Correspondence

Obstructive Uropathy Secondary to Endometriosis

N Engl J Med 1997; 337:1174-1175October 16, 1997

Article

To the Editor:

Ureteral obstruction is an infrequent but serious complication of pelvic endometriosis. Often, endometriosis is not identified as the cause of the obstruction before surgery. Hormonal therapy has been attempted,1 but surgery remains the treatment of choice. The diagnosis of external as opposed to internal endometriosis cannot be made reliably at surgery,2 and therefore there is controversy over whether segmental resection and anastomosis or ureterolysis is indicated. We describe a woman with ureteral obstruction that was managed medically with magnetic resonance imaging and hormonal therapy.

A 46-year-old woman with a history of severe endometriosis and left oophorectomy received progestogen therapy continuously for 25 years. An acute abdomen developed six months after therapy was stopped. Obstructive uropathy on the left side was diagnosed, and endometriosis was suspected. Magnetic resonance imaging with a fat-saturation technique revealed a hemorrhagic lesion at the site of obstruction (Figure 1Figure 1Axial T₁-Weighted Image Obtained with a Fat-Saturation Technique, Showing a Small, Hyperintense Lesion Surrounding the Left Ureter at the Site of Obstruction (Arrow).). A double- J stent was placed, and progestogen therapy was resumed. Three months later the obstruction had resolved, and magnetic resonance imaging showed resolution of the lesion. The stent was removed after six months, and the patient has remained asymptomatic for two years while continuing progestogen therapy.

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus with the functional capacity of menstrual bleeding.3 The diagnosis is usually based on visualization of hemorrhagic lesions at laparoscopy. Small endometriomas measuring 5 mm or more can be reliably detected by magnetic resonance imaging.4 In our patient with obstructive uropathy, the identification of the endometrial cause was based on the history, site, and hemorrhagic nature of the lesion and the resorption of the lesion after the suppression of menstrual bleeding by progestogen therapy.

Failure of hormonal therapy has been reported when the obstruction was caused by fibrotic stenosis, when the duration of therapy was shorter than three months, and in most cases, after the discontinuation of therapy. It would therefore appear that the efficacy of the hormonal treatment is based not on the eradication of the lesion but on the suppression of endometrial bleeding.5

Magnetic resonance imaging can be used both to detect endometriomas obstructing the ureter and to monitor the lesion during hormonal therapy. Findings of resorption of the lesion and clearance of the obstruction indicate that the obstruction is caused by compression and not by fibrotic stricture, and in our patient the compression resolved with the suppression of menstrual bleeding.

Jan Deprest, M.D.
G. Marchal, M.D.
University Hospital Gasthuisberg

Ivo Brosens, M.D.
Leuven Institute for Fertility and Embryology, B-3000 Leuven, Belgium

5 References

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Citing Articles (5)

Citing Articles

1. 1

   Gerard A. J. Dunselman, Regina G. H. Beets-Tan. 2011. Diagnosis of Endometriosis: Imaging. , 299-308.
   CrossRef

2. 2

   Aylur Gopalakrishnan Rajasri, Dominic Byrne. (2006) An unusual case of trapped ovary in a peritoneal pouch causing extrinsic ureteric compression associated with endometriosis. Gynecological Surgery 3:1, 43-44
   CrossRef

3. 3

   CHARLES CHAPRON, NICOLAS CHOPIN, BRUNO BORGHESE, CECILE MALARTIC, FOUZIA DECUYPERE, HERVE FOULOT. (2004) Surgical Management of Deeply Infiltrating Endometriosis: An Update. Annals of the New York Academy of Sciences 1034:1, 326-337
   CrossRef

4. 4

   I BROSENS, P PUTTEMANS, R CAMPO, S GORDTS, K KINKEL. (2004) Diagnosis of endometriosis: pelvic endoscopy and imaging techniques. Best Practice & Research Clinical Obstetrics & Gynaecology 18:2, 285-303
   CrossRef

5. 5

   J BROSENS, D TIMMERMAN, A STARZINSKIPOWITZ, I BROSENS. (2003) Noninvasive diagnosis of endometriosis: the role of imaging and markers. Obstetrics and Gynecology Clinics of North America 30:1, 95-114
   CrossRef