhea could progress to \nurinary system damage. Due to the misinterpretation of \nthis disease, many patients believed that hydronephrosis \nand ureter lesions were synonymous with complete loss \nof kidney function or even uremia. The fear of irrevers -\nible kidney damage and the potential need for long-term \nhemodialysis significantly increased their psychologi -\ncal burden and damaged their mental health and quality \nof life. On the other hand, some patients were informed \nthat their surgery might involve ureter partial resection, \npyelostomy, or long-term indwelling catheterization, \nwhich could have a profound impact on their daily lives \nand sexual satisfaction. The great fear of surgery also fur -\nther exacerbated the strain on their mental health. There-\nfore, doctors and nurses should pay more attention to the \nmental health of UTE patients with urologic abnormali -\nties before their surgery. Integrating targeted psycho -\nlogical counseling into preoperative care should be fully \nconsidered for these patients.\nIn our study, 13 of 92 UTE patients (14.13%) experi -\nenced more than two miscarriages, which was identified \nas an influence factor of lower MCS. Accumulating evi -\ndence shows that endometriosis is an important cause \nof infertility, leading to reduced pregnancy rates and an \nincreased risk of miscarriage [ 37– 39]. Reproduction is \nvery important in women’s lives, and for many women, \nespecially in developing countries, having their own chil -\ndren within their limited childbearing years is considered \nessential. Once diagnosed with endometriosis, the fear of \ninfertility and miscarriage can bring heavy psychological \npressure to them. Miscarriage is a common complication \nof endometriosis, which not only causes physical harm \nbut also seriously affects mental health, increasing the \nincidence of anxiety and depression [ 40]. Recurrent mis -\ncarriages can have an obvious negative impact on both \nwomen and their husbands, straining their relationship \nand family unity, and even leading to divorce in some \ncases, which further damages women’s quality of life. \nTherefore, it is important for doctors and nurses to iden -\ntify those UTE patients with recurrent miscarriage early \nand offer personalized psychological support.\nWith development in technology, UTE patients now \nhave more surgical options available. In addition to tra -\nditional laparoscopic surgery, Pavone has shown that \nrobotic-assisted surgery systems can be advantageous \nin managing complex endometriosis cases [ 41]. This \ninnovative surgical method can alleviate the symptoms \nof dysmenorrhea, dyschezia, dyspareunia and chronic \npelvic pain associated with endometriosis. Moreover, \nseveral studies have also highlighted the reliability and \neffectiveness of image-guided robotic surgical procedures \nin urology operations, which can support intraopera -\ntive decision-making and potentially reduce the dura -\ntion of minimally invasive procedures [ 42]. The choice \nof surgical procedures, time and extent of surgery, and \npostoperative complications can significantly impact the \nquality of life for UTE patients. In our study, we assessed \nthe HQoL of all participants only before they underwent \nlaparoscopic surgery. Further investigation should focus \non evaluating the long-term physical and mental health \noutcomes of UTE patients after surgery.\nThere are some limitations to this study. First, per -\nsonal information and HQoL were obtained through \nself-reported questionnaires, which may introduce \nmeasurement error and bias due to subjective factors. \nAdditionally, all the endometriosis patients enrolled \nunderwent laparoscopic surgery at our hospital, while \npatients who received conservative drug treatment were \nnot included in this study. The findings of this study may \nbe more applicable to the clinical care of UTE patients \nundergoing surgical treatment. Finally, all participants \nwere recruited from a single hospital in China. Extrapola-\ntion of this study requires careful consideration and fur -\nther investigation.\nConclusion\nIn conclusion, our study investigates the quality of life for \nUTE patients and demonstrates that the need for pain -\nkillers is the influence factor of PCS, while the detection \nof urologic abnormalities before surgery and miscarriage \ntimes are the influence factors of MCS. Our results pro -\nvide clinicians with a new insight into improving medical \ncare for UTE patients to prevent negative outcomes.\nAbbreviations\nDIE  Deep infiltrating endometriosis \nUTE  Urinary tract endometriosis\nHQoL  Health-related quality of life \nPCS  Physical component summary scale\nMCS  Mental component summary scale \nBMI  Body mass index \nCA-125  Carbohydrate antigen 125 \nAMH  Anti-müllerian hormone \nMRI  Magnetic resonance imaging\nSupplementary Information\nThe online version contains supplementary material available at  h t t p s :   /  / d o  i .  o r  \ng  /  1 0  . 1 1   8 6  / s 1 2  9 0 5 -  0 2 5 - 0  3 5 7 9 - 5.\nSupplementary Material 1\n\nPage 8 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \nAcknowledgements\nThe research team would like to thank all the participants in this study. We \nwould also like to thank the support from the First Affiliated Hospital of Sun \nYat-sen University.\nAuthor contributions\nXC and TZ contributed to the analysis and interpretation of the data and \nrevising of the manuscript under the guidance of JC. QZ were responsible for \ncollection and entry of the data. GH and XW contributed to distribution of the \nquestionnaires and follow-up with participants. JH and YM concepted and \ndesigned this study. TZ and JC provided support for this research. All authors \nread and approved the final manuscript.\nFunding\nThis work was supported by the China Association for Mental Health (No. \n22-23-90 to Jiebing Chen) and Hangzhou Health Science and Technology \nProject (No. A20230144 to Tingting Zhao).\nData availability\nThe datasets analyzed during the current study available from the \ncorresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nThe study was performed in accordance with the Declaration of Helsinki and \napproved by the Ethics Committee for Clinical Research and Animal Trials of \nthe First Affiliated Hospital of Sun Yat-sen University (Approval No. [2021] 237). \nAll participants were informed and willing to participate in this study, and \nwritten informed consent was obtained from all patients. Personal information \nof the participants will be treated with the strictest confidence.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare no competing interests.\nReceived: 8 October 2024 / Accepted: 23 January 2025\nReferences\n1. Koninckx PR, Fernandes R, Ussia A, Schindler L, Wattiez A, Al-Suwaidi S, et \nal. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Front \nEndocrinol. 2021;12:745548.\n2. Cohen J, Mathieu d’Argent E, Selleret L, Antoine JM, Chabbert-Buffet N, Ben-\ndifallah S et al. [Fertility and deep infiltrating endometriosis]. Presse medicale \n(Paris, France: 1983). 2017;46(12 Pt 1):1184-91.\n3. Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P , \nVercellini P . Bladder endometriosis: a systematic review of Pathogenesis, \ndiagnosis, treatment, impact on fertility, and risk of Malignant Transformation. \nEur Urol. 2017;71(5):790–807.\n4. Seracchioli R, Raimondo D, Di Donato N, Leonardi D, Spagnolo E, Paradisi R, \net al. Histological evaluation of ureteral involvement in women with deep \ninfiltrating endometriosis: analysis of a large series. Hum Reprod (Oxford \nEngland). 2015;30(4):833–9.\n5. Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD. \nUrinary tract endometriosis in patients with deep infiltrating endometriosis: \nprevalence, symptoms, management, and proposal for a new clinical clas-\nsification. Fertil Steril. 2015;103(1):147–52.\n6. Raimondo D, Mabrouk M, Zannoni L, Arena A, Zanello M, Benfenati A, et al. \nSevere ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol-\nogy: J Inst Obstet Gynecol. 2018;38(2):257–60.\n7. Sherman AK, MacLachlan LS. A review of urinary tract endometriosis. Curr \nUrol Rep. 2022;23(10):219–23.\n8. Seracchioli R, Mabrouk M, Montanari G, Manuzzi L, Concetti S, Venturoli S. \nConservative laparoscopic management of urinary tract endometriosis (UTE): \nsurgical outcome and long-term follow-up. Fertil Steril. 2010;94(3):856–61.\n9. Baczek G, Mietus M, Klimanek J, Tataj-Puzyna U, Sienkiewicz Z, Dykowska G, \net al. The impact of endometriosis on the quality of women’s life. Ginekologia \nPolska. 2024;95(5):356–64.\n10. da Silva MCM, Ferreira LPS, Della Giustina A. It is time to change the defini-\ntion: endometriosis is no longer a pelvic disease. Clin (Sao Paulo Brazil). \n2024;79:100326.\n11. Marinho MCP , Magalhaes TF, Fernandes LFC, Augusto KL, Brilhante AVM, \nBezerra L. Quality of life in women with endometriosis: an integrative review. \nJ Womens Health (Larchmt). 2018;27(3):399–408.\n12. Sims OT, Gupta J, Missmer SA, Aninye IO. Stigma and endometriosis: a brief \noverview and recommendations to improve Psychosocial Well-Being and \nDiagnostic Delay. Int J Environ Res Public Health. 2021;18(15).\n13. Della Corte L, Di Filippo C, Gabrielli O, Reppuccia S, La Rosa VL, Ragusa R et \nal. The Burden of Endometriosis on Women’s Lifespan: A Narrative Overview \non Quality of Life and Psychosocial Wellbeing. Int J Environ Res Public Health. \n2020;17(13).\n14. Laganà AS, La Rosa VL, Rapisarda AMC, Valenti G, Sapia F, Chiofalo B, et al. \nAnxiety and depression in patients with endometriosis: impact and manage-\nment challenges. Int J Women’s Health. 2017;9:323–30.\n15. Rush G, Misajon R. Examining subjective wellbeing and health-related \nquality of life in women with endometriosis. Health Care Women Int. \n2018;39(3):303–21.\n16. Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. The \nsocial and psychological impact of endometriosis on women’s lives: a critical \nnarrative review. Hum Reprod Update. 2013;19(6):625–39.\n17. Nassiri Kigloo H, Itani R, Montreuil T, Feferkorn I, Raina J, Tulandi T, et al. Endo-\nmetriosis, chronic pain, anxiety, and depression: a retrospective study among \n12 million women. J Affect Disord. 2024;346:260–5.\n18. Ianieri MM, Nardone AC, Pavone M, Benvenga G, Pafundi MP , Campolo F, et \nal. Are ureterolysis for deep endometriosis really all the same? An anatomi-\ncal classification proposal for ureterolysis: a single-center experience. Int J \nGynaecol Obstet. 2023;162(3):1010–9.\n19. Ianieri MM, Rosati A, Ercoli A, Foschi N, Campolo F, Greco P , et al. Laparoscopic \nureteroneocystostomy and round ligament bladder hitching for ureteral \nstenosis in parametrial deep endometriosis: our tips for a tension-free anasto-\nmosis. Int J Gynaecol Obstet. 2023;160(2):563–70.\n20. Ware J Jr., Kosinski M, Keller SD. A 12-Item short-form Health Survey: con-\nstruction of scales and preliminary tests of reliability and validity. Med Care. \n1996;34(3):220–33.\n21. Lin Y, Yu Y, Zeng J, Zhao X, Wan C. Comparing the reliability and validity \nof the SF-36 and SF-12 in measuring quality of life among adolescents in \nChina: a large sample cross-sectional study. Health Qual Life Outcomes. \n2020;18(1):360.\n22. Arion K, Orr NL, Noga H, Allaire C, Williams C, Bedaiwy MA et al. A Quantitative \nAnalysis of Sleep Quality in Women with Endometriosis. Journal of women’s \nhealth (2002). 2020;29(9):1209-15.\n23. Pontis A, Nappi L, Sedda F, Multinu F, Litta P , Angioni S. Management of blad-\nder endometriosis with combined transurethral and laparoscopic approach. \nFollow-up of pain control, quality of life, and sexual function at 12 months \nafter surgery. Clin Exp Obstet Gynecol. 2016;43(6):836–9.\n24. Kołodziej A, Krajewski W, Dołowy Ł, Hirnle L. Urinary Tract Endometr Urol J. \n2015;12(4):2213–7.\n25. Facchin F, Barbara G, Saita E, Mosconi P , Roberto A, Fedele L, et al. Impact of \nendometriosis on quality of life and mental health: pelvic pain makes the \ndifference. J Psychosom Obstet Gynaecol. 2015;36(4):135–41.\n26. Evans S, Mikocka-Walus A, Olive L, Seidman LC, Druitt M, Payne LA. Pheno-\ntypes of women with and without endometriosis and Relationship with \nFunctional Pain disability. Pain Med (Malden Mass). 2021;22(7):1511–21.\n27. Matías-González Y, Sánchez-Galarza AN, Flores-Caldera I, Rivera-Segarra E. \nEs que tú eres una changa: stigma experiences among Latina women living \nwith endometriosis. J Psychosom Obstet Gynaecol. 2021;42(1):67–74.\n28. Guo Y, Liu FY, Shen Y, Xu JY, Xie LZ, Li SY et al. Complementary and Alternative \nMedicine for Dysmenorrhea Caused by Endometriosis: A Review of Utilization \nand Mechanism. Evidence-based complementary and alternative medicine: \neCAM. 2021;2021:6663602.\n29. Guan Q, Velho RV, Sehouli J, Mechsner S. Endometriosis and opioid receptors: \nare opioids a Possible/Promising treatment for endometriosis? Int J Mol Sci. \n2023;24(2).\n30. Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A. Nonsteroidal anti-\ninflammatory drugs for pain in women with endometriosis. Cochrane \nDatabase Syst Rev. 2017;1(1):Cd004753.\n\nPage 9 of 9\nChen et al. BMC Women's Health           (2025) 25:91 \n31. Leonardi M, Espada M, Kho RM, Magrina JF, Millischer AE, Savelli L et al. \nEndometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment. \nDiagnostics (Basel, Switzerland). 2020;10(10).\n32. Carfagna P , De Cicco Nardone A, Benvenga G, Nardone FC, Greco P , Campolo \nF, et al. Preoperative diagnosis of ureteral medial deviations secondary to \ndeep endometriosis using transvaginal ultrasound examinations: can we \npredict the need for ureterolysis during laparoscopic surgery? Int J Gynaecol \nObstet. 2024;166(2):663–71.\n33. Charatsi D, Koukoura O, Ntavela IG, Chintziou F, Gkorila G, Tsagkoulis M, et al. \nGastrointestinal and urinary tract endometriosis: a review on the commonest \nlocations of Extrapelvic Endometriosis. Adv Med. 2018;2018:3461209.\n34. Machairiotis N, Stylianaki A, Dryllis G, Zarogoulidis P , Kouroutou P , Tsiamis N, et \nal. Extrapelvic endometriosis: a rare entity or an under diagnosed condition? \nDiagn Pathol. 2013;8:194.\n35. Shenoy-Bhangle AS, Pires-Franco IV, Ray LJ, Cao J, Kilcoyne A, Horvat N et al. \nImaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on \nDiagnosis and Technique. Academic radiology. 2023.\n36. Zhao SZ, Li YH, Xu YC, Ke CX. Ureteral endometriosis: a uncommon cause of \nureteral stricture and hydronephrosis. Asian J Surg. 2023;46(12):5832–4.\n37. Vercellini P , Viganò P , Bandini V, Buggio L, Berlanda N, Somigliana E. Associa-\ntion of endometriosis and adenomyosis with pregnancy and infertility. Fertil \nSteril. 2023;119(5):727–40.\n38. Porpora MG, Tomao F, Ticino A, Piacenti I, Scaramuzzino S, Simonetti S et al. \nEndometriosis and pregnancy: a single Institution experience. Int J Environ \nRes Public Health. 2020;17(2).\n39. Boje AD, Egerup P , Westergaard D, Bertelsen MMF, Nyegaard M, Hartwell D, et \nal. Endometriosis is associated with pregnancy loss: a nationwide historical \ncohort study. Fertil Steril. 2023;119(5):826–35.\n40. Huffman CS, Schwartz TA, Swanson KM. Couples and miscarriage: the \ninfluence of gender and Reproductive factors on the impact of Miscarriage. \nWomen’s Health Issues: Official Publication Jacobs Inst Women’s Health. \n2015;25(5):570–8.\n41. Pavone M, Seeliger B, Alesi MV, Goglia M, Marescaux J, Scambia G, et al. \nInitial experience of robotically assisted endometriosis surgery with a novel \nrobotic system: first case series in a tertiary care center. Updates Surg. \n2024;76(1):271–7.\n42. Pavone M, Seeliger B, Teodorico E, Goglia M, Taliento C, Bizzarri N, et al. \nUltrasound-guided robotic surgical procedures: a systematic review. Surg \nEndosc. 2024;38(5):2359–70.\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in \npublished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}