EURURO Vol. 71 No. 5

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reproducible for detection of DIE and in particular BE
(Gwet’s AC1 = 1) A French study including eight
women who reported urinary tract symptoms suggestive
of BE assessed the performance of three-dimensional (3D)
TVS with color Doppler compared to MRI and cystoscopy in
the diagnosis of BE. TVS was superior to cystoscopy and at
least as effective as MRI in diagnosing and planning surgery
for BE. The authors of this study suggested that 3D
acquisition may improve endometriotic nodule localization
and evaluation of its size, volume, and infiltration of the
bladder wall in comparison to two-dimensional TVS .
3.2.5. Magnetic resonance imaging
MRI should be regarded as a second-line imaging technique
for assessment of BE. In the case of cancer suspicion, it is
thought to be helpful because of higher contrast resolution,
better delineation of bladder wall layers, better tissue
characterization, and better multiplanar capability in
comparison with ultrasonography . The MRI appear-
ance of BE is usually of low signal intensity on T2 weighting
with intermediate signal intensity on T1 weighting, and
spots of high signal intensity on T1 and T2 weighting
. Several studies have investigated the role of MRI in the
diagnosis of DIE including bladder localizations
. Medeiros et al conducted a systematic review
and meta-analysis to estimate the accuracy of pelvic MRI in
the diagnosis of DIE. A total of 20 studies including
1819 women were analyzed; four of these, involving
494 women, assessed the presence of BE. Pelvic MRI had
pooled sensitivity of 0.64 (95% CI 0.48–0.77) and pooled
specificity of 0.98 (95% CI 0.96–0.99) for detection of BE. The
diagnostic odds ratio was 97.36 (95% CI 34.50–274.76) and
the area under the curve was 0.93 . No significant
advantage has been reported for 3.0-T MRI or
gadolinium-enhanced MRI
Considering that in experienced hands TVS has similar or
even superior accuracy to MRI in detecting BE and that the
latter is muchmore expensive, we conclude that MRI should
not be routinely performed in clinical practice, in accor-
dance with the emerging concept that it is preferable to
reduce the use of low-value care interventions with
uncertain benefits
3.2.6. Cystoscopy
Cystoscopy is a diagnostic procedure widely performed in
the outpatient setting to assess the interior lining of the
urethra and bladder. When a BE lesion is present, the
cystoscopic findings are more commonly normal owing to
the intraperitoneal origin of the nodule. In fact, an
endometriotic lesion progresses from the serosal layer of
the bladder towards the mucosa through the bladder wall; a
typical adenomatous and nodular red or bluish mass is
observed in half of cases, and ulcerations are rare
. Scheduling of cystoscopy immediately before or
during menstruation is recommended, when the nodule is
larger and more congested, so characterization is optimal.
Cystoscopy allows estimation of the distance between the
ureteral orifices and the nodule borders for planning of the
most appropriate surgical approach. When the caudal
margin of the lesion is far from the ureteral orifices,
excision is generally easy and safe, and can be performed by
a gynecologists, whereas when the endometriotic lesion is
close to or involves the ureteral orifices, ureterovescical
reimplantation should be planned with an expert urologist.
Furthermore, cystoscopy may be helpful in excluding
bladder carcinoma, varices, papillomas or angiomas, and
detrusor mesenchymal tumors. However, it should be
considered that with the exception of transurethral
resection (TUR) procedures, biopsy at cystoscopy is
frequently not diagnostic for endometriosis . In conclu-
sion, cystoscopy should not be routinely performed apart
from in cases of suspicion of malignancy or if the distance
between the nodule and the ureteral orifices is not clearly
evaluable using TVS ).
3.2.7. Urodynamics
The presence of LUTS in patients with DIE is well
established; however, little research has been conducted
to study the lower urinary tract function of patients affected
by DIE using urodynamics . Bonneau et al
performed a systematic review to assess the incidence of
preoperative and postoperative urinary dysfunction in
patients with DIE and evaluate the potential role of
urodynamics. Their review revealed that there was at least
one abnormal urodynamic finding in 48.0–83.3% of patients
with DIE , but no patient with BE was included in this
analysis. Panel et al studied the characteristics of LUTS
and urodynamic findings in 30 patients with DIE to
correlate them with the anatomic location of nodules
found at surgery. All patients had posterior endometriosis
and ten (33.3%) also had BE. Urodynamic examination
results showed changes in 29 (96.7%) women, and those
with BE had a higher rate of bladder sensation (90.0% vs
45.0%) and painful bladder filling (70.0% vs 30.0%), while
voiding symptoms (70.0% vs 55.0%), urgency (80.0% vs
40.0%), frequency (60.0% vs 45.0%), and bladder pain (60.0%
vs 25.0%) were similar in the two study groups .
In conclusion, there is scanty evidence on the role of
urodynamics in the assessment of patients with BE, so this
should not be performed in clinical practice, but limited to
scientific research trials ).
3.3. Treatment of BE
3.3.1. Medical therapies for the treatment of BE
Combined hormonal contraceptives and progestogens
should be regarded as first-line therapy for patients with
DIE, as they are efficacious, safe, and well tolerated
. However, this is a relatively recent and novel
concept, as until a few years ago authoritative surgeons
considered hormonal treatment to be ineffective and
maintained that radical excision was the only successful
modality to deal with these demanding conditions It
has been demonstrated that both combined hormonal
contraceptives and progestogens are effective in several
formulations (oral, cutaneous, vaginal and oral, subcutane-
ous/intramuscular, intrauterine device, and implants),
showing similar results in the treatment of different DIE
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