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Year : 2001  |  Volume : 11  |  Issue : 1  |  Page : 23-24
Case report : Bladder wall endometrioma


1 Department of MRI/CT Scan, NM Medical Centre, Mumbai, India
2 Depts of Gyneocology & Obsterics, Breach Candy Hospital, Mumbai, India

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Keywords: Endometriosis, Bladder Urinary, Uterus, Cesarian section

How to cite this article:
Gupta S, Shah S, Motashaw N D, Shah N, Darshana V, Dave V. Case report : Bladder wall endometrioma. Indian J Radiol Imaging 2001;11:23-4

How to cite this URL:
Gupta S, Shah S, Motashaw N D, Shah N, Darshana V, Dave V. Case report : Bladder wall endometrioma. Indian J Radiol Imaging [serial online] 2001 [cited 2019 Jun 26];11:23-4. Available from: http://www.ijri.org/text.asp?2001/11/1/23/28304
Endometriosis is a common benign gynecological disease characterized by the presence of ectopic endometrial tissue, outside the uterus. Involvement of the urinary tract however is rare.

We report a case of endometrioma involving the posterior wall of the urinary bladder, following Cesarean section.
   Case Report Top


A thirty-two-years old woman complained of vague dull aching lower abdominal and pelvic pain since three months. Her menstrual history was normal. She had undergone two lower segment Cesarean sections (LSCS) in the past. There was no history of hematuria. The pelvic pain was unrelated to the menstrual cycle.

She underwent pelvic ultrasound, followed by CT and MRI of the pelvis.

Ultrasound (transabdominal and endovaginal) showed an iso to hyper-echoic mass with a smooth surface and few cystic areas along the posterior wall of the urinary bladder appearing to protrude into its lumen. It demonstrated presence of flow on color Doppler.

A contrast enhanced spiral CT of the pelvis was performed which showed, a well-defined mildly enhancing soft tissue lesion along the posterior wall of the urinary bladder, protruding into its lumen [Figure - 1]. There was loss of the intervening fat plane between the lesion and the uterus.

MRI was performed for further evaluation. Axial T1W spin echo, T2W fast spin echo, coronal T1 and STIR sequences were obtained. A focal lesion was noted along the posterior wall of the urinary bladder. It was isointense on the T1W images and hypointense on the T2W images [Figure - 2]a. Two small cystic areas were noted along its peripheral portion anteriorly, which were hyperintense on T2 and iso to hyperintense on the T1W images. The lesion had a broad base towards the posterior bladder wall and appeared to protrude into its lumen. A very thin fat-plane was seen separating the lesion from the uterus, except in a small segment which was thought to be due to the anteverted position of the uterus [Figure - 2]b. Due to the broad base of the lesion, the possibility of a neoplasm arising from the bladder wall was considered. The differential diagnosis included leiomyoma and fibroma of the urinary bladder wall, which show low signal on T2W images. A primary uterine neoplasm was considered unlikely because of the well-visualized fat plane between the lesion and the uterus.

A cystoscopy was performed subsequently. This showed intact mucosa along the posterior wall of the bladder with the suggestion of an extrinsic mass compressing the bladder.

At surgery a soft tissue mass was seen infiltrating the wall of the urinary bladder, without significantly involving the bladder mucosa. The lesion was adherent to the lower uterine segment in one region which was the site of the previous LSCS. The histopathology of this lesion was suggestive of an endometrioma.


   Discussion Top


Endometriosis is a benign condition affecting 15-20% of women with a child-bearing potential. Most commonly it affects organs such as the ovaries, uterine ligaments,  Fallopian tube More Detailss, rectum and the cervico-vaginal region. Involvement of the urinary tract, however is rare and seen in about 1 % of patients [1], the vesical location being the most frequent of these presentations (84%). Typically, the catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) is pathognomonic. However, this may not be seen in all patients.

Broadly two different etiologies appear to exist causing vesical endometriosis, one being spontaneous and the other post-Cesarean [2]. In the former, the bladder lesion is a manifestation of the generalized pelvic disease, whereas after iatrogenic dissemination, growth of ectopic endometrium is usually limited to the bladder wall. On microscopy a solid endometrioma demonstrates abundant fibrosis, with small clusters of endometriotic glandular tissue.

These lesions are typically is to hyperechoic on USG. Transvaginal ultrasonography is more accurate and versatile than abdominal ultrasonography [3].

On MRI most lesions show intermediate to hyperintense signal on T1W images and are hypointense on the T2W images. Punctate foci of high signal intensity (representing hemorrhage) may be seen on T1W images and enhancement is often seen after administration of contrast [4]. We postulate that enhancement in an endometrioma on post-contrast studies is due to the presence of fibrosis. This may also cause a hypointense signal on the T2W images, which is otherwise, mainly due to the presence of hemorrhage. Endometriosis may also manifest as multiple homogeneously hyperintense cysts on T1W images. In one study [3] it was found that, MRI although very precise is less versatile than transvaginal ultrasonography and less accurate in establishing the margins of the lesions, as perilesional fibrosis is visualized less clearly than areas containing blood products. However, operator dependency is a well-known drawback of ultrasonography. Involvement of the detrusor muscles, uterovesical septum and adjacent myometrial invasion is better depicted by MRI.

In conclusion, it is important to be acquainted with the various imaging characteristics of endometriosis and to have a high level of suspicion for detecting vesical endometriosis, especially following Cesarean section, since the clinical presentation is not always pathognomonic. MRI is preferred over CT scan, for diagnosis of pelvic endometriosis due to better lesional and anatomical characterization. MRI is the best non-invasive method for evaluating endometriosis, with diagnostic accuracy close to laparoscopy. Its advantages over laparoscopy includes its ability to characterize endometriotic lesions and to evaluate extraperitoneal sites of involvement, contents of a pelvic mass, or lesions hidden by dense adhesions [5].

 
   References Top

1.Garcia Gonzalez JI, Entramiana Cameno J, Esteban Calvo JM, et al. Vesicle endometriosis after cesarean section : diagnostic and therapeutic aspects. Actas Urol Esp 1997; 21: 785-8.   Back to cited text no. 1    
2.Vercellini P, Meschia M, De Giorgio O et al. Bladder detrusor endometriosis: clinical and pathogenetic implications. J.Urol 1996; 155: 84-6   Back to cited text no. 2    
3.Fedele L. Bianchi S, Raffaelli R, et al. Pre-operative assessment of bladder endometriosis. Human Reprod. 1997; 12: 2519-22.   Back to cited text no. 3    
4.Siegelman ES, Outwater E, Wang T, Mitchell DG. Solid pelvic masses caused by endometriosis:MR imaging features - AJR 1994; 163: 357 - 61.   Back to cited text no. 4    
5.Bis KG, Varchliotis TG, Agarwal R, et al. Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls. Radiographics 1997, 17: 639 - 55.  Back to cited text no. 5    

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Correspondence Address:
S Gupta
Department of MRI/CT Scan, NM Medical Centre,Mehta House, Chowpatty, Mumbai
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2]

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