Genitourinary manifestations of endometriosis with emphasis on the urinary tract

  • A. Agely
  • C. BolanEmail author
  • A. Metcalfe
  • W. VanBuren
  • C. Menias
Special Section: Endometriosis


Endometriosis is a common benign condition affecting women. The disease has a broad spectrum of presentations from incidental lesions in asymptomatic women to causing significant and debilitating morbidity in others. Ectopic endometrial glands are located in predictable locations throughout the pelvis, including implantation on the ovaries and in the rectouterine cul-de-sac. Less commonly, the urinary tract may be involved. As genitourinary manifestations may remain symptomatically occult or masquerade as other diagnoses, it is essential for the radiologist to be aware of the imaging features, consider this diagnosis, and potentially save the patient from delayed treatment.


Endometriosis Genitourinary Urogenital Ureteral Bladder 



  1. 1.
    Stovall, D.W., et al., Endometriosis-associated pelvic pain: evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril, 1997. 68(1): p. 13-8.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Guzick, D.S., et al., Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine’s revised classification of endometriosis. Fertil Steril, 1997. 67(5): p. 822-9.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Giudice, L.C. and L.C. Kao, Endometriosis. Lancet, 2004. 364(9447): p. 1789-99.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Carter, J.E., Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc, 1994. 2(1): p. 43-7.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Ling, F.W., Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol, 1999. 93(1): p. 51-8.Google Scholar
  6. 6.
    Practice bulletin no. 114: management of endometriosis. Obstet Gynecol, 2010. 116(1): p. 223-36.CrossRefGoogle Scholar
  7. 7.
    Charatsi, D., et al., Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis. Adv Med, 2018. 2018: p. 3461209.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Chapron, C., et al., Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod, 2003. 18(1): p. 157-61.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Comiter, C.V., Endometriosis of the urinary tract. Urol Clin North Am, 2002. 29(3): p. 625-35.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Knabben, L., et al., Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril, 2015. 103(1): p. 147-52.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Darvishzadeh, A., et al., Deep pelvic endometriosis: a radiologist’s guide to key imaging features with clinical and histopathologic review. Abdom Radiol (NY), 2016. 41(12): p. 2380-2400.CrossRefGoogle Scholar
  12. 12.
    Kolodziej, A., et al., Urinary Tract Endometriosis. Urol J, 2015. 12(4): p. 2213-7.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Sampson, J.A., Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. American Journal of Obstetrics & Gynecology, 1927. 14(4): p. 422-469.CrossRefGoogle Scholar
  14. 14.
    Ferguson, B.R., J.L. Bennington, and S.L. Haber, Histochemistry of mucosubstances and histology of mixed mullerian pelvic lymph node glandular inclusions. Evidence for histogenesis by mullerian metaplasia of coelomic epithelium. Obstet Gynecol, 1969. 33(5): p. 617-25.Google Scholar
  15. 15.
    Sasson, I.E. and H.S. Taylor, Stem cells and the pathogenesis of endometriosis. Ann N Y Acad Sci, 2008. 1127: p. 106-15.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Sampson, J.A., Metastatic or Embolic Endometriosis, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation. Am J Pathol, 1927. 3(2): p. 93-110 43.Google Scholar
  17. 17.
    Chamie, L.P., et al., Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings. Radiographics, 2018. 38(1): p. 309-328.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Jensen, J.R. and C.C. Coddington, 3rd, Evolving spectrum: the pathogenesis of endometriosis. Clin Obstet Gynecol, 2010. 53(2): p. 379-88.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Anglesio, M.S., et al., Cancer-Associated Mutations in Endometriosis without Cancer. N Engl J Med, 2017. 376(19): p. 1835-1848.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Bulun, S.E., Endometriosis. N Engl J Med, 2009. 360(3): p. 268-79.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Burney, R.O. and L.C. Giudice, Pathogenesis and pathophysiology of endometriosis. Fertil Steril, 2012. 98(3): p. 511-9.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Piketty, M., et al., Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod, 2009. 24(3): p. 602-7.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Bazot, M., et al., European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol, 2017. 27(7): p. 2765-2775.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Chamie, L.P., et al., Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics, 2011. 31(4): p. E77-100.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Brosens, I.A., P.J. Puttemans, and J. Deprest, The endoscopic localization of endometrial implants in the ovarian chocolate cyst. Fertil Steril, 1994. 61(6): p. 1034-8.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Brosens, I., et al., Diagnosis of endometriosis: pelvic endoscopy and imaging techniques. Best Pract Res Clin Obstet Gynaecol, 2004. 18(2): p. 285-303.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Patel, M.D., et al., Endometriomas: diagnostic performance of US. Radiology, 1999. 210(3): p. 739-45.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Robinson, K.A., et al., Understanding malignant transformation of endometriosis: imaging features with pathologic correlation. Abdom Radiol (NY), 2019.Google Scholar
  29. 29.
    Giudice, L.C., Clinical practice. Endometriosis. N Engl J Med, 2010. 362(25): p. 2389-98.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Koninckx, P.R., et al., Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril, 1991. 55(4): p. 759-65.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Anaf, V., et al., Smooth muscles are frequent components of endometriotic lesions. Hum Reprod, 2000. 15(4): p. 767-71.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Wang, G., et al., Rich innervation of deep infiltrating endometriosis. Hum Reprod, 2009. 24(4): p. 827-34.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Bazot, M., et al., Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis. Fertil Steril, 2009. 92(6): p. 1825-33.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Maccagnano, C., et al., Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int, 2012. 89(3): p. 249-58.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Siegelman, E.S. and E.R. Oliver, MR imaging of endometriosis: ten imaging pearls. Radiographics, 2012. 32(6): p. 1675-91.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Vercellini, P., et al., The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol, 2002. 187(3): p. 538-42.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Berlanda, N., et al., Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv, 2009. 64(12): p. 830-42.Google Scholar
  38. 38.
    Abrao, M.S., et al., Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril, 2009. 91(5): p. 1662-7.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Fedele, L., et al., Pre-operative assessment of bladder endometriosis. Hum Reprod, 1997. 12(11): p. 2519-22.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Seracchioli, R., et al., Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod, 2015. 30(4): p. 833-9.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Stanley, K.E., Jr., D.C. Utz, and M.B. Dockerty, Clinically Significant Endometriosis of the Urinary Tract. Surg Gynecol Obstet, 1965. 120: p. 491-8.Google Scholar
  42. 42.
    Saavalainen, L., et al., Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013. Gynecol Surg, 2016. 13(4): p. 435-444.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Holland, T.K., et al., Value of transvaginal ultrasound in assessing severity of pelvic endometriosis. Ultrasound Obstet Gynecol, 2010. 36(2): p. 241-8.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Marshall, V.F., The occurrence of endometrial tissue in the kidney. Case report and discussion. The Journal of Urology, 1943. 50(6): p. 652-656.CrossRefGoogle Scholar
  45. 45.
    Giambelluca, D., et al., Renal endometriosis mimicking complicated cysts of kidney: report of two cases. G Chir, 2017. 38(5): p. 250-255.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Yang, J., et al., Renal endometriosis tends to be misdiagnosed as renal tumor: a rare case report. Int Surg, 2015. 100(2): p. 376-80.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Coutinho, A., Jr., et al., MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics, 2011. 31(2): p. 549-67.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Chowdhry, A.A., F.H. Miller, and R.A. Hammer, Endometriosis presenting as a urethral diverticulum: a case report. J Reprod Med, 2004. 49(4): p. 321-3.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Honore, G.M., Extrapelvic endometriosis. Clin Obstet Gynecol, 1999. 42(3): p. 699-711.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Baker, P.M., et al., Superficial endometriosis of the uterine cervix: a report of 20 cases of a process that may be confused with endocervical glandular dysplasia or adenocarcinoma in situ. Int J Gynecol Pathol, 1999. 18(3): p. 198-205.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Gardner, H.L., Cervical and vaginal endometriosis. Clin Obstet Gynecol, 1966. 9(2): p. 358-72.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Foti, P.V., et al., Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging, 2018. 9(2): p. 149-172.PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Medeiros, L.R., et al., Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet, 2015. 291(3): p. 611-21.PubMedCrossRefPubMedCentralGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of RadiologyMayo Clinic FloridaJacksonvilleUSA
  2. 2.Department of RadiologyMayo Clinic RochesterRochesterUSA
  3. 3.Department of RadiologyMayo Clinic ArizonaScottsdaleUSA

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