Deep infiltrating ureteral endometriosis with catamenial hydroureteronephrosis: a case report

Abstract

Background: This aim of this case report is to raise awareness of ureteral endometriosis in women of reproductive age with hydronephrosis in the absence of urolithiasis to enable early diagnosis and prevent loss of renal function.

Case presentation: A 44-year-old Asian woman presented with a 4-year history of cyclic right flank pain and right hydronephrosis during menstruation. Despite several evaluations by physicians, including gynecologists, the cause of her symptoms was not diagnosed. On transvaginal ultrasonography, the uterus was observed deviated to the right, with a nodular lesion at the right uterosacral ligament, and the right ovary was attached to the uterus with no apparent cystic lesion. Magnetic resonance imaging showed a mass in the right uterine wall and mild wall thickening with delayed enhancement of the right distal ureter. Right ureteral endometriosis was suspected. Diagnostic laparoscopy revealed narrowing of the distal right ureter between the right uterosacral ligament and the right ovary with adhesions caused by deep infiltrating endometriosis. The adhesion bands and infiltrating endometriosis around the right ureter were dissected.

Conclusions: The nonspecific symptoms of ureteral endometriosis can result in incorrect diagnosis, with renal damage as a result of prolonged hydronephrosis. A high index of suspicion and use of imaging modalities enable earlier diagnosis and preservation of renal function.

Keywords: Catamenial hydroureteronephrosis; Deep infiltrating endometriosis; Ureteral endometriosis.

Fig. 1

Computed tomography showed right hydronephrosis due to distal ureteral narrowing 4 years prior (a). After balloon dilation, the patient’s right hydronephrosis was relieved (b). Transabdominal ultrasonography (c) and computed tomography (d) demonstrated right hydronephrosis due to narrowing of the distal ureter at the start of menstruation. After menstruation, hydronephrosis was relieved (e). Transvaginal ultrasonography revealed uterine deviation to the right and a nodular lesion at the right uterosacral ligament (f). Magnetic resonance imaging revealed suspected deep infiltrating endometriosis near the right uterus and ovary, with adhesions around the distal ureter (g and h)

Fig. 2

The distal right ureter (arrow) was narrowed because of deep infiltrating endometriosis (a). The ureter was dissected in the direction of the area where the lateral extension of deep infiltrating endometriosis surrounded the ureter (b). After dissection of the uterine artery, the ureter was free to its lowest segment (c)