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Pelvis » Urinary Bladder
Bladder endometrioma, adenomyosis
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Author(s) :
Brian Klimas  |  Harry Zegel
 
Presentation 34 year old female with chronic left lower abdominal pain.
 
 
 
Caption: bladder sagittal
Description: Bladder: left posterior wall mass with minimal doppler flow. Additional mass located anteriorly on the right is better seen on superior images.
 
 
 
Caption: Uterus sagittal
Description: Uterus: posterior fibroid and parenchymal texture inhomogeneity with indistinct endometrial stripe.
 
 
 
Caption: Axial noncontrast CT
Description: Asymmetric nodular wall thickening seen posteriorly to the left in an incompletely distended bladder. Additional nodular thickening is seen anterosuperiorly on the right.
 
 
 
Caption: T1 axial MRI
Description: Bladder: One of the two bladder masses is shown posterolaterally on the right. Foley catheter with balloon inflated in bladder.
 
Differential Diagnosis

 

Differential diagnosis of bladder mass: 2,4

Neoplasm – including uroepithelial carcinoma (90%, includes TCC), squamous cell carcinoma (2-10%), adenocarcinoma (primary and mets), rhabdomyosarcoma (children) and leiomyosarcoma (adults)

Inflammatory pseudotumor

Endometriosis

Nephrogenic adenoma

Malacoplakia

Cystitis (cystica, glandularis, eosinophilic, post chemotherapy or radiation therapy)

Infection (TB, Schistosomiasis)

Extrinsic disease (Crohns and diverticulitis with fistula)

Extrinsic masses – prostate or distal ureter

 

 
Final Diagnosis

Bladder endometrioma, uterine adenomyosis and fibroids.

 
Discussion

 

An endometrioma is a focus of mass-like endometriosis.  Endometriosis results from ectopic endometrial tissue located outside of the endometrium and myometrium.  Pelvic endometriosis commonly occurs in the pelvic peritoneum, fallopian tubes or the ovaries.  Less commonly, extra-pelvic endometriosis can be found in the cervix, vagina, perineum, inguinal canal, extremities, and skin, as well as in the gastrointestinal, urinary, pulmonary, or central nervous systems. 1

 

When involved, the bladder is the most frequent urinary tract site occurring in 1-15% of women with endometriosis.2   Bladder endometriosis may be asymptomatic.  Cyclic hematuria suggests urinary tract involvement but occurs in only 20% of bladder endometriosis.  Additional nonspecific symptoms may include cyclic pain, dysuria, urgency and pelvic or back pain.  Most bladder endometrial lesions are located at the dome or in the posterior bladder wall above the trigone.   They may grow through the muscle into the submucosa causing an obtuse bulge in the bladder lumen. Less commonly endometriosis can penetrate the mucosa producing a polypoid mass.  Endometrial implants may be inseparable from the anterior uterus, obliterating the vesicouterine pouch.2

 

Imaging:    Ultrasound and MRI can be used to evaluate extent of involvement.

Transvaginal ultrasound is used to evaluate bladder involvement including depth of involvement in the bladder wall and continuity to adenomyosis in the anterior myometrium, if present.

 
Case References

 

1.Honore, GM. Extrapelvic endometriosis. Clin Obstet and Gynecol 1999; 42(3):699-708.

2.Wong-You-Cheong JJ, Woodward PJ, Manning MA, Davis CJ. From the archives of the AFIP: inflammatory and nonneoplastic bladder masses: radiologic-pathologic correlation. RadioGraphics 2006; 26:1847–1868.

3.Patel MD, Feldstein VA, Chen DC, Lipson SD, Fily RA. Endometriomas- diagnostic performance of US. Radiology 1999; 210(3): 739-745.

4.Wong-You-Cheong JJ, Woodward PJ, Manning MA, Sesterhenn IA. From the archives of the AFIP: Neoplasms of the urinary bladder: radiologic-pathologic correlation. RadioGraphics 2006; 26:553-580.

 
Follow Up

Pathology: Cystoscopic transurethral resection of bladder mass demonstrates focal endometrioid glandular lining surrounded by inflammatory reaction compatible with endometriosis.

 
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