Ureteral Endometriosis: Proposal for a Diagnostic and Therapeutic Algorithm with a Review of the Literature

Abstract

Introduction: The ureteral involvement in deep pelvic endometriosis in usually asymptomatic and might lead to a silent loss of renal function. As a matter of fact, the diagnosis and the treatment modalities are still a matter of debate. Materials and Methods: We performed a literature review by searching the MEDLINE database for articles published in English between 1996 and 2010, using the key words urinary tract endometriosis, ureteral endometriosis, diagnosis and treatment. We found more than 200 cases of ureteral endometriosis (UE). Results: The disease most commonly affects a single distal segment of the ureter, with a left predisposition in most of the patients. Two major pathological types of UE may be distinguished: intrinsic and extrinsic. The symptoms are usually nonspecific and owing to secondary obstruction. The diagnosis has to be considered as a step- by-step procedure, starting from physical examination to highly detailed imaging methods. Nowadays, the treatment is usually chosen according to the type of UE, the site lesion and the distance to the ureteral orifice, with the use of JJ stents remaining a matter of debate. Conclusions: A close collaboration between the gynecologist and the urologist is advisable, especially in referral centers. Surgical treatment can lead to good results in terms of both patient compliance and prognosis.

Ureteral endometriosis following panhysterectomy a case report

“…The mean age was 36.2 years in a study of 23 cases by Mu et al It is usually rare in post menopausal women except those women who have been on prolonged estrogen supplementation. 1,4 It is more common in the left lower third of the ureter. The predilection to the left can be explained by menstrual reflux theory and the anatomy of left hemipelvis making it more susceptible in the left as seen in ovarian endometriosis.…”

“…Ovarian endometriosis is a pre requisite for ureteral endometriosis. 1 The two types of ureteral endometriosis are extrinsic and intrinsic ureteral endometriosis with the ratio being 4:1. Extrinsic ureteral endometriosis occurs within the ureteral adventitia and adjacent soft tissues only as seen in the present case.…”

“…It is a very rare entity. 1,5 Symptoms associated with ureteral endometriosis are varied. Flank pain, back ache, abdominal pain, urgency, frequency, haematuria etc.…”

“…Since it is frequently associated with pelvic and rectovaginal endometriosis, symptoms related to them like dysmenorrhea, dyspareunia, chronic pelvic pain, constipation, diarrhea, dyschezia, tenesmus, hematochezia, infertility can also be associated. 1,6 Histological study of periureteral resection specimens revealed the presence of endometrial glands in contact with the uterine artery and the ureter. Periarterial invasion by the retroperitoneal adenomyotic disease was demonstrated histologically in all cases where, the uterine artery was resected.…”

“…There is an increasing incidence of ureteral involvement attributable to better imaging modalities. 1 4.4% of women suffering from rectovaginal adenomyosis have ureteric involvement. 2 In those patients with ureteric obstruction as many as 25% will sustain irreversible renal damage because of the delay in diagnosis.…”