Deep bladder endometriosis

Specialty: Gynecology and breast.

• Urothelial endometriosis
• detrusor involvement due to endometriosis
• bladder endometriotic nodule

Why it occurs

• Implantation and growth of functional endometrial tissue in the wall of the urinary bladder, which penetrates deeply into the muscular layer of the detrusor, suffering inflammation and cyclic microbleeds coinciding with menstruation

Initial workup

Transvaginal gynecological and bladder ultrasound with a full bladder (shows a well-defined, irregular hypoechoic nodule that infiltrates the posterior wall of the bladder and protrudes into the bladder lumen). Diagnostic cystoscopy performed preferably during the menstrual phase (bluish or reddish mamelonated or congestive lesions are observed under the urothelium). High-resolution pelvic magnetic resonance imaging.

Standard management

• Combined oral contraceptives prescribed in a continuous regimen to induce amenorrhea and suspend the cyclical shedding of the bladder lesion
• Dienogest 2 mg orally daily continuously
• GnRH analogues (such as Triptorelin 3.75 mg IM monthly) in combination with low-dose estrogens as add-back therapy. The treatment of choice for large nodules (>1.5 cm), refractory to pain or compromising ureteral flow, is surgical wedge resection of the affected bladder wall laparoscopically or robotically with detrusor suturing (note: placement of a postoperative Foley bladder catheter is required for 7 to 14 days to ensure adequate bladder healing).