Int Urogynecol J (2015) 26:159–162 DOI 10.1007/s00192-014-2487-6
CASE REPORT
Urinary incontinence and bladder endometriosis: conservative management Umberto Leone Roberti Maggiore & Simone Ferrero & Stefano Salvatore
Received: 16 April 2014 / Accepted: 4 August 2014 / Published online: 3 September 2014 # The International Urogynecological Association 2014
Abstract Bladder endometriosis causes urinary symptoms including frequency, dysuria, cyclic haematuria and non-urinary pain symptoms. To our knowledge, the association of bladder endometriosis with urinary incontinence has not been described. We present the first case of bladder endometriosis that caused urinary symptoms including mixed urinary incontinence (MUI). A 34-year-old nulliparous woman was referred to our urogynaecology clinic with a 18-month history of urgency urinary incontinence (UUI) and stress urinary incontinence (SUI). A diagnosis of bladder endometriosis was performed on the basis of symptoms and imaging. The patient refused surgery and dienogest was prescribed. At the 12-month follow-up, all endometriosis-related symptoms and questionnaire scores had significantly improved, and there was resolution of the abnormal urodynamic findings. In reproductive-aged women suffering pain symptoms, bladder endometriosis should be considered in the differential diagnosis of urinary incontinence and treatment with dienogest may lead to improvement of both urinary and pain symptoms.
Keywords Bladder . Dienogest . Endometriosis . Urinary incontinence U. Leone Roberti Maggiore (*) : S. Salvatore Obstetrics and Gynaecology Unit, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Via Olgettina 58–60, 20132 Milan, Italy e-mail: [email protected] S. Ferrero Obstetrics and Gynaecology Unit, IRCCS San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy
Introduction Bladder endometriosis affects between 1 and 15 % of women suffering from endometriosis [1, 2]. It is defined as infiltration of the endometrial glands and stroma in the detrusor muscle. Most commonly, the clinical manifestations are urinary symptoms such as frequency, dysuria, haematuria and, less frequently, bladder pain and urgency. These symptoms may worsen during the menstrual cycle or have a non-cyclical presentation. Management with laparoscopic excision of bladder endometriotic nodules is considered the gold standard and is associated with a significant amelioration of urinary symptoms, with a long-lasting clinical benefit. Hormonal therapies including progestins, gonadotropin-releasing hormone analogues and oestroprogestin combinations are commonly used for the conservative management of patients with endometriosis. However, few studies evaluated the role of these therapies in the treatment of urinary symptoms caused by bladder endometriosis. We present a case of bladder endometriosis, which caused severe urinary symptoms, including mixed urinary incontinence (MUI), which was improved by the administration of oral dienogest.
Case report A 34-year-old nulliparous woman referred to our urogynaecology clinic with an 18-month history of mixed urinary incontinence (MUI). This patient also complained of other urinary symptoms such as frequency, dysuria and cyclic haematuria and non-urinary pain symptoms (dysmenorrhoea, non-cyclic pelvic pain and deep dyspareunia). Urinary cytology was performed and was negative for the presence of malignant cells. At vaginal examination, no genital prolapse was diagnosed and the stress cough testing (at 250 mL of bladder volume) was negative. At abdominal and transvaginal
160
Int Urogynecol J (2015) 26:159–162
Fig. 1 Measurement of the volume of the bladder volume at baseline assessed by virtual organ computer-aided analysis (VOCAL)
ultrasound, an iso-hyperechoic, intraluminal round-shaped solid mass with quite regular margins and a volume of about 4 cm3 was observed in the posterior bladder wall (Fig. 1). Bladder endometriosis was suspected. Magnetic resonance imaging (MRI) confirmed the ultrasound diagnosis and showed a heterogeneous isointense nodular lesion (on T2Fig. 2 Measurement of the largest diameter of the bladder nodule by T2-weighted MRI (sagittal view)
weighted images) that caused a full-thickness infiltration of the posterior wall of the bladder (Fig. 2). The multichannel urodynamic study (UDS) was performed (Table 1). The patient was asked to attend the urodynamic studies with a comfortably full bladder. Uroflowmetry was performed with the woman voiding in private. Dual-channel
Int Urogynecol J (2015) 26:159–162
161
Table 1 Urodynamic study results at baseline and at 12-month follow-up
Flowmetry Volume (ml) Flow Qmax (ml/sec) Post-void residual (ml) Cystometry First sensation of bladder filling (ml) First desire to void (ml) Strong desire to void (ml) Cystometric capacity (ml) Pressure flow study Qmax (ml/sec) PdetQmax (cmH2O) Post-void residual (ml)
Baseline
12-month follow-up
215 Continuous 22
189 Continuous 21
0
0
75 122 198 375
195 267 384 500
24 25 0
22 29 0
cystometry was performed with the woman supine, using a 10-F filling catheter at a filling rate of 100 ml/min and two fluid-filled 4.5-F catheters for measuring the intravesical and abdominal pressures. The cystometric filling phase was ended in the event of urgency/strong desire to void or at 500 ml with subsequent removal of the filling. Provocative manoeuvres were employed with the woman standing, asking her to listen to running water; to wash her hands in cold water; and to cough once, three, and five times with maximal effort. Finally, a pressure/flow study was performed in private, and the postvoid residual was measured with an ultrasound scan. The UDS revealed normal uroflowmetry; at cystometry, during which the patient reported urgency and bladder pain, we observed an increased bladder sensation (first sensation of bladder filling: 75 ml), a reduced cystometric capacity (375 ml), low bladder compliance (p det=14 cmH2O at 325 ml) and urodynamic stress incontinence. The pressure flow study did not show any voiding difficulties. At cystoscopy, a bulge with a bluish lesion in the bladder lumen was observed (Fig. 3). Medical and surgical treatment options were discussed with the patient and she preferred to avoid surgery. Therefore, the patient received oral dienogest 2 mg/day
Fig. 3 Bladder nodule at ultrasound (left), magnetic resonance imaging (centre) and at cystoscopy (right)
(Visanne, Bayer S.p.A., Milan, Italy) for 12 months and she was followed-up at 1, 6 and 12 months. At baseline and at the 6- and 12-month follow-up the severity of the symptoms was measured using a 10-cm visual analogue scale (VAS) and with four questionnaires: the International Consultation on Incontinence Questionnaire short form (ICIQ-SF, which was used to assess incontinence), the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB), the Incontinence Impact Questionnaire (IIQ-7, which was used to evaluate the impact of incontinence on quality of life, QoL), and the Patient Global Improvement Impression (PGI-I, which was used to measure the perception of improvement that she experienced by the treatment of her symptoms). Ultrasound was repeated at the 6- and 12-month follow-up; while UDS was performed at the 12-month follow-up (Table 1). A significant improvement in all endometriosis-related symptoms and in all questionnaire scores was reported at both 6- and 12-month follow-up (Table 2). Furthermore, a reduction of the volume of the endometriotic nodule was reported at baseline (4.02 cm3), and at the 6-month (3.42 cm3) and 12month follow-ups (3.11 cm3). At the 12-month follow-up, the UDS showed, at cystometry, a normal bladder sensation (first sensation of bladder filling: 195 ml), a normal cystometric capacity (500 ml), no urgency or bladder pain during the filling phase, the resolution of DO and the absence of urodynamic stress incontinence.
Discussion Bladder endometriosis is not a frequent clinical presentation of endometriosis. When it occurs it is commonly associated with urinary symptoms and may be easily diagnosed by ultrasound. MRI provides more accurate information on the pelvic involvement of endometriosis and it allows better estimation of the detrusor infiltration. This report is particularly interesting and original because, to the best of our knowledge, it is the first case of bladder endometriosis associated with urgency urinary incontinence (UUI) and stress urinary incontinence (SUI), assessed by using validated questionnaires and confirmed by UDS. However, a limitation of the initial work-
162
Int Urogynecol J (2015) 26:159–162
Table 2 Intensity of urinary symptoms and results of questionnaires during the study Baseline
6-month follow-up
12-month follow-up
Dysuriaa Haematuriaa Frequencya Urgencya
8.7 7.2 10 10
3.1* 2.3* 1.8* 3.2*
1.3*, ** 1.1*, ** 0.5*, ** 1.4*, **
UUIa SUIa Bladder paina ICIQ-SF ICIQ-OAB IIQ-7 PGI-I
10 10 2.4 20 10 100 NA
1.7* 1.2* 0* 8* 5* 28.5* Very much better
0*, ** 0*, ** 0*, ** 4*, ** 1*, ** 4.8*, ** Very much better
ICIQ-SF International Consultation on Incontinence Questionnaire Short Form, ICIQ-OAB International Consultation on Incontinence Questionnaire Overactive Bladder, IIQ-7 Incontinence Impact Questionnaire-7, NA not applicable, PGI-I Patient Global Improvement Impression, SUI stress urinary incontinence, UUI urgency urinary incontinence *Statistically significant (vs baseline) **Statistically significant (vs 6-month follow-up) a
Measured on a 10 cm visual analogue score (VAS) scale (range: 0–10)
up is the absence of an objective evaluation of the severity of the leakage by using bladder diaries or a pad test. Very few data are available on endometriosis and functional aspects of the lower urinary tract [3, 4], with a scanty knowledge of pre- and post-operative urodynamic assessment of women with endometriotic lesions of the bladder. Our case report shows a complete resolution of lower urinary tract symptoms (LUTS) related to the bladder filling phase after medical treatment. The treatment did not cause the disappearance of the nodule, but there was a reduction of about 20 % of its volume. A concomitant normalization of urodynamic findings was observed and this is probably the most original and interesting finding. The pretreatment low bladder compliance on urodynamics may be due to irritative mechanisms caused by inflammation secondary to endometriosis, reducing the ability of the bladder to expand and, therefore, causing a reduced capacity and OAB symptoms. Although no
standardization of low bladder compliance is available, a tonic increase in bladder pressure during the filling phase can make the urethra sphincter incompetent when a sudden increase in pressure is added secondary to coughing or effort. Continence is, in fact, maintained when the urethral pressure exceeds the bladder pressure. The raise in bladder pressure secondary to low bladder compliance determines that the overall pressure peak during coughing or effort is higher than in normal bladder compliance. The pressure that the urethral sphincter has to face is therefore also higher, putting the continence mechanism at risk. Therefore, the normalisation of bladder pressure can not only resolve OAB symptoms, but also regain the competence of the urethral sphincter during effort. This is what we believe happened to our patient after hormonal treatment of the endometriotic nodule, with resolution of the bladder symptoms.
Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Conflicts of interest Dr Umberto Leone Roberti Maggiore and Dr Simone Ferrero did not report any potential conflicts of interest; Dr Stefano Salvatore had a financial relationship (lectures, member of advisory boards and/or consultant) with Pfizer Inc and Astellas.
References 1. Ferrero S, Biscaldi E, Luigi Venturini P, Remorgida V (2011) Aromatase inhibitors in the treatment of bladder endometriosis. Gynecol Endocrinol 27:337–340 2. Gabriel B, Nassif J, Trompoukis P, Barata S, Wattiez A (2011) Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 78:1269–1274 3. Serati M, Cattoni E, Braga A, Uccella S, Cromi A, Ghezzi F (2013) Deep endometriosis and bladder and detrusor functions in women without urinary symptoms: a pilot study through an unexplored world. Fertil Steril 100:1332–1336 4. Possover M (2014) Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 101:754–758
CASE REPORT
Urinary incontinence and bladder endometriosis: conservative management Umberto Leone Roberti Maggiore & Simone Ferrero & Stefano Salvatore
Received: 16 April 2014 / Accepted: 4 August 2014 / Published online: 3 September 2014 # The International Urogynecological Association 2014
Abstract Bladder endometriosis causes urinary symptoms including frequency, dysuria, cyclic haematuria and non-urinary pain symptoms. To our knowledge, the association of bladder endometriosis with urinary incontinence has not been described. We present the first case of bladder endometriosis that caused urinary symptoms including mixed urinary incontinence (MUI). A 34-year-old nulliparous woman was referred to our urogynaecology clinic with a 18-month history of urgency urinary incontinence (UUI) and stress urinary incontinence (SUI). A diagnosis of bladder endometriosis was performed on the basis of symptoms and imaging. The patient refused surgery and dienogest was prescribed. At the 12-month follow-up, all endometriosis-related symptoms and questionnaire scores had significantly improved, and there was resolution of the abnormal urodynamic findings. In reproductive-aged women suffering pain symptoms, bladder endometriosis should be considered in the differential diagnosis of urinary incontinence and treatment with dienogest may lead to improvement of both urinary and pain symptoms.
Keywords Bladder . Dienogest . Endometriosis . Urinary incontinence U. Leone Roberti Maggiore (*) : S. Salvatore Obstetrics and Gynaecology Unit, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Via Olgettina 58–60, 20132 Milan, Italy e-mail: [email protected] S. Ferrero Obstetrics and Gynaecology Unit, IRCCS San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy
Introduction Bladder endometriosis affects between 1 and 15 % of women suffering from endometriosis [1, 2]. It is defined as infiltration of the endometrial glands and stroma in the detrusor muscle. Most commonly, the clinical manifestations are urinary symptoms such as frequency, dysuria, haematuria and, less frequently, bladder pain and urgency. These symptoms may worsen during the menstrual cycle or have a non-cyclical presentation. Management with laparoscopic excision of bladder endometriotic nodules is considered the gold standard and is associated with a significant amelioration of urinary symptoms, with a long-lasting clinical benefit. Hormonal therapies including progestins, gonadotropin-releasing hormone analogues and oestroprogestin combinations are commonly used for the conservative management of patients with endometriosis. However, few studies evaluated the role of these therapies in the treatment of urinary symptoms caused by bladder endometriosis. We present a case of bladder endometriosis, which caused severe urinary symptoms, including mixed urinary incontinence (MUI), which was improved by the administration of oral dienogest.
Case report A 34-year-old nulliparous woman referred to our urogynaecology clinic with an 18-month history of mixed urinary incontinence (MUI). This patient also complained of other urinary symptoms such as frequency, dysuria and cyclic haematuria and non-urinary pain symptoms (dysmenorrhoea, non-cyclic pelvic pain and deep dyspareunia). Urinary cytology was performed and was negative for the presence of malignant cells. At vaginal examination, no genital prolapse was diagnosed and the stress cough testing (at 250 mL of bladder volume) was negative. At abdominal and transvaginal
160
Int Urogynecol J (2015) 26:159–162
Fig. 1 Measurement of the volume of the bladder volume at baseline assessed by virtual organ computer-aided analysis (VOCAL)
ultrasound, an iso-hyperechoic, intraluminal round-shaped solid mass with quite regular margins and a volume of about 4 cm3 was observed in the posterior bladder wall (Fig. 1). Bladder endometriosis was suspected. Magnetic resonance imaging (MRI) confirmed the ultrasound diagnosis and showed a heterogeneous isointense nodular lesion (on T2Fig. 2 Measurement of the largest diameter of the bladder nodule by T2-weighted MRI (sagittal view)
weighted images) that caused a full-thickness infiltration of the posterior wall of the bladder (Fig. 2). The multichannel urodynamic study (UDS) was performed (Table 1). The patient was asked to attend the urodynamic studies with a comfortably full bladder. Uroflowmetry was performed with the woman voiding in private. Dual-channel
Int Urogynecol J (2015) 26:159–162
161
Table 1 Urodynamic study results at baseline and at 12-month follow-up
Flowmetry Volume (ml) Flow Qmax (ml/sec) Post-void residual (ml) Cystometry First sensation of bladder filling (ml) First desire to void (ml) Strong desire to void (ml) Cystometric capacity (ml) Pressure flow study Qmax (ml/sec) PdetQmax (cmH2O) Post-void residual (ml)
Baseline
12-month follow-up
215 Continuous 22
189 Continuous 21
0
0
75 122 198 375
195 267 384 500
24 25 0
22 29 0
cystometry was performed with the woman supine, using a 10-F filling catheter at a filling rate of 100 ml/min and two fluid-filled 4.5-F catheters for measuring the intravesical and abdominal pressures. The cystometric filling phase was ended in the event of urgency/strong desire to void or at 500 ml with subsequent removal of the filling. Provocative manoeuvres were employed with the woman standing, asking her to listen to running water; to wash her hands in cold water; and to cough once, three, and five times with maximal effort. Finally, a pressure/flow study was performed in private, and the postvoid residual was measured with an ultrasound scan. The UDS revealed normal uroflowmetry; at cystometry, during which the patient reported urgency and bladder pain, we observed an increased bladder sensation (first sensation of bladder filling: 75 ml), a reduced cystometric capacity (375 ml), low bladder compliance (p det=14 cmH2O at 325 ml) and urodynamic stress incontinence. The pressure flow study did not show any voiding difficulties. At cystoscopy, a bulge with a bluish lesion in the bladder lumen was observed (Fig. 3). Medical and surgical treatment options were discussed with the patient and she preferred to avoid surgery. Therefore, the patient received oral dienogest 2 mg/day
Fig. 3 Bladder nodule at ultrasound (left), magnetic resonance imaging (centre) and at cystoscopy (right)
(Visanne, Bayer S.p.A., Milan, Italy) for 12 months and she was followed-up at 1, 6 and 12 months. At baseline and at the 6- and 12-month follow-up the severity of the symptoms was measured using a 10-cm visual analogue scale (VAS) and with four questionnaires: the International Consultation on Incontinence Questionnaire short form (ICIQ-SF, which was used to assess incontinence), the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB), the Incontinence Impact Questionnaire (IIQ-7, which was used to evaluate the impact of incontinence on quality of life, QoL), and the Patient Global Improvement Impression (PGI-I, which was used to measure the perception of improvement that she experienced by the treatment of her symptoms). Ultrasound was repeated at the 6- and 12-month follow-up; while UDS was performed at the 12-month follow-up (Table 1). A significant improvement in all endometriosis-related symptoms and in all questionnaire scores was reported at both 6- and 12-month follow-up (Table 2). Furthermore, a reduction of the volume of the endometriotic nodule was reported at baseline (4.02 cm3), and at the 6-month (3.42 cm3) and 12month follow-ups (3.11 cm3). At the 12-month follow-up, the UDS showed, at cystometry, a normal bladder sensation (first sensation of bladder filling: 195 ml), a normal cystometric capacity (500 ml), no urgency or bladder pain during the filling phase, the resolution of DO and the absence of urodynamic stress incontinence.
Discussion Bladder endometriosis is not a frequent clinical presentation of endometriosis. When it occurs it is commonly associated with urinary symptoms and may be easily diagnosed by ultrasound. MRI provides more accurate information on the pelvic involvement of endometriosis and it allows better estimation of the detrusor infiltration. This report is particularly interesting and original because, to the best of our knowledge, it is the first case of bladder endometriosis associated with urgency urinary incontinence (UUI) and stress urinary incontinence (SUI), assessed by using validated questionnaires and confirmed by UDS. However, a limitation of the initial work-
162
Int Urogynecol J (2015) 26:159–162
Table 2 Intensity of urinary symptoms and results of questionnaires during the study Baseline
6-month follow-up
12-month follow-up
Dysuriaa Haematuriaa Frequencya Urgencya
8.7 7.2 10 10
3.1* 2.3* 1.8* 3.2*
1.3*, ** 1.1*, ** 0.5*, ** 1.4*, **
UUIa SUIa Bladder paina ICIQ-SF ICIQ-OAB IIQ-7 PGI-I
10 10 2.4 20 10 100 NA
1.7* 1.2* 0* 8* 5* 28.5* Very much better
0*, ** 0*, ** 0*, ** 4*, ** 1*, ** 4.8*, ** Very much better
ICIQ-SF International Consultation on Incontinence Questionnaire Short Form, ICIQ-OAB International Consultation on Incontinence Questionnaire Overactive Bladder, IIQ-7 Incontinence Impact Questionnaire-7, NA not applicable, PGI-I Patient Global Improvement Impression, SUI stress urinary incontinence, UUI urgency urinary incontinence *Statistically significant (vs baseline) **Statistically significant (vs 6-month follow-up) a
Measured on a 10 cm visual analogue score (VAS) scale (range: 0–10)
up is the absence of an objective evaluation of the severity of the leakage by using bladder diaries or a pad test. Very few data are available on endometriosis and functional aspects of the lower urinary tract [3, 4], with a scanty knowledge of pre- and post-operative urodynamic assessment of women with endometriotic lesions of the bladder. Our case report shows a complete resolution of lower urinary tract symptoms (LUTS) related to the bladder filling phase after medical treatment. The treatment did not cause the disappearance of the nodule, but there was a reduction of about 20 % of its volume. A concomitant normalization of urodynamic findings was observed and this is probably the most original and interesting finding. The pretreatment low bladder compliance on urodynamics may be due to irritative mechanisms caused by inflammation secondary to endometriosis, reducing the ability of the bladder to expand and, therefore, causing a reduced capacity and OAB symptoms. Although no
standardization of low bladder compliance is available, a tonic increase in bladder pressure during the filling phase can make the urethra sphincter incompetent when a sudden increase in pressure is added secondary to coughing or effort. Continence is, in fact, maintained when the urethral pressure exceeds the bladder pressure. The raise in bladder pressure secondary to low bladder compliance determines that the overall pressure peak during coughing or effort is higher than in normal bladder compliance. The pressure that the urethral sphincter has to face is therefore also higher, putting the continence mechanism at risk. Therefore, the normalisation of bladder pressure can not only resolve OAB symptoms, but also regain the competence of the urethral sphincter during effort. This is what we believe happened to our patient after hormonal treatment of the endometriotic nodule, with resolution of the bladder symptoms.
Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Conflicts of interest Dr Umberto Leone Roberti Maggiore and Dr Simone Ferrero did not report any potential conflicts of interest; Dr Stefano Salvatore had a financial relationship (lectures, member of advisory boards and/or consultant) with Pfizer Inc and Astellas.
References 1. Ferrero S, Biscaldi E, Luigi Venturini P, Remorgida V (2011) Aromatase inhibitors in the treatment of bladder endometriosis. Gynecol Endocrinol 27:337–340 2. Gabriel B, Nassif J, Trompoukis P, Barata S, Wattiez A (2011) Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 78:1269–1274 3. Serati M, Cattoni E, Braga A, Uccella S, Cromi A, Ghezzi F (2013) Deep endometriosis and bladder and detrusor functions in women without urinary symptoms: a pilot study through an unexplored world. Fertil Steril 100:1332–1336 4. Possover M (2014) Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 101:754–758
