Cyclic catamenial hematuria

Specialty: Gynecology and breast.

• Bloody urine during menstruation
• genuine menstrual hematuria
• catamenial bladder bleeding

Why it occurs

• Infiltrating endometriosis of the bladder wall with invasion of the urothelial mucosa (main cause)
• Acquired uterovesical fistula (Youssef syndrome, complication after previous segmental cesarean section)
• Bilateral or unilateral ureteral endometriosis
• Urothelial neoplasia of the bladder that bleeds incidentally coinciding with the vascular congestion of menstruation

Initial workup

Urgent cystoscopy performed during the days of menstruation to directly visualize the site of bleeding (bleeding endometrial implantation areas or uterovesical fistulous tract). Complete renal and urinary tract ultrasound. Uro-CT or Magnetic Resonance of the pelvis with protocol for endometriosis. Urinary cytology in urine from three consecutive samples to rule out bladder transitional cell neoplasia.

Standard management

• There are no drugs that permanently cure transmural infiltration of the bladder mucosa. First-line symptomatic treatment consists of GnRH analogues (Leuprorelin 3.75 mg subcutaneously monthly) to induce temporary chemical menopause, reducing ectopic follicular bleeding. The treatment of choice for Youssef syndrome (uterovesical fistula) or severe transmural endometriosis is surgical correction (note: it is important to ensure that the bleeding comes from the urethra and is not contamination by external bloody vaginal discharge).