Urinary tract endometriosis: Systematic review

Soorena Fatehchehr, Maggie Jiang, Susan Nasab
In: Journal of Endometriosis and Pelvic Pain Disorders · 2026 · doi:10.1177/22840265261426911 · W7142905772
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This systematic review analyzed 137 studies on urinary tract endometriosis, finding bladder involvement most common, MRI and ultrasound best for diagnosis, and minimally invasive surgery yielding favorable outcomes.

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Abstract

Objective: To systematically evaluate the epidemiology, diagnostic modalities, and treatment strategies for urinary tract endometriosis (UE), with the goal of informing evidence-based clinical practice. Materials and methods: A comprehensive search of PubMed, Ovid, Embase, MEDLINE, and the Cochrane Library was conducted from January 1976 to March 2023. The protocol was registered with INPLASY (INPLASY202420054). Original studies reporting clinical, diagnostic, or therapeutic aspects of urinary tract endometriosis (UE) involving the bladder, ureter, kidney, or urethra were included, while reviews, editorials, and duplicate publications were excluded. Three reviewers independently screened articles, extracted relevant data, and categorized findings by site of involvement and diagnostic or treatment modality. A narrative synthesis of the results was performed. Results: A total of 137 studies were included. Bladder endometriosis was the most common subtype (80%–85%), followed by ureteral involvement (9%–23%). MRI and transvaginal ultrasound showed the highest sensitivity and specificity for diagnosis. Minimally invasive surgery, particularly robotic-assisted laparoscopy, was associated with favorable outcomes and lower recurrence rates. Conclusion: UE is a rare and underdiagnosed manifestation of deep infiltrating endometriosis. Early recognition with appropriate imaging and multidisciplinary surgical planning improves outcomes. Larger prospective studies are needed to inform standard guidelines.
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Abstract

Objective:

Materials and methods

Results:

Conclusion

Introduction

Materials and methods

| Urinary symptoms | |||||||| |---|---|---|---|---|---|---|---|---| | Dysuria | Hematuria | Urinary frequency | Urinary urgency | Urinary hesitancy | Cystitis or Cystalgia | UTI or Pyelonephritis | Hydronephrosis | | | Bladder | 6.67%–72.2%29,30,35,40,60,61 | 6%–42.7%29,30,33,35,40,41 | 47.2%29 | 24.7%29 | 10.1%29 | 10%–18%41,51 | || | Ureter | 2.1%–41.9%37,40,45,47 | 2.1%–46.8%36,37,39,40,47,48 | 3%36 | 1.2%–5.8%45,48 | 25%–35.2%39,40,48 | 5.3%–100%35,37,38,41,43–51 | || | Kidney | +21,22 | ||||||| | Urethra | +145 | +23 | +23 | ||||| | Non-urinary symptoms | |||||||| | Dysmenorrhea | Dyspareunia | Dyschezia | Abdominal or pelvic pain | Lumbar or flank pain | Vulvar edema | ||| | Bladder | 76%–98%30,35,40,60,61 | 42%–64.5%30,35,40,60,61 | 21%–55.4%35,60,61 | 12%–49%30,40,41 | |||| | Ureter | 10%–96.4%37–40,44,45,47,133 | 18.7%–48%39,40,45,47,133 | 32%–47.5%45,133 | 12.5%–28.5%36,39,40,133 | 6.9%–39.5%37,36,41,45,133 | ||| | Kidney | +20,22 | ||||||| | Urethra | +23 | +23,145 | +23 | +145 | | UE diagnostic modalities | Sensitivity (%) | Specificity (%) | |---|---|---| | MRI93,96,97,115 | || | Bladder30–32,137,139 | 67–100 | 83–100 | | Ureteral137,139 | 33–87 | 98–100 | | Ultrasonographyb,74–76,135 | || | Bladder25,29,33,50,61,86,138,139,144 | 50–89 | 98–100 | | Ureteral133,136,138,139,144 | 50–97 | 95–100 | | Hydronephrosis50 | 96 | 99 | | CT Urogram82,84,97 | || | Bladder83 | 46 | 98 | | Ureteral (Left)83,136 | 36–57 | 76–89 | | Ureteral (Right)83,136 | 18–60 | 70–88 | | Computed Tomography82,84,97 | 72.2 (40) | 100 (40) | | Cystoscopy29,91,92,97 | 58–95 | 87–97 | | Intravenous Pyelography82,93,97,99,100 | 85–90a | 95–100a | | MAG3 & Radioisotope renography81,94,98 | 91a | 84a | | KUB77,78,94,95 | 60a | 77a | | Medical treatment | Route, dosage | Nausea and vomiting | Breast tenderness | Breakthrough bleeding | Acne | Depression | Weight gain | Others | | |---|---|---|---|---|---|---|---|---|---| | Combined hormonal contraceptives | ||||||||| | Combined oral contraceptive pills | Oral, once daily | + | + | + | + | + | + | Fatigue, HTN | | | Etonogestrel/Ethinyl Estradiol | Vaginal ring, once monthly | + | + | + | + | + | + | Fatigue, HTN | | | Norelgestromin/Ethinyl Estradiol | Transdermal patch, once weekly | + | + | + | + | + | + | Fatigue, HTN | | | Progestins | ||||||||| | Depo Medroxyprogesterone | IM, 1.150 mg every 13 weeks SubQ, 2.104 mg every 12–14 weeks | + | + | + | + | Hirsutism, decreased BMD | ||| | Levonorgestrl Intrauterine Device | Single for up to 8 years | + | PID, Expulsion | |||||| | Norethindrone | Oral, 5 mg daily | + | + | VTE, Peripheral edema | ||||| | Medical treatment | Route, dosage | Mood swing | Hot flashes | Peripheral edema | Acne | Depression | VTE | Decreased BMD | Others | | Gonadotropin-Releasing Hormone Agonists | ||||||||| | Goserelin | SubQ, 3.6 mg monthly | + | + | + | + | + | + | Vaginitis | | | Leuprolide | IM, 3.75 mg monthly IM 11.25 mg every 3 months | + | + | + | + | + | + | Headache, Dizziness, Anaphylaxis, Vaginitis, Triglyceride elevation, Nausea and Vomiting | | | Nafarelin | Intranasal, 400 µg daily | + | + | + | + | + | Vaginal dryness, VTE, headache | || | Triptorelin | IM, 3.75 mg monthly | + | + | HTN, Anaphylaxis, Angioedema, Headache | ||||| | Androgens | ||||||||| | Danazol | Oral, 100–200 mg twice daily | + | + | Weight gain, Hirsutism, Lipid abnormalities, Hepatic dysfunction | ||||| | Anastrazole | Oral, 1 mg daily | + | + | Arthralgia, myalgia | ||||| | Letrozole | Oral, 2.5 mg daily | + | + | Arthralgia, myalgia | | Surgical procedure | Laparotomy | Conventional laparoscopy | Robot-assisted laparoscopy | |---|---|---|---| | Surgical complication (Calvien-Dindo grade I–IV) | ||| | Resection/Excision of bladder endometriosis | - | 0%–12%35,60,127 | - | | Partial cystectomy | 10%29 | 4.3%–11.1%29,32 | - | | Ureterolysis | - | 0%46 | 16%47 | | Partial ureteral resection & end-end anastomosis | 8%44 | <1%131 | 0%110 | | Ureteroneocystostomy | 0%–57%48,131 | <0.5%–83%45,46,48,131 | 0%–50%44,48,110 | | Ureteronephrectomy | 8%44 | 0%44 | - | | Surgical procedure not specified | 0%–52.9%37,39,49 | 0%–28.5%37–40,49,51,128 | 6.5%–8.5%128,134 | | Recurrence rate (after 12 months) | ||| | Resection/Excision of bladder endometriosis | - | 2.3%–3.4%35,60 | - | | Partial cystectomy | 0%29 | 0%32 | - | | Ureterolysis | - | 0%–18.6%38,46,131 | - | | Partial resection & end-end anastomosis | - | 0%–19%38,131 | 0%110 | | Ureteroneocystostomy | 0%48,131 | 0%–1.2%45,46,48 | 0%48,110 | | Surgical procedure not specified | 2.17%37 | 0%–10.7%37,51 | 0%–9.5%128,134 | | Post-surgical pregnancy rate | ||| | Natural conception & IVF | 25%37 | 19.7%–77%37,40,45,51,60 | 88.9%134 |

Results

Symptoms Diagnostic modalities Imaging Treatment Medical management Surgical management Postoperative follow-up

Discussion

Conclusions Ethical approval Declaration of conflicting interests Funding ORCID iD Footnotes Data availability statement Data availability statement Appendix 1 Search strategy

References

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endometriosisdie_deep_infiltratingbladder_endometriosis

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