Bladder-Endometriosis-A-Rare-Case-Study.pdf

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1. Bladder Endometriosis: A
Rare Case Study
Welcome to this comprehensive presentation on a rare case of bladder
endometriosis with bilateral ovarian endometrioma. We'll explore the
intricacies of this condition, from its pathophysiology to diagnosis and
treatment, highlighting the importance of a multidisciplinary approach in
managing complex endometriosis cases.
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2. Understanding
Endometriosis
1
Definition
Endometriosis is the
presence of functional
endometrial tissue outside
the uterus, affecting 5-10%
of women in their
reproductive years.
2
Symptoms
Chronic pain and infertility
are common manifestations,
often complicating the
clinical picture.
3
Urinary Tract Involvement
In rare cases (about 1%), endometriosis can extend to the urinary
tract, with bladder endometriosis being particularly infrequent.

3. Case Presentation
1
Patient Profile
32-year-old woman (P0A1), married for nine years,
presenting with secondary infertility and
dysmenorrhea for three months. 2
Symptoms
Regular menstrual cycle, possible intermenstrual
spotting, painful defecation for two months. No
dysuria or pelvic pain reported.3
Medical History
Transvaginal ultrasound in 2021, miscarriage in 2022.
Currently taking prenatal vitamins and Dienogest.

4. Physical Examination
Vital Signs
Blood Pressure: 101/82 mmHg
Heart Rate: 88 bpm
Respiratory Rate: 20 breaths/min
Temperature: 36.0 °C
Physical Findings
Flat and soft abdomen without tenderness. No palpable
masses or active vaginal bleeding. Normal cardiac and
pulmonary examinations.

5. Diagnostic Workup
1
Laboratory Results
Hemoglobin, leukocyte, and
platelet values within normal
range. Nonreactive serologic
tests for HBV, HIV, and HCV.
2
Transvaginal
Ultrasonography
Revealed bilateral ovarian
hypoechoic masses and a
2.3 × 1.94 cm hypoechoic
lesion in the urinary bladder.
3
Sliding Sign
Positive, suggesting the presence of pelvic adhesions, supporting
the suspicion of bladder endometriosis.

6. Surgical Intervention
Procedure Plan
Bilateral cystectomy and excision of the endometriotic lesion at the
bladder dome via cystoscopy and laparoscopy.
Intra-abdominal Findings
Adhesions between liver capsule and anterior abdominal wall.
Bilateral bluish cystic masses in adnexa.
Surgical Actions
Cystectomy performed, adhesiolysis led to cyst rupture. Deep
infiltrating endometriosis lesions identified and resected.

7. Pathogenesis of Bladder Endometriosis
1
2
3
Sampson's theory is the most widely accepted and aligns with our patient's presentation of bilateral endometrioma and bladder
dome lesion.
Embryonal Theory
Metaplasia of Müllerian remnants
within the uterine-vesical area.
Extension Theory
Adenomyotic lesions extending from
the myometrium (less likely in this
case).
Sampson's Theory
Retrograde menstruation through
fallopian tubes, leading to
implantation on peritoneal surfaces.

8. Sampson's Theory in
Detail
1
Retrograde Menstruation
Viable endometrial cells reflux through patent fallopian
tubes into the peritoneal cavity.
2
Implantation
Cells implant on peritoneal surfaces, including the bladder
dome or base.
3
Lesion Establishment
Genetic predisposition, immune dysregulation, and local
inflammatory responses contribute to lesion growth.
4
Progression
Angiogenic activity and altered immune environment
facilitate survival and growth of ectopic implants.

9. Clinical Manifestations of
Bladder Endometriosis
Cyclic Symptoms
Lower urinary tract symptoms often worsen during menstruation,
including dysuria and urinary frequency.
Hematuria
Gross hematuria may occur, particularly during menstrual periods.
Atypical Presentations
Some patients may experience urinary incontinence or acute urinary
retention, especially with ureteral obstruction.
Diagnostic Challenges
Symptoms can be nonspecific, and cystoscopic findings may be
normal with extramucosal lesions.

10. Diagnostic Approach
1
Clinical History
Thorough assessment of symptoms, focusing on cyclic
nature and association with menstruation.
2
Physical Examination
Evaluation for pelvic tenderness, masses, or nodularity.
3
Imaging Studies
Transvaginal ultrasound as first-line, MRI for deeper
assessment of lesions.
4
Histopathology
Definitive diagnosis through examination of resected tissue,
confirming endometrial glands and stroma.

11. Management Strategies
Medical Management
Hormonal therapies aim to induce therapeutic amenorrhea
and alleviate pain. Options include combined estrogen-
progesterone regimens, progestogens, or GnRH analogues.
However, these treatments are largely palliative, with
symptoms often recurring upon discontinuation.
Surgical Intervention
Definitive treatment, particularly for deep infiltrating
endometriosis or complications like ureteral obstruction.
Laparoscopic excision of bladder lesions, with or without
partial cystectomy, is favored for its efficacy and lower
postoperative morbidity.

12. Multidisciplinary Approach
Gynecologist
Leads the overall
management and performs
surgical interventions.
Pathologist
Confirms diagnosis through
histopathological
examination.
Radiologist
Provides crucial imaging for
diagnosis and surgical
planning.
Urologist
Collaborates in cases
involving complex bladder or
ureteral involvement.

13. Case Outcome and
Implications
1
Successful
Intervention
Bilateral cystectomy and
excision of bladder lesion
addressed the patient's
endometriosis effectively.
2
Diagnostic Accuracy
The case underscores the
importance of considering
bladder endometriosis in
women with cyclic urinary
symptoms and pelvic pain.
3
Treatment Approach
Highlights the need for individualized care, balancing medical and
surgical options based on symptom severity and patient factors.

14. Future Directions and Research
1
Improved Diagnostic Tools
Developing more sensitive and specific biomarkers for early detection.
2
Targeted Therapies
Exploring novel treatments that address the underlying pathophysiology.
3
Fertility Preservation
Enhancing techniques to manage endometriosis while preserving
reproductive potential.
4
Long-term Outcomes
Conducting longitudinal studies to better understand
disease progression and recurrence rates.

15. Conclusion
Complex Presentation
This case of bladder endometriosis with bilateral ovarian
endometrioma exemplifies the complex nature of endometriosis.
Diagnostic Vigilance
Emphasizes the need for heightened awareness and thorough
evaluation in women with atypical urinary symptoms.
Tailored Treatment
Highlights the importance of individualized care plans, combining
medical and surgical approaches as needed.
Ongoing Research
Underscores the need for continued research to improve diagnosis,
treatment, and long-term outcomes for patients with endometriosis.