Surgical Management of Urinary-Symptom-Dominant Endometriosis: Addressing Persistent Voiding Dysfunction and Pelvic Floor Factors

Zainab Yusufali Motiwala, Motiwala ZY, Sidharth Misra, Misra S, Ishika Sharma, Choudhari S, Sneha Choudhari, Harshita Mahendra Yadav, Yadav HM, Bafna P, Poojal Bafna
International urogynecology journal · 2025 · vol. 37(7) , pp. 1881–1897 · doi:10.1007/s00192-025-06488-1 · PMID:41432909 · W7116959598
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⚙ AI-generated summary by gemini-2.5-flash-lite+body, 2026-06-08 ⓘ

This narrative review found that while endometriosis surgery improves bladder storage symptoms, persistent voiding dysfunction can occur due to neural injury or pelvic floor issues, suggesting adjunct therapies may optimize recovery.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-10 · read from full text ⓘ

This structured narrative review examined surgical management for urinary-tract endometriosis, focusing on urinary outcomes, underlying mechanisms (including possible neural injury, fibrosis, and pelvic floor hypertonicity), and emerging adjunct therapies. Across 63 included studies, storage urinary symptoms improved after surgical approaches such as partial cystectomy, bladder shaving, and ureteral procedures, but up to 50% of patients still had persistent voiding dysfunction. The review notes that nerve-sparing techniques were associated with less dysfunction but did not eliminate it, and it highlights a limitation that advanced imaging risk stratification and prospective level evidence remain lacking. This paper is centrally about endometriosis — it reviews surgery for urinary-symptom–dominant urinary tract endometriosis and mechanisms of persistent postoperative voiding dysfunction, with implications for multidisciplinary management.

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Abstract

INTRODUCTION AND HYPOTHESIS: Urinary tract endometriosis (UTE) commonly presents with urinary urgency, frequency, retention, and hesitancy. Although surgical excision consistently improves storage symptoms postoperatively, voiding dysfunction often persists due to interactions between clearing lesions, potential neural injury, and pelvic floor dysfunction. Understanding these mechanisms is vital for optimizing outcomes and minimizing long-term morbidity. METHODS: We conducted a structured narrative review on surgical management of endometriosis with urinary symptom predominance in PubMed, Scopus, and Cochrane. We thematically synthesized studies on surgical techniques, urinary outcomes, pelvic floor dysfunction, and adjunct neuromodulation to provide insight into current practices, mechanistic understanding, and new approaches. RESULTS: Initially, 928 studies were identified, 798 titles and abstracts were screened after elimination of duplicates, and 63 studies were included after full text screening. Continued improvements in storage symptoms were seen regardless of surgical approach (partial cystectomy, bladder shaving, ureteral procedures) but up to 50% of patients experienced persistent voiding dysfunction. This was due to potential neural injury, fibrosis, and hypertonicity of the pelvic floor. Although nerve-sparing techniques had less dysfunction, they did not eliminate it. Adjuncts, including pelvic floor physiotherapy and neuromodulation, were supported as novel therapies. Advanced imaging techniques might improve risk stratification prior to surgery but prospective level evidence is lacking. CONCLUSIONS: The significant proportion of patients with voiding dysfunction after UTE surgery indicates a need for multi-disciplinary pathways. In addition to lesion excision, co-management with pelvic floor rehabilitation, advanced imaging, and neuromodulation may optimize recovery. There are important priorities for the future, including standardized urodynamic outcomes and prospective study designs.
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Abstract

Introduction and Hypothesis Urinary tract endometriosis (UTE) commonly presents with urinary urgency, frequency, retention, and hesitancy. Although surgical excision consistently improves storage symptoms postoperatively, voiding dysfunction often persists due to interactions between clearing lesions, potential neural injury, and pelvic floor dysfunction. Understanding these mechanisms is vital for optimizing outcomes and minimizing long-term morbidity.

Methods

We conducted a structured narrative review on surgical management of endometriosis with urinary symptom predominance in PubMed, Scopus, and Cochrane. We thematically synthesized studies on surgical techniques, urinary outcomes, pelvic floor dysfunction, and adjunct neuromodulation to provide insight into current practices, mechanistic understanding, and new approaches.

Results

Initially, 928 studies were identified, 798 titles and abstracts were screened after elimination of duplicates, and 63 studies were included after full text screening. Continued improvements in storage symptoms were seen regardless of surgical approach (partial cystectomy, bladder shaving, ureteral procedures) but up to 50% of patients experienced persistent voiding dysfunction. This was due to potential neural injury, fibrosis, and hypertonicity of the pelvic floor. Although nerve-sparing techniques had less dysfunction, they did not eliminate it. Adjuncts, including pelvic floor physiotherapy and neuromodulation, were supported as novel therapies. Advanced imaging techniques might improve risk stratification prior to surgery but prospective level evidence is lacking.

Conclusions

The significant proportion of patients with voiding dysfunction after UTE surgery indicates a need for multi-disciplinary pathways. In addition to lesion excision, co-management with pelvic floor rehabilitation, advanced imaging, and neuromodulation may optimize recovery. There are important priorities for the future, including standardized urodynamic outcomes and prospective study designs. Similar content being viewed by others Data Availability This article is a narrative review. All data used in this manuscript were obtained from previously published studies and are available in the cited sources. No new datasets were generated or analyzed for this work.

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Prog Urol. 2023;33(17):1073–82. https://doi.org/10.1016/j.purol.2023.10.003. Funding No specific funding was received for this study. The research was conducted as part of the authors’ academic and professional interests without any external financial support. Author information Authors and Affiliations Contributions Conceptualization: ZYM, SM, IS; Methodology: ZYM, SM, IS; Validation: ZYM, SM; Formal analysis: ZYM, SM, IS, SC, HMY, PB; Investigation: SC, HMY, PB; Resources: ZYM, SM, IS; Data curation: ZYM, SM, IS, SC, HMY, PB; Writing—original draft preparation: ZYM, IS, SC, HMY, PB; Writing—review and editing: ZYM, SM, IS; Visualization: ZYM, SM, IS; Supervision: ZYM, SM. Corresponding author Ethics declarations Conflicts of Interest The authors declare that they have no conflicts of interest relevant to this study. Additional information Handling Editor: Rok Šumak Editor in Chief: Kaven Baessler Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Appendix Appendix - 1.1. Search String PubMed: ("Endometriosis"[Mesh] OR endometriosis OR "deep infiltrating endometriosis" OR DIE) AND ("Urinary Tract"[Mesh] OR "Urinary Bladder"[Mesh] OR "Ureter"[Mesh] OR urinary OR bladder OR ureter OR urethra OR "urinary tract endometriosis") AND ("Surgical Procedures, Operative"[Mesh] OR surgery OR excision OR resection OR laparoscopy OR laparoscopic OR robotic OR cystectomy OR shaving OR ureterolysis OR "ureteral resection") AND ("Urination Disorders"[Mesh] OR LUTS OR "voiding dysfunction" OR retention OR incontinence OR urgency OR frequency OR dysuria). - 2. Search String Scopus: Endometriosis AND (urinary OR bladder OR ureter* OR urethra*) AND (surg* OR excis* OR resect* OR laparoscop* OR robotic OR cystectom* OR ureterolysis) AND (LUTS OR "urination disorder*" OR "voiding dysfunction" OR incontinence OR urgency OR frequency OR dysuria*). - 3. Search String Cochrane: Endometriosis AND (urinary OR bladder OR ureter* OR urethra*) AND (surg* OR excis* OR resect* OR laparoscop* OR robotic OR cystectom* OR ureterolysis) AND (LUTS OR "urination disorder*" OR "voiding dysfunction" OR incontinence OR urgency OR frequency OR dysuria*). Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Motiwala, Z.Y., Misra, S., Sharma, I. et al. Surgical Management of Urinary-Symptom-Dominant Endometriosis: Addressing Persistent Voiding Dysfunction and Pelvic Floor Factors. Int Urogynecol J (2025). https://doi.org/10.1007/s00192-025-06488-1 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s00192-025-06488-1

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Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

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