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 Endometriosis is the condition of uterus-like cells growing outside the uterus. These cells tend to grow and endanger other organ systems. This condition is common in women who are of an advanced maternal age and they can face growth of cells on their ovaries, bowel, rectum, and the lining of the pelvis. These growths can also occur in other parts of the body. The women who suffer from this condition often face pain and additional bleeding along with other fertility issues.  Often women just bear the discomfort assuming it is all a part of menstruation but endometriosis can be very painful to live with.

Ureteral endometriosis is a rare form of endometriosis. Diagnosis is an important factor in ureteral endometriosis. This form of endometriosis is an additional complication of endometriosis where an obstruction in the ureter can lead to renal failure when undetected. Its asymptomatic nature makes it very dangerous and for any woman complaining of pelvic pain, this diagnosis should not be ruled out without thorough and complete tests.

Ureteral endometriosis occurs because of a physical obstruction. This obstruction can be an endometriotic implant. Its ‘silent’ nature means that it often goes undiagnosed and by the time a definite diagnosis is made, the condition has progressed to where the affected kidney needs to be removed. Usually, the obstruction appears on distal segment of the left ureter which in turn compresses the female reproductive organs.

Ureteral endometriosis has two variants – intrinsic and extrinsic. Eighty percent of the cases tend to be intrinsic endometriosis. A combined version of intrinsic and extrinsic ureteral endometriosis can occur as well.  Scans help determine the obstruction but a physical examination does not usually yield a positive result. Intravenous pyelogram (IVP) is the ideal test for intrinsic ureteral endometriosis. It can even provide information on the degree of renal damage and extent of obstruction in the ureter. A CT scan is used for the diagnosis for intrinsic ureteral endometriosis.

Symptoms: The degree of symptoms will depend on where the obstruction is and how large the obstruction is.

• Pain in the flanks and back
• Pain during periods
• Pain while having sex
• Perpetual discomfort in the pelvic region
• Hematuria or blood in urine
• Excessive bleeding especially during menstruation
• Gastrointestinal symptoms
  

Treatment: Medicines along with surgery are usually the recommended courses of treatment. The degree of each course depends on the stage of the condition when it is diagnosed. The aim is to retain as much kidney function as possible. If the damage of the growth is not extensive then a stenotic ureter is usually sufficient. The growth is removed with surgery and a stent is placed. The stent is removed usually after 3-4 weeks of recovery. Typically the growth is also sent for biopsy.

The most extensive form of surgery in ureteral endometriosis includes a complete hysterectomy along with a nephrectomy or a kidney removal. Hormone therapy is sometimes used if the condition is identified in the early stages. Nowadays there are even minimally invasive procedures like uretereostomy, laparoscopic ureterolysis and reimplantation that are used in  the treatment for ureteral endometriosis.

Endometriosis can often be mistaken for other conditions like ovarian cysts, ectopic pregnancy, irritable bowel syndrome, fibroids, colon cancer, or even ovarian cancer. This condition also makes women susceptible to other illnesses like rheumatoid arthritis, chronic fatigue syndrome, hypothyroidism and fibromyalgia. The symptoms of endometriosis can differ greatly from one woman to the next and so it can be a little difficult to diagnose.

A new treatment called endoluminal ultrasonography has been introduced to evaluate the obstruction and help proper treatment during an endoscopy.

References:

1. http://www.ncbi.nlm.nih.gov/pubmed/11779587
2. http://www.ncbi.nlm.nih.gov/pubmed/21609579
3. Dorian Bosev, Linda M. Nicoll, Lisa Bhagan, Madeleine Lemyre, Christopher K. Payne, Harcharan Gill, Camran Nezhat, Laparoscopic Management of Ureteral Endometriosis: The Stanford University Hospital Experience With 96 Consecutive Cases, The Journal of Urology, Volume 182, Issue 6, December 2009, Pages 2748-2752, ISSN 0022-5347, 10.1016/j.juro.2009.08.019.

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