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Indian Journal of Surgery, Vol. 66, No. 4, July-August, 2004, pp. 238-239 Case Report Vesical endometriosis with left sided hydroureteronephrosis Das Kashinath, Majhi Tapas Kumar, Chattopadhyay Sankar Das Department of Surgery, R. G. Kar Medical College, Kolkata - 700 004 Code Number: is04057 ABSTRACT A rare case of upper urinary tract obstruction due to vesical endometriosis at the left ureteric orifice complicated with hydronephrosis is presented. Surgical excision of the mass with ureteric reimplantation relieved the patient of all her symptoms. Literature is briefly reviewed.KEY WORDS:Urinary Bladder-Endometriosis-Hydronephrosis INTRODUCTION Endometriosis is characterized by the presence of endometrial tissue in ectopic foci outside the uterus. This may involve other pelvic organs but the involvement of urinary tract is rare (1%).[1] Involvement of urinary bladder at the ureteric orifice and distal ureter complicated with obstructive uropathy is still less common. Vague urinary symptoms (mimicking interstitial cystits)[2] often masquerade the diagnosis unless properly investigated. Here we present one such case which was diagnosed and operated upon with successful outcome. CASE REPORT The patient who had her last childbirth 18 years back underwent an M.T.P. operation (D/E) one year after the last childbirth. For the last 10 years the patient had been suffering from urinary symptoms, e.g. pain over the lower abdomen, frequency of micturition and dysuria. She was treated outside with supportive treatment but to no effect. Since last 2 years she had been suffering from left loin pain also. The symptoms in the last few years were more prominent during menstruation but the patient had never suffered from haematuria. Menstrual flow and circle was normal. On examination the patient was a little obese. No lump was felt per abdomen. P/R and P/V examinations did not reveal any significant abnormality. Urine culture showed no growth of micro-organisms. I.V.U showed left sided hydronephrosis with hydroureter. USG revealed a mass lesion in the urinary bladder near the left ureterovesical junction. Cystoscopy showed a sessile irregular mass. Biopsy was taken which showed endometrial tissue on histopathological examination. On surgical exploration partial cystectomy with ureteroneocystostomy was done which relieved her of all symptoms. DISCUSSION Endometriosis is a disease of adult sexual life and is found in 15-20% women of child bearing potential. The peak incidence is around 30-40yrs. And the pt. is either nulliparous in over 50% or has had one or at most two children several years previously. This patient had only one child born 18 years back. Usually it involves organs such as ovaries uterine ligaments, fallopian tubes, rectum and cervico-vaginal region. Involvement of urinary tract is seen in just about 1% of cases. Vescical location is most frequent of these presentations (84%).[1] Nezhat C et al (1996)[5] however reported a higher incidence of ureteral involvement (21 out of 28) and four of them had complete obstruction (3 of them underwent resection and ureteroureterostomy and one had ureteroneocystostomy). Implantation and serosal theory have been incriminated as two casual factors. Here, M.T.P (D/E) done 17 years back might have induced the disease by regurgitation. Classic presenting symptoms of vesical endometriosis include cyclic irritative voiding symptoms and suprapubic discomfort with or without haematuria. Here the catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. The patient had no haematuria.[3] This probably delayed the diagnosis and was repeatedly treated for urinary tract infection. Cyclical nature of urinary symptoms, when present, is however a good indication towards the diagnosis. USG is very much useful in demonstrating a mass lesion in the urinary bladder. CT and MRI do not provide more information than USG.[4] Histopathology sometimes poses difficulty in diagnosis. The presence of typical endometrial stroma surrounding the glandular spaces are characteristic but its absence does not rule out diagnosis. Management of endometriosis involving other pelvic organs can be done with some success by inhibiting oestrogenic stimulus by danazol and supportive treatment. Affection of urinary tract , however, require early surgical intervention particularly when it comes to compromise renal function by ureteric obstruction. Partial cystectomy with ureteroureterostomy or ureteroneocystostomy are done depending on the situation. Nezhat. C et al[5] has performed the procedure even laparoscopically with good surgical outcome. REFERENCES
Copyright 2004 - Indian Journal of Surgery |
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