it is a well - known fact that endometriosis most commonly affects such organs as the ovaries , utero - sacral ligaments , uterine tubes , pouch of douglas , and rectum . the bladder , however , is an infrequent site of endometriosis localization , and it is estimated that only 1% of patients suffering from this disease have lesions involving the urinary system . three leading theories explain the origin of bladder endometriosis : 
 it develops from mllerian remnants in the vesicouterine / vesicovaginal septum.it is in fact an extension of an adenomyotic nodule of the anterior uterine wall.it results from implantation of regurgitated endometrium . it is in fact an extension of an adenomyotic nodule of the anterior uterine wall . from january 2003 to october 2006 , six patients with bladder endometriosis were treated at the department of obstetrics and gynaecology , university hospitals schleswig- holstein , campus kiel . the symptoms varied from dysmenorrhoea , cystitis , and pain in the abdomen to menorrhagia . in 2 cases , endometriosis of the bladder was an accidental finding in a diagnostic pelviscopy performed for primary sterility . the eec classification was grade iv in 2 cases and grade ii in 4 cases . . associated endometriotic lesions involving the ovaries and pouch of douglas were seen in 5 patients . another patient experienced urethral dilation 3 years prior to laparoscopic treatment of endometriosis , and a third patient underwent laparoscopic bilateral endometrioma enucleation . of 6 patients , 2 with recurrent cystitis , menstrual hematuria , and lower abdominal pain underwent laparoscopic resection of the bladder wall , followed by suturing of the bladder defect with 40 pds in 2 layers . one of these patients had been treated with gnrh analogues for 3 months for an associated fibroid . associated endometriotic lesions were treated in 5 patients , treatments including adhesiolysis and myoma enucleation in one patient . symptomatic relief of hematuria , recurrent cystitis , and abdominal pain was seen in all patients . after these treatments , all patients were without pain and reported none of the previous symptoms . in the following report a 38-year - old lady presented with pain in the lower abdomen in a 4-week rhythm although the uterus had been previously resected . she also suffered from pain while urinating , menstrual hematuria , and hypermenorrhea every 3 weeks to 4 weeks . symptoms started after the second vaginal birth in 1998 ; a cystoscopy was without pathological findings . the patient underwent a pelviscopy in 2001 for suspected endometriosis and adhesions and a vaginal cystectomy in 2003 . at the vaginal examination in 2005 , a walnut - sized nodule at the top of the anterior vaginal wall could be touched , which was painful at compression . we recommended transvaginal excision to remove the nodule and to detach the endometriotic lesions , followed by operative laparoscopy . the nodule in the anterior vaginal wall was palpated in the septum vesico - vaginale . the pelviscopy was begun by insufflation of 3.6 liters of co2 and positioning of 3 trocars ; the optic trocar in the caudal umbilicus and two 5-mm trocars in the right and left lower abdomen . the diagnostic laparoscopy and pelviscopy revealed no adhesions in the upper and mid abdomen , no uterus , an appendix without signs of irritation , a right ovary of normal size , and a left ovary partially adherent to the pelvic wall . on the right twisted tube , we discovered a 1-cm pedicled hydatid that was displaced by coagulation at the pedicle and sent for histological clarification . in the pouch of douglas on the dorsal the main manifestation of endometriosis was found in the dome of the bladder , appearing as endometriosis extragenitalis , eec iv. the peritoneum over the bladder was star - like inserted ; the center of the lesion was brown and white colored . the lesion appeared as a 2  3-cm large nodule infiltrating into the bladder wall ( figure 1 ) . the gynecologist and urologist cooperated to excise the nodule circularly from the peritoneum with the hook scissors , mobilized on the level of the muscular bladder wall and removed completely with the simultaneous excision of a 2  2.5-cm large adherent lobe of urothelium off the bladder wall . this resulted in an unobstructed view into the bladder with clean , smooth , and bloodless wound edges ( figure 2 ) . to reduce the tension at the margins of the wound , we laid an extracorporal , knotted pds size 0 suture through all layers of the bladder . view into the urinary bladder after complete laparoscopic resection of an endometriotic nodule . at the right and left wound slot , the urothelium was closed completely with an intracorporal , knotted pds size 4 suture . for the second layer , we laid an extracorporal , knotted pds size 0 suture in the middle of the wound to place the peritoneum of the bladder over the wound . on the right and left side , we closed the peritoneum permanently over the wound of the bladder with simple interrupted sutures , size 40 . to check the closure , we filled the bladder with 80 ml to 100 ml of blue solution and no leakage occurred . after irrigation of the abdominal cavity and placing of a 5-mm robinson drainage for 24 hours , we removed the trocars under vision and closed the skin incisions . three weeks after the operation , a cystoscopy with contrast medium was performed without pathological findings , and the patient reported no pain . at a control examination broadly speaking , vesical endometriosis has 2 different causes : a primary and a secondary form . the secondary form is iatrogenic , occurring after pelvic surgery , such as cesarean delivery or hysterectomy . after iatrogenic dissemination , growth of ectopic endometrium symptoms , when present , mimic those of recurrent cystitis , or more rarely the condition is characterized by pathognomic menstrual hematuria . early diagnosis and treatment of urinary tract endometriosis is necessary to avoid loss of kidney function . transabdominal and transvaginal ultrasound are the initial investigation of choice in evaluation of suspected bladder endometriosis due to immediate availability and easy access . it has proved adequate in determining the site and size of lesion , the degree of infiltration of detrusor and mucosa , and the relationship with concomitant adenomyosis of the uterus . magnetic resonance imaging can not only delineate the morphologic abnormalities of bladder endometriosis but can also potentially identify other common sites , particularly at the uterosacral ligaments , where ultrasound is less reliable . cystoscopy is able to visualize the endometriosis foci only when present on bladder mucosal surface , but is unable to define the extent of endometriosis lesion , which can be better detected by tv sonography . hormonal therapy is a reasonable and effective management for bladder endometriosis reaching into the genital tract . however , experienced laparoscopists , familiar with endometriosis , can also treat urogenital endometriosis safely and effectively using excision . segmented resection may be performed , or transurethral resection of the bladder mass , and ureterolysis , if necessary . in cases of submucosal transmural location of the lesion , a minimally invasive combined endoscopic procedure ( laparoscopy and cystoscopy ) represents a good alternative to partial cystectomy for muscle infiltrating bladder endometriosis that does not involve the vesical mucosa . bladder endometriosis should be considered in women of reproductive age who present with urinary tract symptoms not responding to routine medical management with a view to laparoscopic treatment . an optimal treatment of bladder and urethral endometriosis should ideally involve a team of experts , ie , gynecological endoscopists , radiologists , and urologists , who are familiar with endometriosis .