endometriosis is characterized by the presence of active endometrial tissue outside of the uterine cavity .
endometriosis can involve the genitourinary tract , with the bladder being the most commonly affected site .
symptomatic urinary tract involvement is rare , occurring in 1% to 2% of women , and it typically presents with dysuria , suprapubic pain , and , rarely , hematuria . medical therapy is palliative and definitive therapy is surgical .
a 47-year - old african american woman ( gravida 1 , para 1 ) with a 25-week size fibroid uterus presented with pelvic pain and menorrhagia and wanted definitive surgical management . despite prior management with depot - lupron and a prior open myomectomy ,
the patient continued to complain of heavy vaginal bleeding , with increasing dysmenorrhea and occasional dyspareunia .
the patient reported pelvic pressure symptoms but denied any urinary symptoms of hematuria or flank pain on evaluation and review of her past medical records .
her past medical history was significant for hypertension , and her past surgical history included laparoscopic surgery for endometriosis and an open myomectomy .
a pelvic examination revealed a uterus palpable 4 cm above the umbilicus that was fixed and slightly tender .
there were no other masses noted on the examination and there was no fullness or tenderness of the bladder .
transvaginal ultrasonography demonstrated a 17-cm uterus with multiple intramural myomas , the largest being 5  5 cm ; a 4  4-cm submucosal myoma , normal right adnexa , and a left adnexa and bladder could not be visualized .
a computed tomography scan of the abdomen and pelvis from a prior emergency department visit demonstrated left hydronephrosis with marked cortical thinning and the possibility of a 5-cm bladder mass described along the dome of the bladder ( figure 1 ) .
a , the arrow shows the left marked hydronephrosis with cortical thinning ( b ) 5.5  3.2-cm irregular enhancing lesion within the left bladder ( arrow ) .
the patient 's surgery was a joint case between the urology and gynecology departments , and the patient underwent an abdominal supracervical hysterectomy because of extensive pelvic adhesive disease , enterolysis , and transurethral resection of a bladder mass .
findings at the surgery included a 25-week size uterus with multiple fibroids on the anterior uterus , fundus , and bilateral broad ligaments , overlying small intestine on the anterior surface of the uterus and adherent to the left pelvic side wall .
there was also severe pelvic adhesive disease to the posterior surface of the uterus , posterior cul - de - sac endometriosis , contributing to a distorted pelvic anatomy .
a cystoscopy was performed and revealed a 5- to 7-cm lobulated and nodular solid mass at the left hemitrigone that involved the left ureteral orifice ( figure 2 , a and b ) .
a retrograde pyelogram demonstrated severe left hydronephrosis and narrowing of the distal ureter . despite multiple attempts , a ureteral stent was unable to be passed .
a transurethral resection of the bladder mass with negative margins was performed , with a preliminary diagnosis of endometriosis .
a , nodular and lobulated bladder mass found medial and superior to the left ureter on cystoscopy .
a panel of immunohistochemical stains was performed on the bladder mass that were positive for estrogen and progesterone receptors and ck7 with the diagnosis of endometriosis .
the patient recovered well after her surgery and is currently being treated with 3 monthly depot lupron injections and daily 5-mg norethindrone add - back therapy .
she will be followed up with a cystoscopy and pelvic magnetic resonance imaging scan in 6 months to check for endometriosis recurrence .
bladder endometriosis ( be ) usually affects women in the reproductive age - group , at an average age of 35 years . within the urinary system ,
as many as 30% of patients remain asymptomatic and diagnosis is incidental although symptomatic , urinary tract involvement is rare , occurring in 1% to 2% of women ; it typically presents with dysuria , suprapubic pain , cyclic urgency , and rarely hematuria , symptoms similar to those of recurrent cystitis , which may be responsible for its delayed diagnosis .
according to the onset type , be is defined as  primary  or  secondary .
 primary be is a spontaneously occurring disease , whereas secondary be is an iatrogenic lesion occurring after pelvic surgery .
in fact , up to 50% of patients with be have a history of prior pelvic surgery with lesions from implanted endometrium or extensions from adenomyosis from the anterior uterine wall .
our patient had a prior pelvic surgery of an abdominal myomectomy , and we speculate her bladder lesion may have emerged from implanted endometrial tissue .
the pathogenesis of be is controversial , but the lesion has been described to evolve from the serosal surface of the bladder toward the mucosa .
it is often multifocal , with the trigone and the dome the most frequently affected sites .
imaging modalities for be include transvaginal bladder ultrasonography , with specificity and positive and negative predictive values of 100% , and pelvic magnetic resonance ( mr ) reaching a sensitivity of 88% and specificity of 99% .
cystoscopy is one of the most cost - effective tests and may reveal isolated or multifocal lesions usually located at the dome or base of the bladder .
calculating the distance between the ureteral orifices and the lower endometrotic margin is critically important to define the most correct surgical approach .
endoscopic biopsy is critical to exclude bladder carcinomas , varices , papillomas or angiomas , as well as detrusor mesenchymal tumors .
although long - term medical management is preferred over serial surgeries for the management of endometriosis , a recent study showed that 25% of patients who underwent surgery for endometriosis had additional surgery within 4 years . in our case , a supracervical hysterectomy was performed because of extensive anatomical distortion caused by her fibroids , and we have successfully controlled her symptoms postoperatively with medical suppression therapy .
the main surgical debate is whether to preserve the ovaries at the time of hysterectomy .
data have shown that women who undergo hysterectomy with ovarian preservation have a higher risk of undergoing repeat surgery up to 7 years later as opposed to women who have ovarian removal .
however , health implications of ovarian removal need to be reviewed with the patient , and the surgical plan must be individualized based on health risks and benefits . on the other hand , the treatment of be is controversial because of the rarity of the condition .
treatment includes medical therapy using gonadotrophin - releasing hormone agonist and antagonist , progestins , and combined oral contraceptives .
medical therapy , however , has a high recurrence rate after treatment cessation and is often considered a palliative modality for the treatment of be .
surgical management of be includes transurethral resection , which has a higher incidence of recurrence compared with partial cystectomy , laparotomy , or laparoscopy , with or without associated cystoscopy , combined transurethral partial cystectomy , and laparoscopic reconstruction of the bladder , robotic approach to surgery , and association of surgical and medical therapy ; whereas ureteral endometriosis is treated by surgery ; ureterolysis is preferred for nonbstructive lesions , and ureteral resection for obstructive lesions .
both adequate diagnosis and successful treatment should be completed with a multidisciplinary team with a dedicated gynecologist and urologist .
hormone therapy still remains an option , while surgical treatment leads to satisfactory long - term outcome results .
 a 47-year - old woman ( gravida 1 , para 1 ) with menorrhagia and pelvic pain was found to have an enlarged fibroid uterus and bladder mass on ultrasonographic imaging . 
 the patient underwent an abdominal supracervical hysterectomy and transurethral bladder mass resection . 
 histopathologic findings revealed leiomyoma uteri , intramural adenomyosis , and bladder endometriosis . 
 most case series of bladder endometriosis include women that present with urinary symptoms . 
 this is a rare case of obstructive uropathy secondary to bladder endometriosis in a patient without any urinary signs or symptoms . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION