Urinary tract involvement in endometriosis involves presence of endometriosis deposits within or around the bladder, ureters, urethra, or kidney. Urethral lesions may cause major morbidity as silent loss of renal function is common in these patients. Symptoms related to pelvic endometriosis and/or of urinary involvement maybe often nonspecific. The most common findings include menstrual symptoms, flank pain, gross hematuria, and pelvic mass.
Ureteric obstruction resulting in hydronephrosis is a rare manifestation of ureteric endometriosis. It occurs as a consequence of intrinsic involvement within the ureteric, or from extrinsic compression of the ureteric by a pelvic endometrioma. In cases of intrinsic involvement, ectopic endometrial tissue is present within the muscular is propria, lamina propriety or ureteric lumen. In extrinsic cases endometriosis occurs within the ureteric adventitia and adjacent soft tissues only. Extrinsic involvement is approximately 4 times more common than intrinsic disease.
Deeply infiltrating Endometriosis (DIE) most commonly invades the rectovaginal space, uterosacral ligaments, bowel or urinary tract. Our case was a DIE because of the bilateral ureteric involvement.
Diagnosis of ureteric endometriosis is elusive and relies heavily on clinical suspicion. In our case, patient complained of hesitancy of maturation typically during menses which is a rather uncommon presentation of ureteric endometriosis. This symptom could be explained by enlargement of active endometriosis tissue around the ureters. Since ureteric endometriosis occurs commonly with pelvic endometriosis there is a need for multidisciplinary management. Progressive ureteric obstruction can be insidious and bilateral compromise of ureters may ultimately lead to renal failure. 30% of patients will have reduced kidney function at the time of diagnosis that may result in silent kidney loss.
Medical and surgical treatment is available for ureteric endometriosis. Factors influencing treatment choice include patients’ age, interest in maintaining fertility, severity of symptoms and presence or absence of ureteric obstruction and its consequences. Medical therapy may be offered to those wanting to preserve reproductive capacity or those with normal renal function and no significant obstruction. In our case surgical management was decided so that the young woman is relieved of the obstruction and prevents future renal damage. More conservative ureterolysis was performed minimizing morbidity associated with surgery. To reduce the risk of ureteric fibrosis a double J stent was placed for 6 weeks. A check IVP after removal of ureteric stents showed resolution of the obstruction. At 6 months follow up, the patient is relieved of her symptoms and USG KUB shows normal pelvic clypeal system. She has been advised and counseled to follow up regularly keeping a vigilant eye on recurrence.