Resection of Bilateral Endometriosis of the Uterosacral Ligaments Resolves Voiding Dysfunction: A Case Report

Patients with deep endometriosis of the posterior pelvic compartment might present various lower urinary tract symptoms, including urinary retention, without any prior pelvic surgery in their medical history. These symptoms, including urinary retention, pollakiuria or urge incontinence, urinary urgency, and decreased bladder sensitivity, imply an infiltration of the pelvic autonomic nerves by endometriosis lesions, in combination with inflammatory phenomena. Although there are numerous publications dealing with de novo urinary dysfunction after endometriosis surgery, significantly less scientific information is available on the effect of endometriosis surgery specifically tailored to improve preoperative voiding dysfunction in endometriosis. Therefore, in this case report, we analyze the effect of laparoscopic endometriosis surgery in a 28-year-old nulliparous woman with serious preoperative urinary retention mandating clean intermittent self-catheterization three to four times daily. Patient history revealed neither prior pelvic nor abdominal operation, nor any neurological or other known disease. Uroflowmetry demonstrated significant voiding dysfunction. Filling cystometry showed signs of reduced bladder sensation (normal desire to void at 400 mL) along with preserved bladder compliance. During the pressure-flow study, the patient was unable to initiate micturition, although abdominal straining and detrusor contraction were registered. The cause of voiding dysfunction was deemed to be pelvic floor dysfunction (dysfunctional voiding) rather than detrusor underactivity. Alpha blocker, muscle relaxant therapy, and pelvic floor relaxation training were introduced, achieving poor short-term response. Transvaginal ultrasound examination showed hypoechogenic alterations on both uterosacral ligaments in the vicinity of their cervical attachment sites. These areas appeared to be painful while scanning with the probe. MRI examination confirmed the previous finding of transvaginal ultrasound with regard to bilateral alteration of the uterosacral ligaments characteristic of endometriosis. During laparoscopy, we confirmed the presence of endometriotic lesions of both uterosacral ligaments that were completely removed. The patient showed significantly improved emptying function following surgery. Uroflowmetry also demonstrated improved voiding parameters. We conclude that laparoscopic removal of endometriotic lesions of the uterosacral ligaments can significantly improve bladder function in patients suffering from preoperative voiding dysfunction.