P27.11: Transvaginal ultrasonography in the diagnosis of vesico-peritoneal fistula due to deep infiltrating endometriosis as a cause of uroperitoneum

Deep infiltrating endometriosis can also involve the bladder and is associated with severe chronic pelvic pain and dysuria. Transvaginal ultrasonography (TVS) is considered the first-line procedure in the assessment of deep endometriosis. To our knowledge, no case reports are present in the literature regarding the role of TVS in the diagnosis of complications of anterior deep endometriosis. We report a case of a 42-year-old woman with acute onset of abdominal pain associated with nausea and vomiting and a distended abdomen. Transabdominal ultrasonography performed in emergency room showed presence of ascites in absence of abdominal masses. The patient reported a medical history positive for chronic pelvic pain. Two year before the patient suffered of dysuria and cystoscopic diagnosis demonstrated the presence of bladder endometriosis. For this reason the patients was submitted to transurethral resectoscopic excision of bladder endometriosis. A magnetic resonance imaging performed after two months of bladder excision confirmed the suspicion of persistence of bladder endometriosis in absence of peritoneal free fluid. Due to previous diagnosis of endometriosis a TVS was performed that confirmed the presence of free fluid in abdomen but also suspected the presence of small nodule in the bladder wall and a interruption of vesical wall near the vescico-uterine pouch of few millimeters. An operative laparoscopy was performed to remove the uroperitoneum, repair of vesico-peritoneal fistula and perform the excision of the endometriotic nodule. The pathology confirmed the presence of deep endometriosis in the bladder wall. After six month the follow-up of the patients remains negative. This is the first report of a case of uroperitoneum related to endometriosis but not due to major surgical procedures as to colorectal resection or ureteral lesions. In addition TVS seems to be useful in the differential diagnosis with endometriosis associated with massive ascitis.