Endometriosis · Urinary tract involvement
Bladder and ureteric endometriosis — silent disease that needs early detection
Endometriosis of the urinary tract is less common than bowel involvement but is more dangerous when missed, because ureteric obstruction can damage the kidney silently. This page describes how bladder and ureteric endometriosis present, how they are evaluated, and how they are treated.
Where the disease sits
Endometriosis of the urinary tract typically involves the bladder dome (the part of the bladder closest to the uterus and posterior peritoneum) or the lower ureter (where it crosses the pelvis to enter the bladder). Renal endometriosis is rare. Around 1 to 2 percent of women with endometriosis have urinary-tract involvement, and it is associated with deep infiltrating disease elsewhere in the pelvis.
The silent risk
The most important clinical fact about ureteric endometriosis is that it can be silent. The disease compresses or strictures the ureter from outside, urine backs up, the kidney slowly loses function, and the patient does not feel it. By the time pain or renal dysfunction is noticed, kidney damage may be irreversible.
For this reason, in any patient with deep endometriosis or a posterior pelvic mass, renal ultrasound to look for hydroureter or hydronephrosis is part of the diagnostic work-up.
Symptoms to recognise
Bladder endometriosis tends to be symptomatic; ureteric endometriosis is often silent until late.
- Cyclical dysuria — painful urination worse around menses
- Cyclical haematuria — uncommon but highly suggestive when present
- Urinary frequency and urgency
- Suprapubic pain related to bladder filling, cyclical pattern
- Recurrent urinary tract infection in the absence of usual risk factors
- Flank pain or asymptomatic hydronephrosis on imaging done for another reason
- Coexistent pelvic pain, deep dyspareunia, or known endometriosis
Diagnostic pathway
- Targeted history — pattern of urinary symptoms, cycle correlation, prior endometriosis or pelvic surgery
- Examination — including assessment for posterior pelvic nodules
- Urinalysis and culture — to exclude infection
- Transvaginal ultrasound (ISUOG IDEA protocol) — the bladder is examined as part of the IDEA scan; bladder nodules are usually visible
- MRI of the pelvis — for mapping bladder and ureteric disease, particularly the depth and length of bladder-wall involvement and any ureteric encasement
- Renal ultrasound and split renal function (DTPA renogram) — where ureteric disease is suspected, to detect hydronephrosis and quantify the affected kidney’s function
- Cystoscopy — for direct visualisation, biopsy of any mucosal lesion, and assessment of the ureteric orifices; particularly important where surgery is planned
Treatment principles
Treatment is individualised by site, depth, ureteric involvement, renal function, and fertility goals.
- Medical therapy — useful for bladder-wall disease without ureteric involvement and without renal compromise. Progestogens, combined hormonal contraception, dienogest, GnRH analogues with add-back are the standard options.
- Surgical excision — the definitive treatment. For the bladder, partial cystectomy removes the involved area of bladder wall with primary repair. For the ureter, ureterolysis (freeing the ureter from surrounding endometriotic tissue) is the most common operation; segmental ureteric resection with re-implantation is reserved for cases where ureterolysis alone is inadequate.
- Renal preservation — where significant renal function is already lost on the affected side, the urologist guides the decision between aggressive renal-preserving surgery and acceptance of the deficit, depending on contralateral renal function.
Surgical considerations
- Laparoscopic approach as standard
- Joint operating with a urologist for any procedure beyond simple ureterolysis
- Pre-operative ureteric stenting in selected cases
- Cystoscopic assessment of the ureteric orifices intra-operatively after major ureteric work
- Watertight primary repair of the bladder after partial cystectomy, with a Foley catheter typically kept in for 7 to 14 days
- Cystogram before catheter removal where the bladder repair was demanding
Long-term follow-up
After bladder or ureteric surgery, follow-up includes renal ultrasound and renal function tests at 3, 6, and 12 months, then annually for at least 5 years. Recurrence at the same site is uncommon after complete excision but recurrence elsewhere in the pelvis is possible. Hormonal suppression is discussed.
When to seek a specialist opinion
- Cyclical urinary symptoms in a patient with known endometriosis
- An imaging report mentioning bladder-wall disease, ureteric involvement, or hydronephrosis
- Recurrent UTI in the absence of usual risk factors
- Asymptomatic hydronephrosis discovered on imaging
- Subfertility with deep pelvic disease
Guidelines we follow on this topic
- ESHRE Endometriosis Guideline 2022
- ESGE recommendations on urinary tract endometriosis
- EAU urological consensus
- ISUOG IDEA imaging consensus
- NICE NG73 Endometriosis
Related reading
Dr. Priyadatt Patel
Senior Gynecologist · Advanced Laparoscopic Surgeon · IVF and Endometriosis Programme Lead
MS OBGyn · Pregnancy Care · Advanced Gynaecological Ultrasound · Fertility Preservation
ESHRE / ESGE / AAGL / ASRM guideline-aligned practice. 3D Karl Storz precision technique. Fertility-preservation-first philosophy. Evidence-based decisions, honest counselling, long-term outcomes orientation.
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