Hydronephrosis due to ureteral endometriosis in women of reproductive age

Abstract

Objective: The aim of the present study was to improve the understanding of ureteral endometriosis, and remind the clinics to be highly suspicious of it in women of reproductive age with hydronephrosis without evidence of stones and malignancy.

Methods: A retrospective analysis was performed on a database of 82 patients who underwent surgery for hydronephrosis due to ureteral endometriosis between Jan. 2007 and Apr. 2014.

Results: All patients evaluated in this study were divided into three groups: Group A consisted of patients between 20-30 years (n = 12), Group B comprised of patients between 31-40 years (n = 29), Group C consisted of patients between 41-50 years (n = 41). Patients in Group C had a greater prevalence of pelvic pain compared with patients in Group A and Group B (P < 0.05). However there were no differences with respect to the prevalence of other non-specific genitourinary symptoms and the urinary symptoms. Infertility was found to occur more frequently in patients in Group A compared with patients in Group B and Group C (P < 0.05). Because of the lack of specific symptoms, ureteral endometriosis was diagnosed (20.1 ± 10.3) months on average after the patients suffered from mild hydronephrosis or mild loin pain. Preoperative examinations showed different degree of hydronephrosis, but lack of specificity. All patients underwent surgery by laparotomy or laparoscopy, such as ureterectomy with ureteroureterostomy or ureterocystoneostomy. The pathological examination confirmed the diagnosis of ureteral endometriosis.

Conclusion: The diagnosis of ureteral endometriosis is elusive and relies heavily on clinical suspicion. Hence, women in the reproductive age, especially with infertility and pelvic pain, who have hydronephrosis without evidence of stones and malignance, should be adequately assessed via imaging techniques or diagnostic laparoscopy or cystoscopy to highly suspect the diagnosis of ureteral endometriosis.

Keywords: Ureteral endometriosis; hydronephrosis; infertility; pelvic pain.

Figure 1

Magnetic resonance urography demonstrates severe left uretero-hydronephrosis and obstruction of the left distal ureter with proximal left ureter showing redundant kinking.

Figure 2

Extrinsic ureteral endometriosis. A. Reduced from ×50. B. Endometrial glands and stroma invading ureteral serosa. Reduced from ×100.