Endometriosis: A Rare Cause of Gross Hematuria

Endometriosis is a condition described as growth of ectopically located endometrial tissue in sites other than uterine cavity. Since gross hematuria and frequency are rare symptoms of endometriosis, this diagnosis should be kept in mind in encountering these symptoms, even in the absence of other endometriosis features ( 6). Previously, mullerianosis has been indicated as the cause of microscopic hematuria in a case study, in 2012. In this study a mass intruding into the posterior aspect of the bladder was found, and for management LH-RH analogue was used, which achieved acceptable results ( 7). Therefore, we tried this treatment in managing our patient. Metaplasia (a change in cell morphology into another cell type that is considered abnormal for that location) frequently occurs in urothelium, supposedly as a response to local stimuli (e.g. urinary tract infection, inflammation especially chronic, calculi, diverticula, catheterization, or surgical procedures). Involvement of genitourinary tract with one of the non-neoplastic mullerian lesions includes: endocervicosis, endometriosis or endosalpingiosis occurs in 1 to 2% of cases, most of which are endometriosis ( 2). Conversely, endocervicosis is considered a rare condition, which was first described as a distinct concept, by Clement and Young in 1992, as a benign variation of endometriosis ( 8). Ever since, few cases of this entity occurring almost exclusively in women of reproductive age have been reported. This condition is characterized by existence of mucinous endocervical epithelium within the detrusor muscle of the bladder ( 9). This situation is characterized by the following features: occurring during reproductive age, being located in the posterior bladder wall and coexisting with endometriosis and endosalpingiosis ( 10). Among different predisposing factors associated with endocervicosis, history of previous Caesarean section appears to be the most prominent one ( 11). This association is not only apparent from our report, but it also is shown by all previous cases reported in this regard ( 12). They all have the same presentations as our case, with the main clinical features including a mass in the bladder and urinary complaints. Although this condition is very rare, considering the features of our case, it should be envisaged as a possible diagnosis. Eosinophilic cystitis, an uncommon inflammatory bladder condition, for which the pathophysiology is still unknown, usually presents with hematuria, frequency, urgency and supra-pubic pain, in addition to sterile urine culture ( 13). Since we had two of these symptoms in our case this condition was considered a differential diagnosis until the pathology reported otherwise. There are different causes for hematuria ranging from benign to malignant yet endometriosis and endocervicosis should be regarded in patients with gross hematuria and in differential diagnosis of urothelial carcinoma.