Ultrasound Differential Diagnosis in Deep Infiltrating Endometriosis of the Urinary Tract

Abstract

Endometriosis of the urinary tract is a rare condition that may lead to severe complications. At present, the major challenge appears to be the ultrasound differential diagnosis with diseases that can afflict the ureter and the bladder. Preoperative scan findings were compared with surgical and histologic records. Twenty-three cases were selected as being of interest, as they were referred for suspected endometriosis, whereas second-level ultrasound revealed a different disease in some cases. This case series aims to help in becoming familiar with the possible differential diagnosis of lesions of the urinary tract that resemble endometriosis.

Differential Diagnosis of Endometriosis by Ultrasound: A Rising Challenge

“…Colonic endometriosis is not a rare condition. It affects 37% of women with severe endometriosis [ 13 ], and its correct diagnosis is essential for the proper planning of treatment [ 15 , 48 , 50 , 51 ]. Recently, the ultrasound detection rate of endometriosis foci of the bowels has increased, exhibiting both high sensitivity and specificity [ 46 , 52 ].…”

“…The bladder wall can be examined by ultrasound because it is surrounded by a low-echogenic tissue (i.e., perivesical loose connective tissue) and the peritoneum, which appears as a hyperechoic line. In most cases, a hypoechoic lesion that alters the profile of the peritoneum of the bladder and infiltrates into the detrusor muscle indicates bladder endometriosis and originates from uterine adenomyosis [ 50 ]. Endometriosis of the bladder is often symptomatic (e.g., urgency, frequency, and pain on passing urine, which worsen days before and during menstruation, and recurrent urinary tract infections) and appears as a consistently solid mass that involves the prevesical space, the serosa (adventitia), and the detrusor muscle, sometimes up to the urothelium [ 22 , 42 , 57 ].…”

“…Furthermore, bladder cancer is typically found in postmenopausal women and originates from the internal surface (urothelium) of the lateral wall of the bladder. In cases of advanced-stage cervical cancer, the lesion clearly involves the cervix and quite often the lateral parametrial and paracervical tissues [ 50 , 58 ]. Endometriosis of the bladder may present some uncommon features, such as cystic lesions and multifocal endometriosis.…”

“…Color Doppler imaging is not useful for this condition because cystic endometriosis of the bladder usually shows no vascularization. When making the DD, the facts that bladder carcinomas typically occur in elderly women and that urinary cytology is the simplest, less-invasive, and least expensive method to obtain a correct diagnosis warrants consideration [ 50 ].…”

“…We recently reviewed the DD of urinary tract endometriosis [ 50 ]. The DD may sometimes be difficult due to the presence of external masses that encroach the bladder dome (i.e., uterine fibroids or an attached small bowel from a previous surgery, such as a cesarean section), an intravesical ureterocele that may resemble deep lesions of endometriosis, or hypertrophic areas of the bladder wall due to a chronic, complete cystocele and recurrent cystitis [ 50 ]. In such cases, although bladder endometriosis very often appears as an endophytic lesion, it may sometimes appear flat and may be confused with hypertrophic areas due to chronic mechanical trauma (cystocele) or recurrent cystitis ( Figure 5 ).…”