Association of urinary tract endometriosis with physical and mental health: a cross-sectional study

Background Urinary tract endometriosis (UTE) is a special type of endometriosis affecting the urinary system, yet the physical and mental health of UTE patients remain unexplored.

We enrolled 92 women with UTE and another 234 with deep infiltrating endometriosis from the First Affiliated Hospital of Sun Yat-sen University. Personal information was collected via paper questionnaires. Health- related quality of life, including physical and mental health, was measured by physical component summary scale (PCS) and mental component summary scale (MCS) of the 12-item Short Form Health Survey (SF-12). Multiple linear regression analysis was conducted to identify factors influencing physical and mental health.

Patients in the UTE group had a higher creatinine level and detection rate of urinary leukocyte, erythrocyte and protein. The PCS score was lower in the UTE group, while the MCS was similar between two groups. Multiple linear regression analysis shown that patients using painkillers had lower PCS scores, while those aware of urologic abnormalities before surgery or with a history of more than two miscarriages had lower MCS scores.

Our study explores the quality of life in UTE patients and identifies influencing factors. Individualized and targeted care should be added to clinical practice to prevent negative outcomes for UTE patients.

Urinary tract endometriosis, Health-related quality of life, Physical health, Mental health, SF-12 Association of urinary tract endometriosis with physical and mental health: a cross- sectional study Xuanmin Chen1,2,6†, Qiaojian Zou1,6†, Tingting Zhao3†, Guimei He1,6, Xiaohui Wang1,6, Yinglei Mo4*, Jinfeng Huang5* and Jiebing Chen1,6* Page 2 of 9 Chen et al. BMC Women's Health (2025) 25:91

Endometriosis is a frequent estrogen-dependent benign tumor affecting over 10% of women of reproductive age [1]. Deep infiltrating endometriosis (DIE) is the most severe form, characterized by lesions that infiltrate the peritoneum beyond 5  mm. DIE can affect various ana - tomical sites, including the uterosacral ligament, recto - vaginal septum, bladder, ureter, and colon-rectum [ 2]. Among them, DIE involving the urinary system includ - ing the urethra, bladder, ureters, or kidney is called uri - nary tract endometriosis (UTE). The most common form of UTE is bladder endometriosis (70–85% of cases), fol - lowed by ureteral endometriosis (9–23%), while urethra and kidney endometriosis are very rare [ 3, 4]. It is esti - mated that 0.3–12% of women with endometriosis suffer from UTE, and one-third of them remain asymptomatic or experience only mild discomfort [ 5]. Symptoms of UTE include such as dysuria, urinary urgency and fre - quency, painful micturition, burning sensation in the ure- thra or discomfort in the retropubic area. Without proper diagnosis and treatment, these patients would eventually develop hydronephrosis, hydroureter, and even kidney function loss [6, 7]. Currently, surgical treatment is often recommended, especially in cases with urinary function impairment [8]. Endometriosis, particularly DIE and UTE, can lead to dysmenorrhea, dyspareunia, intolerable chronic pelvic pain, urinary tract symptoms, and infertility, significantly affecting patients’ health-related quality of life (HQoL) and damaging their physical and mental health [ 9, 10]. Increasing research has highlighted the impact of endo - metriosis on quality of life, mood disorders, and sexual function [11, 12]. Many studies indicates that pain asso - ciated with endometriosis is the main factor of those negative outcomes [ 13]. Chronic pain can seriously dis - rupt daily life and work, sleep quality, sexual satisfaction, and physical and mental health [ 14– 16]. This long-term impairment can contribute to mood disorders such as anxiety, depression, and even suicidal tendencies [ 17]. Research has shown that more invasive surgical pro - cedures in UTE cases are associated with higher rate of severe postoperative complications, which may further affect their quality of life [ 18]. However, the impact on quality of life of UTE still remains unclear, underscoring the necessity of great attention to their physical and men- tal health. In this study, we assessed the quality of life in UTE patients, including both physical and mental health, and discovered their potential influence factors, thus enhanc - ing their quality of life and providing valuable evidence and guidance for clinical and nursing work.

Study design and participants A total of 326 participants were enrolled from July 2020 to December 2023 at the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. Inclusion cri - teria were: aged 18 or above, underwent laparoscopic surgery in our hospital and were diagnosed with DIE by at least two pathologists, able to read the questionnaire and voluntarily participate in this survey, and no history of other mental disorders. Exclusion criteria were: diag - nosis of any psychiatric disorders or long-term use of antipsychotic medications, and refusal to cooperate with follow-up or withdrawal from this survey. Based on oper- ative findings and pathological results, 92 patients were divided into the UTE group, while 234 DIE patients were divided into the control group. Surgical intervention All 326 participants in this study underwent laparoscopic surgery. The primary surgical goal for DIE patients was to excise as much of the lesion as possible, relieve dys - menorrhea, prevent recurrence, and preserve fertility for those desiring pregnancy. For UTE patients, an addi - tional focus was to alleviate urologic abnormalities, par - ticularly urinary obstruction caused by endometriosis [ 5, 8]. Depending on the UTE lesions observed during sur - gery, surgeons might perform ureterolysis, ureterectomy with end-to-end anastomosis or ureteroneocystostomy for lesion removal. Partial cystectomy was commonly performed for bladder endometriosis [ 19]. Ureteral stent implantation was usually done preoperatively to relieve obstruction or intraoperatively to prevent postoperative complications. Data collection All researchers, including gynaecological doctors and nurses, received training on data collection before this study. The name, age, body weight, height, educational experience, family monthly income, reproduction his - tory, fertility requirements, condition of dysmenorrhea and painkillers, and other basic information were col - lected via paper questionnaires within one week before surgery. Body mass index (BMI) was calculated as weight divided by height squared. Blood and urine test results were also collected within this period. Before surgery, participants underwent abdominal type B ultrasonic examination or magnetic resonance imaging (MRI) to assess urologic abnormalities such as hydronephrosis, ureter obstruction, stricture, dilation, hydroureter, or other pathological changes. All data was reviewed by at least two researchers. Page 3 of 9 Chen et al. BMC Women's Health (2025) 25:91 Main outcome measures In this study, we measured the HQoL of participants by the 12-item Short Form Health Survey (SF-12). The SF-12, which derived from the 36-item Short-Form Health Survey (SF-36) in 1996, includes 12 items involv - ing physical functioning, role physical, bodily pain, gen - eral health, vitality, social functioning, role emotional and mental health [ 20]. In China, the SF-12 has been shown to perform similarly to the SF-36 [ 21]. The physical com- ponent summary scale (PCS) and mental component summary scale (MCS) are calculated by the score of 12 items and reflect the physical and mental health, respec - tively. Higher PCS and MCS scores indicate better HQoL. The SF-12 was collected within one week before surgery by well-trained gynaecological doctors or nurses. Statistical analysis Statistical analysis was performed by Statistical Package for the Social Sciences (SPSS) 23.0. Continuous variables were described using means and standard deviations, while categorical variables were described by constitu - ent ratios. Comparisons of continuous and unordered categorical variables were conducted by an indepen - dent sample t-test and rank-sum test, while binary vari - ables and ordered categorical variables were compared using chi-square test. Univariate analysis and multiple linear regression analysis were used to identify factors associated with mental or physical health and UTE. A P-value < 0.05 was considered statistically significant.

Analysis of baseline data between two groups Baseline data were compared between 92 UTE patients and 234 DIE patients in the control group. As shown in Table 1, the incidence of complication was higher t s in UTE group, but no significant difference was found in other baseline information. For SF-12 scores, the PCS was significantly lower in the UTE group ( P < 0.05), while the MCS was similar between two groups. We also compared the laboratory tests between the two groups. As shown in Table  2, the UTE group had higher creatinine level as well as a greater detection rate of uri - nary leukocyte, erythrocyte and protein ( P < 0.05). Addi- tionally, patients in the UTE group were more likely to have urologic abnormalities, including hydronephrosis and ureter lesions, and had a higher incidence of ureteral stent implantation before surgery. All 92 patients in the UTE group underwent laparo - scopic surgery. Most underwent ureterolysis (55.43%) or ureterectomy with end-to-end anastomosis (29.35%), while a small portion received ureteroneocystostomy or partial cystectomy (Table 3). Additionally, 70.65% of UTE patients received ureteral stent implantation on one or both sides of ureter to promote wound healing or prevent postoperative complications. Influence factors of PCS and MCS in UTE group To identify the factors affecting physical and mental health in UTE patients, we conducted a univariate anal - ysis of PCS and MCS for 92 patients. Our results sug - gested that the need for painkillers significantly impacted PCS, while miscarriage times, the need for painkillers, presence of urine occult blood and detection of urologic abnormalities before surgery were significant factors of MCS in the UTE group (Table  4 and Supplementary Table 1). We further conducted multiple linear regression analy- sis to investigate the influence factors of PCS and MCS in UTE group. As shown in Tables  5 and 6, that UTE patients requiring painkillers had lower PCS scores, and those with more than two times of miscarriage or urologic abnormalities before surgery had lower MCS, reflecting worse physical or mental health, respectively.

Arion investigated 275 endometriosis patients and found that bladder pain was linked to poorer sleep qual - ity and overall quality of life [ 22]. Pontis demonstrated that surgery improved the quality of life for 16 patients with bladder endometriosis [ 23], but yet now, few stud - ies have focused on the quality of life in UTE patients. To explore this further, we enrolled 92 women with UTE and 234 women with DIE in our study. Compared to the control group, UTE patients had higher creatinine lev - els and elevated detection rates of urinary leukocyte, erythrocyte and protein. Besides, UTE patients shown a higher rate of hydronephrosis and ureter abnormalities, likely due to UTE’s impact on bladder and ureter, caus - ing urinary obstruction and even renal function damage. Elevated creatinine and abnormal urine tests are com - mon accompanying symptoms of UTE. Similarly, because of the higher incidence of ureteral abnormalities, UTE patients in our study also had a higher rate of ureteral stent implantation before surgery, consistent with previ - ous research [7, 24]. To further investigate the HQoL of UTE patients, we analyzed the PCS and MCS of SF-12 among those candi - dates, respectively. Our data show that UTE patients had lower PCS scores compared to the control group, indicat- ing poorer physical health. We also found that the need for painkillers was an influential factor of physical health in UTE patients. Those requiring painkillers had lower PCS scores, which may be related to their more severe physical symptoms. Facchin’s research also suggested that pain from endometriosis severely affects physical health, which aligns with our findings [ 25]. Management of pain in endometriosis remains a significant challenge. Page 4 of 9 Chen et al. BMC Women's Health (2025) 25:91 Variables UTE group Mean ± SD / N (%) Control Group Mean ± SD / N (%) t or χ2 P-value Age (year) 35.90 ± 6.77 36.65 ± 6.52 0.926 0.355 BMI (kg/m2) 21.99 ± 3.48 21.26 ± 2.93 -1.911 0.057 Education experience (year) 14.25 ± 3.06 14.13 ± 3.77 -0.276 0.783 Nationality Han 88(95.65%) 222(94.87%) 0.000 0.993 Other nationality 4(4.35%) 12(5.13%) Residence Rural 25(27.17%) 66(28.21%) 0.002 0.960 Urban 67(72.83%) 168(71.79%) Employment situation Employed 77(83.70%) 202(86.32%) 0.188 0.665 Unemployed 15(16.30%) 32(13.68%) Family monthly income < 10,000 yuan 46(50.00%) 89(38.03%) 4.890 0.180 10,000–19,999 yuan 25(27.17%) 66(28.21%) 20,000–29,999 yuan 8(8.70%) 31(13.25%) ≥ 30,000 yuan 13(14.13%) 48(20.51%) Caring from family Cared 84(91.30%) 215(91.88%) 0.000 1.000 Not cared or living alone 8(8.70%) 19(8.12%) Marriage and childbearing Married with children 52(56.52%) 134(57.26%) 0.442 0.932 Married but childless 20(21.74%) 47(20.09%) Unmarried and childless 17(18.48%) 45(19.23%) Divorced 2(2.17%) 8(3.42%) Pregnancy times 0 34(36.96%) 82(35.04%) 0.191 0.662 1 21(22.83%) 73(31.20%) ≥ 2 37(40.22%) 79(33.76%) Miscarriage times 0 61(66.30%) 170(72.65%) 1.414 0.234 1 18(19.57%) 40(17.09%) ≥ 2 13(14.13%) 24(10.26%) Cesarean times 0 67(72.83%) 157(67.09%) 1.001 0.317 1 19(20.65%) 58(24.79%) ≥ 2 6(6.52%) 19(8.12%) Children number 0 42(45.65%) 94(40.17%) 0.504 0.478 1 32(34.78%) 93(39.74%) ≥ 2 18(19.57%) 47(20.09%) Need for fertility Yes 48(52.17%) 104(44.44%) 1.290 0.256 No 44(47.83%) 130(55.56%) Time until diagnosis (month) 25.11 ± 33.14 35.38 ± 49.72 1.826 0.069 Dysmenorrhea Yes 75(81.52%) 194(82.91%) 0.018 0.893 No 17(18.48%) 40(17.09%) Need for painkillers Yes 44(47.83%) 122(52.14%) 0.333 0.564 No 48(52.17%) 112(47.86%) Dyspareunia Table 1 Comparison of personal characteristics between two groups Page 5 of 9 Chen et al. BMC Women's Health (2025) 25:91 Endometriosis-associated pain, including dysmenor - rhea, chronic pelvic pain, dyspareunia and tenesmus, is the most common and influential symptom and affects 70-80% of patients [ 26]. However, due to the misconcep - tions about endometriosis, patients often receive insuf - ficient understanding and support from friends, family members, and even their husbands, who often believe that pain during menstruation is normal and manage - able and that women should be able to face it alone [ 27]. Therefore, patients with endometriosis often lack suffi - cient understanding and support from others. Through interactions with participants, we noticed that most women with dysmenorrhea experienced significant dis - ruptions to their daily lives. While some relied on pain - killers like nonsteroidal anti-inflammatory drugs, either orally or through injection, many chose to endure the pain due to concerns about side effects such as gastroin - testinal reactions, cardiovascular effects, nephrotoxicity, and risk of addiction [ 28– 30]. With prolonged painkiller use, some patients may develop drug resistance and diminish the effectiveness of pain relief. In our study, 47.83% of UTE patients required painkillers, but only 26.09% found them effective. Long-term, severe pain can significantly impact patients’ physical health, mental health and quality of life. Confusingly, our results show that UTE patients have lower PCS scores compared to other DIE patients with - out urinary system involvement in the control group, but there has been no significant difference in MCS scores. We speculate this may be due to DIE patients usually having a long duration of suffering pain and illness and continuously impacting their mental health, to the extent where no difference in MCS can be found between UTE and DIE patients. Another possible reason is that while the PCS is more directly influenced by physiological factors, MCS may also correlate with other influences, such as family or social factors. To further explore this, we conducted a multiple linear regression analysis of MCS scores in 92 UTE patients. Our analysis found that miscarriage times and the detection of urologic abnor - malities before surgery were the influential factors of MCS. Preoperative imaging examinations such as type B ultrasound and MRI are meaningful for detecting renal and ureteral lesions, which are important for diagnos - ing UTE [ 31, 32]. Early diagnosis of UTE can optimize patient management, improve preoperative counsel - ing, and facilitate better surgical planning. In our study, all participants underwent abdominal imaging exami - nations before surgery. Among the 92 UTE patients, 53 were found to have urologic abnormalities by type B ultrasound or MRI, including 49 with ureter lesions and 45 with hydronephrosis. Interestingly, we observed a significant correlation between the detection of urologic abnormalities and MCS in UTE patients. UTE primar - ily affects the urethra, bladder, ureters, or kidney, lead - ing to urinary tract obstruction or renal dysfunction. In our study, UTE patients exhibited higher creatinine levels and a greater detection rate of urinary leukocyte, eryth - rocyte and protein than the DIE group, and they also had a higher incidence of hydronephrosis, consistent with previous studies [33]. However, only the detection of uro- logic abnormalities significantly impacted their mental Variables UTE group Mean ± SD / N (%) Control Group Mean ± SD / N (%) t or χ2 P-value Yes 37(40.22%) 85(36.32%) 1.577 0.455 No 46(50.00%) 133(56.84%) Asexual 9(9.78%) 16(6.84%) Accompany with adenomyosis Yes 41(44.67%) 114(48.72%) 0.305 0.581 No 51(55.43%) 120(51.28%) Accompany with ovarian endometriosis Yes 52(56.52%) 142(60.68%) 0.368 0.544 No 40(43.48%) 91(38.89%) Recurrent endometriosis Yes 24(26.09%) 56(23.93%) 0.070 0.792 No 68(73.91%) 178(76.07%) Complications a Yes 33(35.89%) 47(20.09%) 8.053 0.005* No 59(64.13%) 187(79.91%) SF-12 score PCS 38.54 ± 8.54 41.64 ± 9.58 2.703 0.007* MCS 43.62 ± 10.96 42.19 ± 11.37 -1.033 0.302 a Complications refer to existing diseases of another system, including but not limited to hypertension, diabetes mellitus and thyroid dysfunction. * Statistically significant. BMI, body mass index Table 1 (continued) Page 6 of 9 Chen et al. BMC Women's Health (2025) 25:91 health. Our data shown that UTE patients with explicitly urologic abnormalities before surgery had significantly lower MCS scores than those without abnormalities (41.26 ± 11.29 vs. 46.81 ± 9.74, P = 0.016), while their PCS shown no difference (38.16 ± 8.06 vs. 39.04 ± 9.25, P = 0.629). We speculate that this may be due to the Table 2 Comparison of clinical examinations between two groups before surgery Variables UTE group Mean ± SD / N (%) Control Group Mean ± SD / N (%) t / χ2 P-value Hemoglobin 114.51 ± 19.00 115.75 ± 15.60 0.605 0.546 Creatinine 67.57 ± 28.44 57.41 ± 11.95 -4.542 < 0.001* AMH Normal 63(68.48%) 162(69.23%) 0.000 1.000 Abnormal 12(13.04%) 31(13.25%) CA-125 Normal 22(23.91%) 63(26.92%) 0.229 0.632 Abnormal 70(76.09%) 168(71.79%) Urinary leukocyte Negative 60(65.22%) 182(77.78%) 4.810 0.028* Positive 32(34.78%) 52(22.22%) Urinary erythrocyte Negative 62(67.39%) 205(87.61%) 16.868 < 0.001* Positive 30(32.61%) 29(12.39%) Urinary protein Negative 79(85.87%) 224(95.73%) 8.339 0.004* Positive 13(14.13%) 10(4.27%) Urine occult blood Negative 44(47.83%) 138(58.97%) 2.891 0.089 Positive 48(52.17%) 96(41.03%) Ureteral stent im- plantation before surgery No 76(82.61%) 231(98.72%) 28.357 < 0.001* Yes 16(17.39%) 3(1.28%) Urologic abnor- malities before surgery a No 39(42.39%) 215(91.88%) 91.134 < 0.001* Yes 53(57.61%) 19(8.12%) a Urologic abnormalities refer to unilateral or bilateral hydronephrosis or the obstruction, stricture, dilation, hydroureter, or other pathological changes of one or both sides of the ureters, detected by type B ultrasonic examination and MRI before surgery and ultimately confirmed during surgery. * Statistically significant. AMH, anti-Müllerian hormone Table 3 Surgical procedure of 92 patients in UTE group Surgical procedure n (%) Ureterolysis 51 (55.43%) Ureterectomy with end-to-end anastomosis 27 (29.35%) Ureteroneocystostomy 16 (17.39%) Partial cystectomy 8 (8.70%) Ureteral stent implantation 65 (70.65%) Table 4 Univariate analysis of SF-12 scores in UTE group Variables PCS P-value MCS P-value Miscarriage times 0 38.85 ± 7.79 0.140 44.72 ± 10.30 0.042* 1 41.33 ± 10.75 44.77 ± 11.66 ≥ 2 33.21 ± 6.60 36.83 ± 11.36 Need for painkillers Yes 35.62 ± 8.37 0.001* 40.94 ± 11.65 0.024* No 41.21 ± 7.87 46.06 ± 9.77 Urine occult blood Negative 39.67 ± 8.35 0.226 46.32 ± 9.87 0.023* Positive 37.50 ± 8.68 41.14 ± 11.41 Urologic abnormali- ties before surgery No 37.57 ± 10.76 0.742 46.81 ± 9.74 0.013* Yes 36.85 ± 9.61 41.26 ± 11.29 * Statistically significant Table 5 Multiple linear regression analysis of PCS in UTE group Variables β 95% CI t P-value BMI -0.388 -0.870 ~ 0.094 -1.599 0.113 Need for painkillers No (Reference) Yes -5.721 -9.062~-2.381 -3.403 0.001* Intercept 49.809 38.885 ~ 60.733 9.060 < 0.001* * Statistically significant. β, standardized regression coefficient. 95% CI, 95% confidence interval. BMI, body mass index Table 6 Multiple linear regression analysis of MCS in UTE group Variables β 95% CI t P-value BMI -0.461 -1.078 ~ 0.155 -1.487 0.141 Time until diagnosis (month) 0.059 -0.007 ~ 0.124 1.785 0.078 Miscarriage times 0 (Reference) 1 0.146 -5.273 ~ 5.566 0.054 0.957 ≥ 2 -9.300 -15.592~-3.007 -2.938 0.004* Urine occult blood Negative (Reference) Positive -3.499 -8.005 ~ 1.008 -1.544 0.126 Urologic abnormali- ties before surgery No (Reference) Yes -5.562 -10.189~-0.935 -2.390 0.019* Intercept 58.597 44.549 ~ 72.646 8.293 < 0.001* * Statistically significant. β, standardized regression coefficient. 95% CI, 95% confidence interval. BMI, body mass index Page 7 of 9 Chen et al. BMC Women's Health (2025) 25:91 misunderstanding and fear of urologic abnormalities. The early symptoms of UTE, such as painful micturition, dys - uria, urinary urgency and frequency, are often nonspe - cific and can easily be mistaken for symptoms of urinary tract infections. This can lead to delayed diagnosis and treatment, resulting in ureteral lesions, hydronephro - sis and loss of kidney function [ 34– 36]. Many patients in our study expressed confusion, puzzlement, and even panic about why their dysmenorrhea could progress to urinary system damage. Due to the misinterpretation of this disease, many patients believed that hydronephrosis and ureter lesions were synonymous with complete loss of kidney function or even uremia. The fear of irrevers - ible kidney damage and the potential need for long-term hemodialysis significantly increased their psychologi - cal burden and damaged their mental health and quality of life. On the other hand, some patients were informed that their surgery might involve ureter partial resection, pyelostomy, or long-term indwelling catheterization, which could have a profound impact on their daily lives and sexual satisfaction. The great fear of surgery also fur - ther exacerbated the strain on their mental health. There- fore, doctors and nurses should pay more attention to the mental health of UTE patients with urologic abnormali - ties before their surgery. Integrating targeted psycho - logical counseling into preoperative care should be fully considered for these patients. In our study, 13 of 92 UTE patients (14.13%) experi - enced more than two miscarriages, which was identified as an influence factor of lower MCS. Accumulating evi - dence shows that endometriosis is an important cause of infertility, leading to reduced pregnancy rates and an increased risk of miscarriage [ 37– 39]. Reproduction is very important in women’s lives, and for many women, especially in developing countries, having their own chil - dren within their limited childbearing years is considered essential. Once diagnosed with endometriosis, the fear of infertility and miscarriage can bring heavy psychological pressure to them. Miscarriage is a common complication of endometriosis, which not only causes physical harm but also seriously affects mental health, increasing the incidence of anxiety and depression [ 40]. Recurrent mis - carriages can have an obvious negative impact on both women and their husbands, straining their relationship and family unity, and even leading to divorce in some cases, which further damages women’s quality of life. Therefore, it is important for doctors and nurses to iden - tify those UTE patients with recurrent miscarriage early and offer personalized psychological support. With development in technology, UTE patients now have more surgical options available. In addition to tra - ditional laparoscopic surgery, Pavone has shown that robotic-assisted surgery systems can be advantageous in managing complex endometriosis cases [ 41]. This innovative surgical method can alleviate the symptoms of dysmenorrhea, dyschezia, dyspareunia and chronic pelvic pain associated with endometriosis. Moreover, several studies have also highlighted the reliability and effectiveness of image-guided robotic surgical procedures in urology operations, which can support intraopera - tive decision-making and potentially reduce the dura - tion of minimally invasive procedures [ 42]. The choice of surgical procedures, time and extent of surgery, and postoperative complications can significantly impact the quality of life for UTE patients. In our study, we assessed the HQoL of all participants only before they underwent laparoscopic surgery. Further investigation should focus on evaluating the long-term physical and mental health outcomes of UTE patients after surgery. There are some limitations to this study. First, per - sonal information and HQoL were obtained through self-reported questionnaires, which may introduce measurement error and bias due to subjective factors. Additionally, all the endometriosis patients enrolled underwent laparoscopic surgery at our hospital, while patients who received conservative drug treatment were not included in this study. The findings of this study may be more applicable to the clinical care of UTE patients undergoing surgical treatment. Finally, all participants were recruited from a single hospital in China. Extrapola- tion of this study requires careful consideration and fur - ther investigation.

In conclusion, our study investigates the quality of life for UTE patients and demonstrates that the need for pain - killers is the influence factor of PCS, while the detection of urologic abnormalities before surgery and miscarriage times are the influence factors of MCS. Our results pro - vide clinicians with a new insight into improving medical care for UTE patients to prevent negative outcomes. Abbreviations DIE Deep infiltrating endometriosis UTE Urinary tract endometriosis HQoL Health-related quality of life PCS Physical component summary scale MCS Mental component summary scale BMI Body mass index CA-125 Carbohydrate antigen 125 AMH Anti-müllerian hormone MRI Magnetic resonance imaging Supplementary Information The online version contains supplementary material available at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 0 5 - 0 2 5 - 0 3 5 7 9 - 5. Supplementary Material 1 Page 8 of 9 Chen et al. BMC Women's Health (2025) 25:91

The research team would like to thank all the participants in this study. We would also like to thank the support from the First Affiliated Hospital of Sun Yat-sen University. Author contributions XC and TZ contributed to the analysis and interpretation of the data and revising of the manuscript under the guidance of JC. QZ were responsible for collection and entry of the data. GH and XW contributed to distribution of the questionnaires and follow-up with participants. JH and YM concepted and designed this study. TZ and JC provided support for this research. All authors read and approved the final manuscript. Funding This work was supported by the China Association for Mental Health (No. 22-23-90 to Jiebing Chen) and Hangzhou Health Science and Technology Project (No. A20230144 to Tingting Zhao). Data availability The datasets analyzed during the current study available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate The study was performed in accordance with the Declaration of Helsinki and approved by the Ethics Committee for Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-sen University (Approval No. [2021] 237). All participants were informed and willing to participate in this study, and written informed consent was obtained from all patients. Personal information of the participants will be treated with the strictest confidence. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Received: 8 October 2024 / Accepted: 23 January 2025

1. Koninckx PR, Fernandes R, Ussia A, Schindler L, Wattiez A, Al-Suwaidi S, et al. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Front Endocrinol. 2021;12:745548. 2. Cohen J, Mathieu d’Argent E, Selleret L, Antoine JM, Chabbert-Buffet N, Ben- difallah S et al. [Fertility and deep infiltrating endometriosis]. Presse medicale (Paris, France: 1983). 2017;46(12 Pt 1):1184-91. 3. Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P , Vercellini P . Bladder endometriosis: a systematic review of Pathogenesis, diagnosis, treatment, impact on fertility, and risk of Malignant Transformation. Eur Urol. 2017;71(5):790–807. 4. Seracchioli R, Raimondo D, Di Donato N, Leonardi D, Spagnolo E, Paradisi R, et al. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod (Oxford England). 2015;30(4):833–9. 5. Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical clas- sification. Fertil Steril. 2015;103(1):147–52. 6. Raimondo D, Mabrouk M, Zannoni L, Arena A, Zanello M, Benfenati A, et al. Severe ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol- ogy: J Inst Obstet Gynecol. 2018;38(2):257–60. 7. Sherman AK, MacLachlan LS. A review of urinary tract endometriosis. Curr Urol Rep. 2022;23(10):219–23. 8. Seracchioli R, Mabrouk M, Montanari G, Manuzzi L, Concetti S, Venturoli S. Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril. 2010;94(3):856–61. 9. Baczek G, Mietus M, Klimanek J, Tataj-Puzyna U, Sienkiewicz Z, Dykowska G, et al. The impact of endometriosis on the quality of women’s life. Ginekologia Polska. 2024;95(5):356–64. 10. da Silva MCM, Ferreira LPS, Della Giustina A. It is time to change the defini- tion: endometriosis is no longer a pelvic disease. Clin (Sao Paulo Brazil). 2024;79:100326. 11. Marinho MCP , Magalhaes TF, Fernandes LFC, Augusto KL, Brilhante AVM, Bezerra L. Quality of life in women with endometriosis: an integrative review. J Womens Health (Larchmt). 2018;27(3):399–408. 12. Sims OT, Gupta J, Missmer SA, Aninye IO. Stigma and endometriosis: a brief overview and recommendations to improve Psychosocial Well-Being and Diagnostic Delay. Int J Environ Res Public Health. 2021;18(15). 13. Della Corte L, Di Filippo C, Gabrielli O, Reppuccia S, La Rosa VL, Ragusa R et al. The Burden of Endometriosis on Women’s Lifespan: A Narrative Overview on Quality of Life and Psychosocial Wellbeing. Int J Environ Res Public Health. 2020;17(13). 14. Laganà AS, La Rosa VL, Rapisarda AMC, Valenti G, Sapia F, Chiofalo B, et al. Anxiety and depression in patients with endometriosis: impact and manage- ment challenges. Int J Women’s Health. 2017;9:323–30. 15. Rush G, Misajon R. Examining subjective wellbeing and health-related quality of life in women with endometriosis. Health Care Women Int. 2018;39(3):303–21. 16. Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. The social and psychological impact of endometriosis on women’s lives: a critical narrative review. Hum Reprod Update. 2013;19(6):625–39. 17. Nassiri Kigloo H, Itani R, Montreuil T, Feferkorn I, Raina J, Tulandi T, et al. Endo- metriosis, chronic pain, anxiety, and depression: a retrospective study among 12 million women. J Affect Disord. 2024;346:260–5. 18. Ianieri MM, Nardone AC, Pavone M, Benvenga G, Pafundi MP , Campolo F, et al. Are ureterolysis for deep endometriosis really all the same? An anatomi- cal classification proposal for ureterolysis: a single-center experience. Int J Gynaecol Obstet. 2023;162(3):1010–9. 19. Ianieri MM, Rosati A, Ercoli A, Foschi N, Campolo F, Greco P , et al. Laparoscopic ureteroneocystostomy and round ligament bladder hitching for ureteral stenosis in parametrial deep endometriosis: our tips for a tension-free anasto- mosis. Int J Gynaecol Obstet. 2023;160(2):563–70. 20. Ware J Jr., Kosinski M, Keller SD. A 12-Item short-form Health Survey: con- struction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–33. 21. Lin Y, Yu Y, Zeng J, Zhao X, Wan C. Comparing the reliability and validity of the SF-36 and SF-12 in measuring quality of life among adolescents in China: a large sample cross-sectional study. Health Qual Life Outcomes. 2020;18(1):360. 22. Arion K, Orr NL, Noga H, Allaire C, Williams C, Bedaiwy MA et al. A Quantitative Analysis of Sleep Quality in Women with Endometriosis. Journal of women’s health (2002). 2020;29(9):1209-15. 23. Pontis A, Nappi L, Sedda F, Multinu F, Litta P , Angioni S. Management of blad- der endometriosis with combined transurethral and laparoscopic approach. Follow-up of pain control, quality of life, and sexual function at 12 months after surgery. Clin Exp Obstet Gynecol. 2016;43(6):836–9. 24. Kołodziej A, Krajewski W, Dołowy Ł, Hirnle L. Urinary Tract Endometr Urol J. 2015;12(4):2213–7. 25. Facchin F, Barbara G, Saita E, Mosconi P , Roberto A, Fedele L, et al. Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference. J Psychosom Obstet Gynaecol. 2015;36(4):135–41. 26. Evans S, Mikocka-Walus A, Olive L, Seidman LC, Druitt M, Payne LA. Pheno- types of women with and without endometriosis and Relationship with Functional Pain disability. Pain Med (Malden Mass). 2021;22(7):1511–21. 27. Matías-González Y, Sánchez-Galarza AN, Flores-Caldera I, Rivera-Segarra E. Es que tú eres una changa: stigma experiences among Latina women living with endometriosis. J Psychosom Obstet Gynaecol. 2021;42(1):67–74. 28. Guo Y, Liu FY, Shen Y, Xu JY, Xie LZ, Li SY et al. Complementary and Alternative Medicine for Dysmenorrhea Caused by Endometriosis: A Review of Utilization and Mechanism. Evidence-based complementary and alternative medicine: eCAM. 2021;2021:6663602. 29. Guan Q, Velho RV, Sehouli J, Mechsner S. Endometriosis and opioid receptors: are opioids a Possible/Promising treatment for endometriosis? Int J Mol Sci. 2023;24(2). 30. Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A. Nonsteroidal anti- inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev. 2017;1(1):Cd004753. Page 9 of 9 Chen et al. BMC Women's Health (2025) 25:91 31. Leonardi M, Espada M, Kho RM, Magrina JF, Millischer AE, Savelli L et al. Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment. Diagnostics (Basel, Switzerland). 2020;10(10). 32. Carfagna P , De Cicco Nardone A, Benvenga G, Nardone FC, Greco P , Campolo F, et al. Preoperative diagnosis of ureteral medial deviations secondary to deep endometriosis using transvaginal ultrasound examinations: can we predict the need for ureterolysis during laparoscopic surgery? Int J Gynaecol Obstet. 2024;166(2):663–71. 33. Charatsi D, Koukoura O, Ntavela IG, Chintziou F, Gkorila G, Tsagkoulis M, et al. Gastrointestinal and urinary tract endometriosis: a review on the commonest locations of Extrapelvic Endometriosis. Adv Med. 2018;2018:3461209. 34. Machairiotis N, Stylianaki A, Dryllis G, Zarogoulidis P , Kouroutou P , Tsiamis N, et al. Extrapelvic endometriosis: a rare entity or an under diagnosed condition? Diagn Pathol. 2013;8:194. 35. Shenoy-Bhangle AS, Pires-Franco IV, Ray LJ, Cao J, Kilcoyne A, Horvat N et al. Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique. Academic radiology. 2023. 36. Zhao SZ, Li YH, Xu YC, Ke CX. Ureteral endometriosis: a uncommon cause of ureteral stricture and hydronephrosis. Asian J Surg. 2023;46(12):5832–4. 37. Vercellini P , Viganò P , Bandini V, Buggio L, Berlanda N, Somigliana E. Associa- tion of endometriosis and adenomyosis with pregnancy and infertility. Fertil Steril. 2023;119(5):727–40. 38. Porpora MG, Tomao F, Ticino A, Piacenti I, Scaramuzzino S, Simonetti S et al. Endometriosis and pregnancy: a single Institution experience. Int J Environ Res Public Health. 2020;17(2). 39. Boje AD, Egerup P , Westergaard D, Bertelsen MMF, Nyegaard M, Hartwell D, et al. Endometriosis is associated with pregnancy loss: a nationwide historical cohort study. Fertil Steril. 2023;119(5):826–35. 40. Huffman CS, Schwartz TA, Swanson KM. Couples and miscarriage: the influence of gender and Reproductive factors on the impact of Miscarriage. Women’s Health Issues: Official Publication Jacobs Inst Women’s Health. 2015;25(5):570–8. 41. Pavone M, Seeliger B, Alesi MV, Goglia M, Marescaux J, Scambia G, et al. Initial experience of robotically assisted endometriosis surgery with a novel robotic system: first case series in a tertiary care center. Updates Surg. 2024;76(1):271–7. 42. Pavone M, Seeliger B, Teodorico E, Goglia M, Taliento C, Bizzarri N, et al. Ultrasound-guided robotic surgical procedures: a systematic review. Surg Endosc. 2024;38(5):2359–70. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.