Management of deep infiltrative endometriosis (DIE) causing gynecological morbidity: A urologist's perspective

Endometriosis has been classically classified as follows: ovarian endometriosis, superficial peritoneal endometriosis, and deep infiltrating endometriosis (DIE). DIE is one of the most severe forms of endometriosis and the prevalence of DIE is about 1% among females in the reproductive age group [1]. DIE is defined as endometriosis infiltration of more than 5 mm beneath the peritoneum. The common locations of DIE include the following: uterine body, posterior fornix, vagina, rectum, and urinary tract. The presence of endometrium (glandular and stromal components) in or around the urethra, bladder, ureters, or kidney entails the urinary tract involvement by DIE. Urinary tract endometriosis (UTE) per se is rare, with an incidence of 1%–5.5% in patients with endometriosis [1–4]. However, the prevalence of UTE in DIE ranges from 19% to 53% [3–6]. Involvement of the bladder is the most common form of UTE, occurring in 70%–85% of cases, followed by ureteral involvement in 9%–23% of UTE cases with DIE [6]. The age group commonly affected is the fourth decade [6,7]. Abeshouse and Abeshouse, in their review of 147 patients with UTE, noted involvement of the bladder, ureter, kidney, and urethra to be 85%, 10%, 4%, and 2%, respectively [8].