Bladder endometeriosis with recurrent urinary tract infection as a rare case report

Bladder endometeriosis with recurrent urinary tract infection as a rare case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bladder endometeriosis with recurrent urinary tract infection as a rare case report Hadi Alabdullah, Ahmad Alhamid, Malek Belal, Ahmad Alhadla, Mohamad Yasin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4196961/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background About 1% of women with endometriosis have urological endometriosis, which is an uncommon condition.The patient may be asymptomatic clinically or exhibit symptoms such as dysmenorrhea, irregular or heavy periods, and pelvic, lower abdominal, or back pain. During the prolonged diagnostic process, the patient is often misdiagnosed with urinary tract infection or interstitial cystitis. Case presentation: We present a case of a 37-year-old female patient who presented with varied symptoms including irregular menstrual cycles, dyspareunia, blood in the urine during menstruation, and sometimes unrelated to menstruation. Conclusion Enhancing awareness regarding the potential connection between Caesarean scar and bladder endometriosis is crucial. Bladder endometeriosis recurrent urinary tract infection rare case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 introduction Endometriosis is a health condition that affects women and is characterized by the presence of endometrial tissue outside the uterine cavity. It affects about 10% of women in their reproductive years, with approximately 25–35% of female infertility cases, peaking between the ages of 30 and 40. Common sites of involvement include the ovaries, uterosacral ligament, and pouch of Douglas. The rate of urinary system infection is very rare, about 1% [1]. The most common site of urinary tract involvement is the bladder, especially its posterior wall near the uterus [2].The exact cause of endometriosis is unknown, with theories including retrograde menstruation and hematogenous or lymphatic spread of endometrial cells [1]. Women with bladder endometriosis often experience pelvic pain, urinary urgency, recurrent urinary tract infections, discomfort during urination, blood in the urine during menstruation, dysuria, and dyspareunia [3]. Diagnosis involves ultrasound and magnetic resonance imaging (MRI) [4], drug therapy can lead to temporary improvement in symptoms, but recurrence may occur, so surgical option remains the best in most cases [5]. This report presents a case of bladder endometriosis with Caesarean scar, which was initially misdiagnosed as a bladder tumor. And it could be a rare case of medical literature. Case report A 37-year-old woman, married with a child, is experiencing urinary hesitancy, pain in the pubic area, and the presence of bloody spots at the beginning of urination unrelated to menstruation. Her medical history indicates a urinary tract infection a year ago that did not respond to traditional treatments. She also experiences bloody spots during her menstrual cycle, irregular periods, dyspareunia (painful intercourse), and pelvic pain for the past 3 years. There is a venous thrombosis in the left lower thigh for the past 7 years. The patient is taking warfarin. In terms of surgical history, she had a cesarean section 5 years ago and underwent a laparoscopic procedure to address infertility issues due to adhesions 7 years ago. Ultrasound examination of the urinary tract showed normal kidneys, but a 3 cm diameter mass was discovered on the posterior wall of the bladde . A series of laboratory tests were requested, and the results showed the following: - Urinalysis and sediment examination: Presence of red blood cells filling the microscopic arena ,Creatinine level: 1 and ( International Normalized Ratio) INR: 2.5. A cystoscopy was requested, but the patient's family refused, even though the patient underwent cystoscopy two years ago and the result was normal. During the ( Computed Tomography ) CT scan of the patient, a 3 cm mass was noted on the posterior wall of the bladder, extending towards the uterus. This suggests the possibility that it could have originated from the bladder itself or might be part of the uterine wall protruding into the bladder(Figure. 1). Additionally, a 5 cm functional cyst was identified in the left ovary, likely benign in origin(Figure. 2). During the magnetic resonance imaging (MRI) using sagittal, coronal, and axial sequences at the first timepoint (1T) and the second timepoint (2T) pre-contrast injection, imaging was conducted on a 1.5 Tesla closed MRI system post-injection into the pelvis. The results were as follows: Scarring from a previous caesarean section was observed on the lower anterior wall of the uterus, with thinning of the uterine wall. Thickening of the posterior bladder wall with signal loss on T2-weighted imaging at the second timepoint (T2) was noted(Figure. 3). Several small cystic spaces with high signal on T2-weighted imaging, measuring approximately 23 × 16 mm, were seen. These spaces were substantially enhanced by contrast, indicative of a potential presence of endometriosis in the posterior bladder wall. Enlargement of the posterior uterine wall near the cervical region was detected, without any clear masses. No focal lesions were observed in the uterus, and both right and left ovaries appeared normal in size.During the surgical procedure, a transverse incision was made below the abdomen, beneath the umbilicus, and above the pubic symphysis (Pfannenstiel incision) to access the bladder, which was opened longitudinally(Figure. 4). A solid and movable mass was difficultly found on the posterior wall of the uterus and was excised after meticulous dissection and examination of the pelvic openings(Figure. 5). The posterior wall was carefully closed in two layers. Pathological examination of serial sections reveals benign soft connective tissue consisting of anastomosed and whorled fascicles of fusiform cells of uniform size. The nuclei are elongated and their extremities rounded. mitoses are not observed. blood vessels are small and not numerous .between the bundles of smooth muscle fibres are found variable amounts of fibrous connective tissue, associated with the presence of rare endometrial glands surrounded by endometrial stroma .however, there is no histologic evidence of abnormal mitoses, no cellular atypia and no malignant changes. the results indicating Benign endometriosis. Subsequently, the patient underwent follow-up with cystoscopy, which revealed that everything was normal. Discussion Endometriosis is a benign medical disorder characterized by the formation of glands and uterine tissues outside the uterus[2]. Despite the common occurrence of endometriosis, its impact on the urinary tract is a rare phenomenon. Urinary tract involvement can manifest in various locations, with statistics indicating that the majority occurs in the bladder, up to 85%[2]. This is usually attributed to fluctuations in hormone levels such as estrogen and progesterone, which can lead to primary or secondary infertility issues due to endometriosis[6]. This could explain the secondary infertility in our patient, who underwent diagnostic laparoscopy and adhesiolysis as part of an infertility assessment seven years ago. Despite doubts surrounding the hypothesis of uterine tissue implantation as a result of surgical interventions, there is an observed increase in cases of endometriosis in the bladder, especially among women who have undergone pelvic surgeries, particularly cesarean sections[3]. This was evident in our patient who had a cesarean section five years ago and underwent ( Intracytoplasmic Sperm Injetion ) ICSI tube baby. In a previous study, Donnez and colleagues analyzed a series of cases and found that 4 out of 17 patients had undergone previous cesarean sections[1]. The clinical presentation of patients with bladder endometriosis (BE) varies significantly based on the size and location of the lesion. Common symptoms include increased urinary frequency, bladder pain, and difficulty urinating. Difficulty urinating has been observed in 21–69% of BE patients. The presence of blood in the urine during menstruation occurs in 20–25% of cases due to the effect on the mucosal layer. It is important to note that BE rarely penetrates the mucosal layer, making the presence of blood in the urine a rare occurrence[7].This rarity is what makes our case unique, as the patient presented to us with symptoms including the presence of blood in the urine. In a study conducted by Vercellini and colleagues, they observed bladder abnormalities in only two out of 40 women, noting that these two women did not experience any symptoms. The absence of periodic symptoms for pelvic uterine abnormalities may be related to the use of Mirena[1]. In the case of our patient, a 37-year-old married woman with a child, she has been suffering from recurrent urinary tract infections for a year, experiencing burning during urination and pelvic pain for three years. She had a history of bloody urine during menstruation two years ago, difficulty in sexual intercourse, along with the complaint of bloody discharge at the beginning of urination unrelated to menstruation. Based on these symptoms, a differential diagnosis was made: Uterine mass fibroid,Atypical bladder mass,Uterine bladder fistula, Bladder endometriosis, Sarcoma and Foreign body. Studies have shown that the assessment of urinary bladder deformities relies on the use of techniques such as uroscopy, magnetic resonance imaging. The research emphasizes the role of cystoscopy in diagnosing these deformities and even the possibility of taking samples for confirmation[1]. In our patient, upon conducting some laboratory tests, the following findings were observed: Urine analysis: the field is filled with red blood cells, Creatinine: 1 and INR: 2.5. Upon requesting an ultrasound imaging for our patient, it was found that both kidneys are normal, but a 3 cm mass was noted on the posterior wall of the bladder. Cystoscopy Report without Injection: An irregular solid mass on the upper posterior wall of the bladder triangle near the ureteric orifices without biopsy. Computed Tomography Report: A 3 cm mass on the posterior wall of the bladder extending towards the uterus suggesting origin from the bladder or a uterine wall mass protruding into the bladder. Additionally, a 5 cm ovarian cyst was observed on the left side. A bladder cystoscopy was requested for further evaluation, but the family refused this procedure. However, the patient mentioned that she underwent a bladder cystoscopy two years ago which was normal. Magnetic resonance imaging stands out as an effective method for evaluating endometriosis in the bladder. It distinguishes tissues with precision and offers advanced imaging capabilities, thereby providing a clearer visualization of the bladder wall layers compared to ultrasound imaging techniques. The features of bladder endometriosis in magnetic resonance imaging typically manifest as a low-density signal on T2-weighted images, and a medium-density signal on T1-weighted images, with the appearance of high-density signal spots at the interface between the T2 and T1 timings. According to research conducted by Medeiros and colleagues, pelvic magnetic resonance imaging shows a sensitivity of up to 0.6 (95% CI: 0.48–0.77) and an accuracy of 0.98 (95% CI: 0.96–0.99) in detecting cases of bladder endometriosis[2]. In our patient, she underwent MRI with sagittal, coronal, and axial sequences in T1 and T2 timings before injection, sagittal, coronal, and axial sequences in T1 after pelvic injection, followed by imaging with a closed 1.5 Tesla MRI machine. The findings were as follows: Scarring from a previous caesarean section was observed on the lower anterior wall of the uterus with thinning of the uterine wall. Thickening of the posterior bladder wall with decreased signal on T2 timing and several small high-signal cavities on T2 timing, measuring 16x23 mm, was noted. Also observed was thickening of the posterior uterine wall near the cervical region without explicit masses. In this context, the discussion should revolve around treatment options, where medical therapy is considered the primary choice due to its safety and effectiveness. Hormonal therapies are the cornerstone in the treatment strategy, playing a crucial role in the treatment plan[7]. Using hormonal treatments along with oral contraceptives helps alleviate symptoms, although it is not considered a definitive cure[3]. It is important to note that medical literature advises resorting to hormonal therapy as a first step in cases where the condition is mild, and the patient does not have severe symptoms, especially if the patient desires future pregnancy[6]. Surgical treatment is considered necessary when medical treatment fails[3], as was the case with our patient who was treated with oral contraceptives (Dimsylate) but did not respond to the treatment. When it comes to surgical treatment, our patient underwent a surgical procedure involving a vertical incision reaching the bladder, followed by a longitudinal incision in the bladder and suspension suture. There was no observed direct connection between the uterus and the bladder, but a solid, movable mass was noted on the posterior wall of the bladder. The mass was cautiously dissected, completely excised, sent to the pathology lab, and the posterior wall of the bladder was closed in two layers[8]. In conclusion, bladder endometriosis is a rare condition, usually accompanying other forms of endometriosis in the abdominal area. This underscores the importance of collaborating with a specialized team of physicians to ensure comprehensive excision of endometriosis and achieve thorough and effective care. Abbreviations MRI magnetic resonance imaging INR International Normalized Ratio CT Computed Tomography ICSC Intracytoplasmic Sperm Injetion BE bladder endometriosis Declarations Ethical approval was obtained from the ethics committee of the First affiliated hospital of Soochow University. Consent for publication: Written informed consent for publication of the clinical details and clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal. Availability of data and materials: The data used to support the findings of this case report are included within the article Competing interests: The authors have no conflicts of interest to disclose. Funding: None. Authors contributions: H.A. and A.A. wrote the main manuscript text and M.B. and A.A. prepared figures. M.Y.L. reviewed the manuscript. Acknowledgements: Not applicable References Kho Lily CL, Goh C, Lim YK. Isolated Bladder Endometriosis in a Patient With Previous Cesarean Sections. J Med Cases. 2020 Nov;11(11):370-373. doi: 10.14740/jmc3543. Epub 2020 Sep 23. PMID: 34434349; PMCID: PMC8383495. Hakeem A, Anwar SS, Anwar SS, Fatima F, Ahmed A. Bladder Endometriosis Masquerading as Bladder Tumor: The Role of Magnetic Resonance Imaging in Diagnosis. Cureus. 2021 Jul 3;13(7):e16133. doi: 10.7759/cureus.16133. PMID: 34354879; PMCID: PMC8327303.. Xu MC, Yunker AC, Kaufman MR. Conservative management of bladder endometriosis with acute renal failure. Urol Case Rep. 2020 May 19;33:101263. doi: 10.1016/j.eucr.2020.101263. PMID: 32489896; PMCID: PMC7260429. Beaty SD, Silva AC, De Petris G. Bladder Endometriosis: Ultrasound and MRI Findings. Radiol Case Rep. 2015 Nov 6;1(3):92-5. doi: 10.2484/rcr.v1i3.16. PMID: 27298692; PMCID: PMC4891555. Al-Omari MH, Hamid AS. Vesico-Adnexal Fistula Treated with Transurethral Embolization Under Fluoroscopic Guidance. Am J Case Rep. 2017 Sep 4;18:949-952. doi: 10.12659/ajcr.904202. PMID: 28867817; PMCID: PMC5595408. Gupta A, Bhatnagar A, Seth BN, Dang A, Gupta V. Bladder Endometriosis Mimicking TCC - A Case Report. J Clin Diagn Res. 2016 Feb;10(2):PD12-3. doi: 10.7860/JCDR/2016/17488.7213. Epub 2016 Feb 1. PMID: 27042525; PMCID: PMC4800591.. Bahadur A, Mundhra R, Sherwani P, Kumar S. Robot-assisted partial cystectomy for bladder endometriosis: dual approach involving cystoscopy and robotic surgery. BMJ Case Rep. 2021 Aug 24;14(8):e244342. doi: 10.1136/bcr-2021-244342. PMID: 34429296; PMCID: PMC8386226.. Pang ST, Chao A, Wang CJ, Lin G, Lee CL. Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis. Fertil Steril. 2008 Nov;90(5):2014.e1-3. doi: 10.1016/j.fertnstert.2008.04.045. Epub 2008 Aug 3. PMID: 18675963.. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 01 Apr, 2024 Submission checks completed at journal 01 Apr, 2024 First submitted to journal 31 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4196961","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":286078905,"identity":"22a478d1-0241-4c70-8f7e-c099521653ab","order_by":0,"name":"Hadi 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CT).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/eba3eab72b0f7a71acb0d22a.jpeg"},{"id":54097829,"identity":"ce96a287-36eb-48a3-ad5c-23bdcb83debb","added_by":"auto","created_at":"2024-04-04 14:49:29","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171922,"visible":true,"origin":"","legend":"\u003cp\u003eThis picture using axial tomography , shows the presence of an ovarian cyst.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/069508db41e5fe1e140ffe6e.jpeg"},{"id":54097094,"identity":"8ff13ab5-9130-409b-b115-ad4cd3710e73","added_by":"auto","created_at":"2024-04-04 14:41:29","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":195792,"visible":true,"origin":"","legend":"\u003cp\u003eThis picture using ultrasonic imaging ( MRI) ,shows the presence of a mass in the bladder\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/04de0c0705c9eec7643412e2.jpeg"},{"id":54097092,"identity":"d12ff2cc-d05e-4b75-b323-4b0154796c0c","added_by":"auto","created_at":"2024-04-04 14:41:29","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":442161,"visible":true,"origin":"","legend":"\u003cp\u003eThis picture shows a surgical view after the excision of the endometriosis mass and its relation to the bladder trigone\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/e657b534db36a460664cff31.jpeg"},{"id":54097089,"identity":"d36b226a-f9a2-4ea8-88e1-a3906b1dc97c","added_by":"auto","created_at":"2024-04-04 14:41:29","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":544099,"visible":true,"origin":"","legend":"\u003cp\u003eThis picture shows the endometriosis mass after surgical excision\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/e4c52ec58bb815f6984c6cfe.jpeg"},{"id":54098289,"identity":"ac16b839-cc68-4786-86d7-97d1b4c787b8","added_by":"auto","created_at":"2024-04-04 14:57:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":603732,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4196961/v1/df9564a6-4d70-4c64-9637-bcdfa34cea99.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bladder endometeriosis with recurrent urinary tract infection as a rare case report","fulltext":[{"header":"introduction","content":"\u003cp\u003eEndometriosis is a health condition that affects women and is characterized by the presence of endometrial tissue outside the uterine cavity. It affects about 10% of women in their reproductive years, with approximately 25–35% of female infertility cases, peaking between the ages of 30 and 40. Common sites of involvement include the ovaries, uterosacral ligament, and pouch of Douglas. The rate of urinary system infection is very rare, about 1% [1]. The most common site of urinary tract involvement is the bladder, especially its posterior wall near the uterus [2].The exact cause of endometriosis is unknown, with theories including retrograde menstruation and hematogenous or lymphatic spread of endometrial cells [1]. Women with bladder endometriosis often experience pelvic pain, urinary urgency, recurrent urinary tract infections, discomfort during urination, blood in the urine during menstruation, dysuria, and dyspareunia [3]. Diagnosis involves ultrasound and magnetic resonance imaging (MRI) [4], drug therapy can lead to temporary improvement in symptoms, but recurrence may occur, so surgical option remains the best in most cases [5]. This report presents a case of bladder endometriosis with Caesarean scar, which was initially misdiagnosed as a bladder tumor. And it could be a rare case of medical literature.\u003c/p\u003e "},{"header":"Case report","content":"\u003cp\u003eA 37-year-old woman, married with a child, is experiencing urinary hesitancy, pain in the pubic area, and the presence of bloody spots at the beginning of urination unrelated to menstruation. Her medical history indicates a urinary tract infection a year ago that did not respond to traditional treatments. She also experiences bloody spots during her menstrual cycle, irregular periods, dyspareunia (painful intercourse), and pelvic pain for the past 3 years. There is a venous thrombosis in the left lower thigh for the past 7 years. The patient is taking warfarin. In terms of surgical history, she had a cesarean section 5 years ago and underwent a laparoscopic procedure to address infertility issues due to adhesions 7 years ago. Ultrasound examination of the urinary tract showed normal kidneys, but a 3 cm diameter mass was discovered on the posterior wall of the bladde .\u003c/p\u003e\u003cp\u003eA series of laboratory tests were requested, and the results showed the following:\u003c/p\u003e\u003cp\u003e- Urinalysis and sediment examination: Presence of red blood cells filling the microscopic arena ,Creatinine level: 1 and ( International Normalized Ratio) INR: 2.5.\u003c/p\u003e\u003cp\u003eA cystoscopy was requested, but the patient's family refused, even though the patient underwent cystoscopy two years ago and the result was normal.\u003c/p\u003e\u003cp\u003eDuring the ( Computed Tomography ) CT scan of the patient, a 3 cm mass was noted on the posterior wall of the bladder, extending towards the uterus. This suggests the possibility that it could have originated from the bladder itself or might be part of the uterine wall protruding into the bladder(Figure. 1). Additionally, a 5 cm functional cyst was identified in the left ovary, likely benign in origin(Figure. 2).\u003c/p\u003e\u003cp\u003eDuring the magnetic resonance imaging (MRI) using sagittal, coronal, and axial sequences at the first timepoint (1T) and the second timepoint (2T) pre-contrast injection, imaging was conducted on a 1.5 Tesla closed MRI system post-injection into the pelvis. The results were as follows:\u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eScarring from a previous caesarean section was observed on the lower anterior wall of the uterus, with thinning of the uterine wall.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThickening of the posterior bladder wall with signal loss on T2-weighted imaging at the second timepoint (T2) was noted(Figure. 3). Several small cystic spaces with high signal on T2-weighted imaging, measuring approximately 23 × 16 mm, were seen. These spaces were substantially enhanced by contrast, indicative of a potential presence of endometriosis in the posterior bladder wall.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEnlargement of the posterior uterine wall near the cervical region was detected, without any clear masses. No focal lesions were observed in the uterus, and both right and left ovaries appeared normal in size.During the surgical procedure, a transverse incision was made below the abdomen, beneath the umbilicus, and above the pubic symphysis (Pfannenstiel incision) to access the bladder, which was opened longitudinally(Figure. 4). A solid and movable mass was difficultly found on the posterior wall of the uterus and was excised after meticulous dissection and examination of the pelvic openings(Figure. 5). The posterior wall was carefully closed in two layers.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003ePathological examination of serial sections reveals benign soft connective tissue consisting of anastomosed and whorled fascicles of fusiform cells of uniform size. The nuclei are elongated and their extremities rounded. mitoses are not observed. blood vessels are small and not numerous .between the bundles of smooth muscle fibres are found variable amounts of fibrous connective tissue, associated with the presence of rare endometrial glands surrounded by endometrial stroma .however, there is no histologic evidence of abnormal mitoses, no cellular atypia and no malignant changes. the results indicating Benign endometriosis. Subsequently, the patient underwent follow-up with cystoscopy, which revealed that everything was normal.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndometriosis is a benign medical disorder characterized by the formation of glands and uterine tissues outside the uterus[2]. Despite the common occurrence of endometriosis, its impact on the urinary tract is a rare phenomenon. Urinary tract involvement can manifest in various locations, with statistics indicating that the majority occurs in the bladder, up to 85%[2]. This is usually attributed to fluctuations in hormone levels such as estrogen and progesterone, which can lead to primary or secondary infertility issues due to endometriosis[6]. This could explain the secondary infertility in our patient, who underwent diagnostic laparoscopy and adhesiolysis as part of an infertility assessment seven years ago.\u003c/p\u003e \u003cp\u003eDespite doubts surrounding the hypothesis of uterine tissue implantation as a result of surgical interventions, there is an observed increase in cases of endometriosis in the bladder, especially among women who have undergone pelvic surgeries, particularly cesarean sections[3]. This was evident in our patient who had a cesarean section five years ago and underwent ( Intracytoplasmic Sperm Injetion ) ICSI tube baby. In a previous study, Donnez and colleagues analyzed a series of cases and found that 4 out of 17 patients had undergone previous cesarean sections[1]. The clinical presentation of patients with bladder endometriosis (BE) varies significantly based on the size and location of the lesion. Common symptoms include increased urinary frequency, bladder pain, and difficulty urinating. Difficulty urinating has been observed in 21\u0026ndash;69% of BE patients. The presence of blood in the urine during menstruation occurs in 20\u0026ndash;25% of cases due to the effect on the mucosal layer. It is important to note that BE rarely penetrates the mucosal layer, making the presence of blood in the urine a rare occurrence[7].This rarity is what makes our case unique, as the patient presented to us with symptoms including the presence of blood in the urine. In a study conducted by Vercellini and colleagues, they observed bladder abnormalities in only two out of 40 women, noting that these two women did not experience any symptoms. The absence of periodic symptoms for pelvic uterine abnormalities may be related to the use of Mirena[1]. In the case of our patient, a 37-year-old married woman with a child, she has been suffering from recurrent urinary tract infections for a year, experiencing burning during urination and pelvic pain for three years. She had a history of bloody urine during menstruation two years ago, difficulty in sexual intercourse, along with the complaint of bloody discharge at the beginning of urination unrelated to menstruation. Based on these symptoms, a differential diagnosis was made:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUterine mass fibroid,Atypical bladder mass,Uterine bladder fistula, Bladder endometriosis, Sarcoma and Foreign body. Studies have shown that the assessment of urinary bladder deformities relies on the use of techniques such as uroscopy, magnetic resonance imaging. The research emphasizes the role of cystoscopy in diagnosing these deformities and even the possibility of taking samples for confirmation[1]. In our patient, upon conducting some laboratory tests, the following findings were observed:\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUrine analysis: the field is filled with red blood cells, Creatinine: 1 and INR: 2.5.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eUpon requesting an ultrasound imaging for our patient, it was found that both kidneys are normal, but a 3 cm mass was noted on the posterior wall of the bladder.\u003c/p\u003e \u003cp\u003eCystoscopy Report without Injection: An irregular solid mass on the upper posterior wall of the bladder triangle near the ureteric orifices without biopsy. Computed Tomography Report: A 3 cm mass on the posterior wall of the bladder extending towards the uterus suggesting origin from the bladder or a uterine wall mass protruding into the bladder. Additionally, a 5 cm ovarian cyst was observed on the left side. A bladder cystoscopy was requested for further evaluation, but the family refused this procedure. However, the patient mentioned that she underwent a bladder cystoscopy two years ago which was normal. Magnetic resonance imaging stands out as an effective method for evaluating endometriosis in the bladder. It distinguishes tissues with precision and offers advanced imaging capabilities, thereby providing a clearer visualization of the bladder wall layers compared to ultrasound imaging techniques. The features of bladder endometriosis in magnetic resonance imaging typically manifest as a low-density signal on T2-weighted images, and a medium-density signal on T1-weighted images, with the appearance of high-density signal spots at the interface between the T2 and T1 timings. According to research conducted by Medeiros and colleagues, pelvic magnetic resonance imaging shows a sensitivity of up to 0.6 (95% CI: 0.48\u0026ndash;0.77) and an accuracy of 0.98 (95% CI: 0.96\u0026ndash;0.99) in detecting cases of bladder endometriosis[2]. In our patient, she underwent MRI with sagittal, coronal, and axial sequences in T1 and T2 timings before injection, sagittal, coronal, and axial sequences in T1 after pelvic injection, followed by imaging with a closed 1.5 Tesla MRI machine. The findings were as follows: Scarring from a previous caesarean section was observed on the lower anterior wall of the uterus with thinning of the uterine wall. Thickening of the posterior bladder wall with decreased signal on T2 timing and several small high-signal cavities on T2 timing, measuring 16x23 mm, was noted. Also observed was thickening of the posterior uterine wall near the cervical region without explicit masses.\u003c/p\u003e \u003cp\u003eIn this context, the discussion should revolve around treatment options, where medical therapy is considered the primary choice due to its safety and effectiveness. Hormonal therapies are the cornerstone in the treatment strategy, playing a crucial role in the treatment plan[7]. Using hormonal treatments along with oral contraceptives helps alleviate symptoms, although it is not considered a definitive cure[3]. It is important to note that medical literature advises resorting to hormonal therapy as a first step in cases where the condition is mild, and the patient does not have severe symptoms, especially if the patient desires future pregnancy[6]. Surgical treatment is considered necessary when medical treatment fails[3], as was the case with our patient who was treated with oral contraceptives (Dimsylate) but did not respond to the treatment.\u003c/p\u003e \u003cp\u003eWhen it comes to surgical treatment, our patient underwent a surgical procedure involving a vertical incision reaching the bladder, followed by a longitudinal incision in the bladder and suspension suture. There was no observed direct connection between the uterus and the bladder, but a solid, movable mass was noted on the posterior wall of the bladder. The mass was cautiously dissected, completely excised, sent to the pathology lab, and the posterior wall of the bladder was closed in two layers[8].\u003c/p\u003e \u003cp\u003eIn conclusion, bladder endometriosis is a rare condition, usually accompanying other forms of endometriosis in the abdominal area. This underscores the importance of collaborating with a specialized team of physicians to ensure comprehensive excision of endometriosis and achieve thorough and effective care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMRI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eINR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; International Normalized Ratio\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed Tomography\u003c/p\u003e\n\u003cp\u003eICSC \u0026nbsp; \u0026nbsp; \u0026nbsp; Intracytoplasmic Sperm Injetion\u003c/p\u003e\n\u003cp\u003eBE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;bladder endometriosis\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval was obtained from the ethics committee of the First affiliated hospital of Soochow University.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the clinical details and clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this case report are included within the article\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eAuthors contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH.A. and A.A. wrote the main manuscript text and M.B. and A.A. prepared figures. M.Y.L. reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKho Lily CL, Goh C, Lim YK. Isolated Bladder Endometriosis in a Patient With Previous Cesarean Sections. J Med Cases. 2020 Nov;11(11):370-373. doi: 10.14740/jmc3543. Epub 2020 Sep 23. PMID: 34434349; PMCID: PMC8383495.\u003c/li\u003e\n\u003cli\u003eHakeem A, Anwar SS, Anwar SS, Fatima F, Ahmed A. Bladder Endometriosis Masquerading as Bladder Tumor: The Role of Magnetic Resonance Imaging in Diagnosis. Cureus. 2021 Jul 3;13(7):e16133. doi: 10.7759/cureus.16133. PMID: 34354879; PMCID: PMC8327303..\u003c/li\u003e\n\u003cli\u003eXu MC, Yunker AC, Kaufman MR. Conservative management of bladder endometriosis with acute renal failure. Urol Case Rep. 2020 May 19;33:101263. doi: 10.1016/j.eucr.2020.101263. PMID: 32489896; PMCID: PMC7260429.\u003c/li\u003e\n\u003cli\u003eBeaty SD, Silva AC, De Petris G. Bladder Endometriosis: Ultrasound and MRI Findings. Radiol Case Rep. 2015 Nov 6;1(3):92-5. doi: 10.2484/rcr.v1i3.16. PMID: 27298692; PMCID: PMC4891555.\u003c/li\u003e\n\u003cli\u003eAl-Omari MH, Hamid AS. Vesico-Adnexal Fistula Treated with Transurethral Embolization Under Fluoroscopic Guidance. Am J Case Rep. 2017 Sep 4;18:949-952. doi: 10.12659/ajcr.904202. PMID: 28867817; PMCID: PMC5595408.\u003c/li\u003e\n\u003cli\u003eGupta A, Bhatnagar A, Seth BN, Dang A, Gupta V. Bladder Endometriosis Mimicking TCC - A Case Report. J Clin Diagn Res. 2016 Feb;10(2):PD12-3. doi: 10.7860/JCDR/2016/17488.7213. Epub 2016 Feb 1. PMID: 27042525; PMCID: PMC4800591..\u003c/li\u003e\n\u003cli\u003eBahadur A, Mundhra R, Sherwani P, Kumar S. Robot-assisted partial cystectomy for bladder endometriosis: dual approach involving cystoscopy and robotic surgery. BMJ Case Rep. 2021 Aug 24;14(8):e244342. doi: 10.1136/bcr-2021-244342. PMID: 34429296; PMCID: PMC8386226..\u003c/li\u003e\n\u003cli\u003ePang ST, Chao A, Wang CJ, Lin G, Lee CL. Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis. Fertil Steril. 2008 Nov;90(5):2014.e1-3. doi: 10.1016/j.fertnstert.2008.04.045. Epub 2008 Aug 3. PMID: 18675963..\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bladder, endometeriosis, recurrent urinary tract infection, rare case report","lastPublishedDoi":"10.21203/rs.3.rs-4196961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4196961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAbout 1% of women with endometriosis have urological endometriosis, which is an uncommon condition.The patient may be asymptomatic clinically or exhibit symptoms such as dysmenorrhea, irregular or heavy periods, and pelvic, lower abdominal, or back pain. During the prolonged diagnostic process, the patient is often misdiagnosed with urinary tract infection or interstitial cystitis.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe present a case of a 37-year-old female patient who presented with varied symptoms including irregular menstrual cycles, dyspareunia, blood in the urine during menstruation, and sometimes unrelated to menstruation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEnhancing awareness regarding the potential connection between Caesarean scar and bladder endometriosis is crucial.\u003c/p\u003e","manuscriptTitle":"Bladder endometeriosis with recurrent urinary tract infection as a rare case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 14:41:24","doi":"10.21203/rs.3.rs-4196961/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-04-01T08:48:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-01T08:48:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-03-31T19:50:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3375aed1-123c-4b89-9d88-b0d7aa254503","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-04T14:41:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-04 14:41:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4196961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4196961","identity":"rs-4196961","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}