|OJHAS Vol. 14, Issue 3:
Primary Intramural Vesical Endometriosis Mimicking Urothelial Carcinoma in a Middle Aged Female
Nadia Shirazi, Department of Pathology,
Manvendra S Rawat, Department of
Babar Rehmani, Department of Surgery,
Himalayan Institute of Medical Sciences, Swami Rama Himalayan University. Jolly Grant, Dehradun. India.
Address for Correspondence
>Dr. Nadia Shirazi,
Associate Professor (Pathology),
Himalayan Institute of Medical Sciences,
Swami Rama Himalayan University,
Jolly Grant, Dehradun- 248140,
Shirazi N, Rawat MS, Rehmani B. Primary Intramural Vesical Endometriosis Mimicking Urothelial Carcinoma in a Middle Aged Female. Online J Health Allied Scs.
2015;14(3):15. Available at URL:
Open Access Archives
Submitted: Jul 24,
2015; Accepted: Sep 28, 2015; Published: Oct 15, 2015
Abstract: Endometriosis is the presence of ectopic endometrial tissue outside the uterus. Presence of endometrial glands and/or stroma may interfere with the normal physiological process by their infiltrative nature or by forming adhesions. Endometriosis occurs in 15-20% of women of child bearing age and commonly involves the ovaries, utero-sacral ligaments, fallopian tubes, rectum, scar sites and cervico-vaginal regions. Incidence of urinary tract involvement is estimated to be 1%. We report a case of a 38 year female presenting with low back pain, single episode of haematuria and burning during micturition. Urine culture was negative. There was no past history of pelvic surgery. On cystoscopy, a growth was visualised in the posterior urinary bladder wall suspicious of neoplastic origin. Tansurethral resection of bladder nodule was done and sent for histopathology, on which it was diagnosed as endometriosis. The case merits interest due to its atypical clinical presentation and the rarity of the lesion at this site.
Urinary Bladder, Endometriosis, Hematuria.
Endometriosis is a frequently encountered problem in women of child bearing age with multifocal sites of involvement in the pelvis. Involvement of the urinary tract is rare with a reported incidence of 1%, mostly, the urinary bladder. The ratio of bladder-to-ureteral-to-renal involvement is 40:5:1.[1,2] Endometriosis usually starts from the serosal surface of the dome of the bladder and then progressively infiltrates through the inner layers of the bladder wall to present as an intramural mass. It is difficult to distinguish the mass from a primary bladder neoplasm on imaging studies.[3,4] Since ectopic sites of endometriosis are influenced by ovarian hormones, bleeding and fibrosis are the secondary changes noted in bladder endometriosis. Malignant transformation is seen in less than 1% cases.
A 38 years old female presented to the Urology OPD with complains of burning during micturition, pelvic and low back pain since 3 months. There was history of a single episode of hematuria a week prior to presentation. Urine culture was negative. Past history of surgery, especially caesarean section, was absent. The general and systemic examination was unremarkable. On ultrasonography of genito-urinary tract, an irregular nodule simulating bladder tumor, measuring 1.5 cm in size, was reported. Intravenous urography confirmed irregularity in posterior wall of urinary bladder with sparing of ureters. A provisional diagnosis of urothelial carcinoma was made, transurethral resection of bladder growth was done and sample sent for histopathology.
On gross examination, there were multiple tissue bits together measuring 2x1x1cm. On microscopic examination, all these bits showed sub-urothelial clustering of endometrial glands with dense intervening stroma. Many hemosiderin laden macrophages were also seen. There was no evidence of malignancy in the tissue submitted. (Photomicrograph 1,2). The patient was discharged on Gonadotropin releasing hormone (GnRH) analogues and is currently asymptomatic.
Photomicrograph 1: 4 x 10X, H & E: Collection of endometrial glands and stroma in urinary bladder
Photomicrograph 2: 40 x 10 X, H & E: Endometrial glands with scanty intervening stroma and few hemosiderin laden macrophages (arrow)
Endometriosis of the urinary tract was first reported by Judd in 1921. Urinary tract disease is involved in only 1% of the cases, 84% of which is restricted to the urinary bladder. It exists in two forms- primary and secondary. The primary form is generally a part of generalized pelvic disease whereas the secondary is iatrogenic .i.e. it follows pelvic surgery like caesarean section or hysterectomy. Diagnosis of such cases of endometriosis is difficult and delayed due to non-specific symptoms leading to significant morbidity. Cyclical haematuria is seen in only 10-20% of the patients while caesarean section in the past gives a clue to diagnosis. Imaging with CT or MRI does not add to the information obtained by ultrasonography.
Differential diagnosis includes epithelial tumors of bladder and rarer mesenchymal tumors such as hemangioma, fibroma and leiomyoma which grow in detrusor. There are three theories postulated for the development of endometriosis. These include i) retrograde menstrual endometrial cell implants ii) coelomic metaplasia and iii) extension of deep adenomyosis from the uterus.
Treatment varies according to the severity and site of involvement of each case. Medical therapy with oral contraceptives, Danazol, progestins and gonadotropin releasing hormone agonists have a proven beneficial role in regression of the lesion. However, aggressive surgical management is advised in patients having urinary tract involvement because the condition may lead to loss of renal functions by upto 30%. Removal of ectopic tissue, relief of urinary obstruction, if present and castration with or without hysterectomy is recommended depending upon parity status of the patient. Cystoscopy on follow-ups is strongly recommended, since the condition leads to recurrence and malignant transformation
All pre-menopausal women who present with complains of irritative urinary symptoms or hematuria with negative urine cultures should be suspected and evaluated for endometriosis. Delay in detection can lead to significant morbidity, loss of renal functions and may also lead to malignant transformation.
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