Introduction

Endometriosis is a complex and debilitating condition affecting approximately 10% of women during their reproductive years and beyond.¹ Endometriosis is characterized by the growth of endometrial-like tissue outside the uterus, including the ovaries, fallopian tubes, peritoneum, and bowel.² The hallmarks of the condition include chronic pelvic pain, dysmenorrhea, and infertility.³ In some cases, endometriosis can also involve the urinary tract, affecting the bladder, ureters, and kidneys.⁴ In severe cases, urinary tract endometriosis can cause loss of function of the bladder and/or the kidney.³ Many patients with endometriosis suffer from urinary and defecatory dysfunction.^5,6 Despite its significant prevalence, and despite advances in imaging modalities to detect it, endometriosis can be challenging to diagnose as direct laparoscopic examination of the peritoneal cavity remains the gold standard for diagnosis.⁷ Many people with the condition experience a delay in diagnosis, and on average this delay is 7-10 years.⁸

As a urologist, I play a critical role in the diagnosis and management of endometriosis, particularly when it involves the urinary tract. This article provides insight into my work with endometriosis patients, highlighting the importance of a multidisciplinary approach and the urologist’s role in the diagnosis and treatment of a complex disease.

Role of a Urologist in Endometriosis Management

Urologists are often the first health care providers to encounter endometriosis patients, especially those presenting with urinary complaints such as urgency, frequency, incomplete emptying, and painful urination.⁵ Rectal fecal incontinence is also present in many of these patients (although it is often difficult to elicit this history).⁹ Through detailed medical history taking, physical examination, and appropriate imaging studies, urologists can identify signs and symptoms suggestive of endometriosis. I have found that the following 3 questions have been sensitive in increasing the likelihood of an accurate diagnosis¹⁰:

1. Do you or have you ever had pain with your period that has resulted in missing school or work?
2. Do you ever have pain with sex?
3. Have you had recurrent urinary tract infections (with cultures showing no growth)?

Affirmative responses to the above questions in combination with elevated AUA Symptom Index scores are highly suggestive of urinary tract endometriosis.

When endometriosis is suspected or confirmed to involve the urinary tract, urologists play a critical role in the multidisciplinary management of the condition. This team typically includes gynecologists, general surgeons, pain management specialists, physical therapists, and mental health professionals. Together, we develop a comprehensive treatment plan tailored to each patient’s unique needs, taking into account factors such as pain severity, fertility goals, and the extent of disease involvement.

Once a week, I meet with my multidisciplinary team to review imaging, case presentations, and insights. I find these weekly meetings to be informative, educational, fulfilling, and necessary to offer the best care to our patients.

Surgery is often an essential component of endometriosis management, particularly when the urinary tract is involved. In these cases I perform robotic-assisted laparoscopic ureterolysis, ureteral reimplantations, partial cystectomies, and pelvic lymphadenectomies. Reconstruction of the urinary tract is the rule, not the exception when it comes to the management of urinary tract endometriosis.

Because many endometriosis patients have bladder and bowel dysfunction, I also find myself treating these complaints with a tailored approach unique to each patient. I use a stepwise approach based on the AUA Overactive Bladder Guideline,¹¹ starting with lifestyle modifications and escalating to second-line pharmacological treatment, and in many cases reverting to third-line therapies including the use of bladder botulinum toxin and sacral neuromodulation.

Because this disease is underrecognized and often misdiagnosed, patient advocacy is critical to anyone caring for patients with endometriosis. The Endometriosis Summit, a patient and practitioner town hall–style meeting that takes place annually, is a unique forum for advocacy and exchange. Physicians can hear directly from patients, centering their experiences as they work to provide state-of-the-art care.

Conclusions

As a urologist, I provide diagnostic and therapeutic care to endometriosis patients, often as part of a multidisciplinary team. The focus of my practice is both reconstruction of the urinary tract and rehabilitation of urinary and defecatory function.

Increased awareness, early diagnosis, and a comprehensive approach to treatment are essential to addressing this complex and often debilitating condition.

I urge you to consider the possibility of this diagnosis the next time a woman of child-bearing age enters your office with complaints of pelvic pain.