Polypoid Endometriosis of Urinary Bladder

A nulliparous 47-year-old woman suffered from urinary urgency during menstrual period and mild increase of menstrual flow for 6 months. Ultrasonography was performed which showed a left ovarian tumor (8.6 cm) and uterine mass (3.3 cm) suspected of endometrioma and adenomyosis. She had undergone laparoscopic left salpingo-oophorectomy, excision of left utero-sacral ligament, and cystoscope [Figure 1]. Four months later after operation, she still had frequency of urination during menstruation and so she was referred for transurethral resection of bladder tumor. Pathological examination reported endometriosis and after that frequency of urination was not reported anymore. There is a 0.3%–12% incidence of endometriosis, and the most commonly affected sites are the bladder (85%), ureter (9%), kidney (4%), and the urethra (2%). When bladder is affected, 70% of women present symptoms such as abnormal urination, especially during the peri-menstrual period.[] When the bladder mass or abnormal lesion was found by cystoscopy, the differential diagnosis should include bladder carcinoma, angiomas, leiomyoma, amyloidosis, malakoplakia, glandular cystitis, and nephrogenic adenoma. Polypoid endometriosis of urinary bladder is a rare disease, and the symptoms are not specific to endometriosis: urinary urgency during menstrual period and mild increase of menstrual flow. The diagnosis of choice is biopsy; bladder endometriosis is an endometriotic lesion that infiltrates the detrusor muscle and can be with either partial or full thickness,[] typically presents bladder pain or dysuria, but may have urinary frequency, hematuria, and urinary tract infection.[,] The treatment depends on several factors, such as age, fertility desire, extent of disease, severity of symptoms, and the presence of pelvic lesion, but the most important factor is to resolve symptoms. However, sometimes, only cystoscopy procedure can miss endometriosis that affects the outside of bladder. Therefore, multiple diagnostic tools are sometimes required to achieve an accurate diagnosis. The aim of surgical treatment of bladder endometriosis is complete excision of symptomatic endometriotic lesion to prevent recurrence. The data comparing medical and surgical therapy in bladder endometriosis are limited; however, surgical treatment is suitable in women who cannot use hormone, have pregnancy desire and poor compliance, and do not respond to medical treatment. The prognosis after complete surgical removal is associated with long-term control of symptoms.[,] However, knowledge of the pathogenic process of endometriosis is clear: the retrograde menstruation theory has gained widespread acceptance. In this case, the patient had an endometrioma of the left ovary and had undergone laparoscopic left salpingo-oophorectomy and excision of the left uterosacral ligament. She had deep endometriosis. Hence, in majority of cases, after surgery, patients should undergo medical treatment to reduce the recurrent rate and improve their quality of life. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES 1 Stopiglia RM, Ferreira U, Faundes DG, Petta CA. Cystoscopy-assisted laparoscopy for bladder endometriosis: Modified light-to-light technique for bladder preservation. Int Braz J Urol 2017;43: 87-94.2 Kovoor E, Nassif J, Miranda-Mendoza I, Wattiez A. Endometriosis of bladder: Outcomes after laparoscopic surgery. J Minim Invasive Gynecol 2010;17: 600-4.3 Gabriel B, Nassif J, Trompoukis P, Barata S, Wattiez A. Prevalence and management of urinary tract endometriosis: A clinical case series. Urology 2011;78: 1269-74.4 Sinaii N, Plumb K, Cotton L, Lambert A, Kennedy S, Zondervan K, et al. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil Steril 2008;89: 538-45.5 Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: Pathogenesis and treatment. Nat Rev Endocrinol 2014;10: 261-75.6 Schonman R, Dotan Z, Weintraub AY, Bibi G, Eisenberg VH, Seidman DS, et al. Deep endometriosis inflicting the bladder: Long-term outcomes of surgical management. Arch Gynecol Obstet 2013;288: 1323-8.