Cyclic catamenial dysuria

Specialty: Gynecology and breast.

• Pain when urinating during menstruation
• recurrent menstrual dysuria
• painful bladder endometriosis

Why it occurs

• Deep bladder endometriosis (infiltration of the detrusor wall by ectopic endometrial tissue)
• Interstitial cystitis with severe premenstrual exacerbation
• Recurrent urinary tract infections that coincide with the hormonal changes of the menstrual cycle
• Cyclic urethral syndrome due to pelvic congestion of the period

Initial workup

Sediment and complete urine culture (both in the symptomatic and asymptomatic phase to rule out standard bacterial infection). High-resolution transvaginal ultrasound with a moderately full bladder to visualize infiltrating hypoechoic nodules in the anterior bladder wall. Diagnostic cystoscopy preferably performed during the menstrual phase of the cycle (raised bluish or erythematous areas are observed that correspond to foci of endometriosis). Magnetic resonance imaging of the pelvis with contrast.

Standard management

• Ibuprofen 600 mg orally every 8 hours or Naproxen 500 mg every 12 hours orally
• Combined oral contraceptives in a continuous regimen to suppress menstruation and the proliferative stimulus of bladder lesions
• Dienogest 2 mg per day orally uninterruptedly
• GnRH analogues (triptorelin or leuprorelin) as rescue second-line hormonal treatment (note: if the endometrial lesion penetrates deeply into the bladder mucosa or involves the trigone/ureters, cystoscopic or partial laparoscopic bladder surgical resection is required).