Endometriosis: Perilous impact on kidneys

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By Nancy Petersen

Yes, it’s a tough headline. But last year in Nancy’s Nook, we had 18 cases of hydronephrosis reported secondary to fibrotic compression of the ureter due to endometriosis. Four of those people lost kidneys- one of the four lost both. Almost all of them, except one, reported symptoms over and over that were ignored, tossed aside, dismissed, and/or were told have nothing to do with endometriosis. One case was discovered when she developed pyelonephritis, the rest picked up at surgery or in various scanning after years of asking about symptoms and being ignored. Only by a stroke of luck did not all 18 patients lose kidneys.

One study found ureteral endometriosis in 14.2% of 315 patients with endometriosis, with urinary symptoms only present in 15.9% of those patients (Soriano et al., 2011). Langebrekke and Qvigstad (2011) note as well that “symptoms related to ureteral endometriosis are often nonspecific, and the onset of severe stenosis may lead to symptomatic hydronephrosis and finally compromise renal function” and that “the risk of silent renal loss in these patients is reported to be as high as 25–50%”. While ureteral endometriosis may often be silent, some symptoms might include “flank or abdominal pain, renal colic, hematuria associated with flank pain, or cyclic gross hematuria” as well as “unexplained hypertension and silent renal failure” in addition to usual symptoms of endometriosis (Palla, Karaolanis, Katafigiotis, & Anastasiou, 2017). With hydronephrosis, patients may experience back pain, flank pain, pain when they step on the affected side (not sure this one is in the literature, but it happened to me with an obstructed ureter following bladder cancer surgery), pyelonephritis, pelvic pain, and/or localized swelling on palpation. The risk of ureteral endometriosis “can occur with both minimal and extensive disease” (Wang et al., 2015).

One study noted that “56.5% of asymptomatic ureteral involvement in patients with known pelvic endometriosis seems to warrant the need for further investigations regarding the possibility to avoid the high percentage of silent renal losses” (Carmignani et al., 2010). Carmignani et al. (2010) noted that there is no “specific risk factor to allow for early suspicion nor a validated preventive diagnostic and therapeutic program” but that a urinary ultrasound is a way to screen.

Once it is found, then it needs to be treated quickly and effectively. Our most recent case was told she would have to keep the stent, and then they were going to put her on lupron and remove her normal ovaries. It is unclear what they hoped to gain since endometriosis makes its own estrogen and can progress despite ovaries being removed (see Can Endometriosis Persist After Hysterectomy Ovary Removal). Removing normal ovaries is not a treatment for endometriosis (noted 9 years ago from ACOG) (Armstrong, 2011). Even ten years ago, Ponticelli, Graziani, and Montanari (2010) noted:

“The prognosis of ureteral endometriosis depends on the time of diagnosis. In too many cases of bilateral obstruction, the patient is referred to the nephrologist because of an advanced, irreversible renal failure. Although some patients may benefit from progestin or anti-arotamase therapy, in most cases of ureteral endometriosis surgery is needed.”

Medication is only a temporary hold until the patient can see someone with the surgical skill to remove it (Barra et al., 2018). Medical therapy will not treat nor stop progression of ureter closure. In the study done by Soriano et al. (2011), hydronephrosis was noted in 22.2% of the patients they studied and 80% had full resolution after surgery.

We ought to be deeply alarmed at this trend of missing renal disease. If it is something a local gyn cannot handle, then seek one of the specialty centers where they remove fibrotic disease from ureters frequently. It takes specific skills, but it can be done. Is it worth it to risk loss of a kidney, or loss of two kidneys, and subsequent renal failure in a benign disease that sufficient surgical skill could resolve? Patients complain of symptoms, ask for help, in some cases, fibrosis is noted at surgery and left alone without future referral to address it. Repeatedly the patients report having their complaints blown off, set aside, dismissed, sometimes even disputed. The risks are too great to just let it go. We should be listening to patients and investigating their complaints. How difficult it is to do a renal ultrasound, or an IVP with runoff, or CT scan with contrast? I mean, it’s not hard to find these issues if we look.

While not all endo on the ureters is invasive, it does need to be monitored. It won’t take care of itself. No one should lose renal function in a benign albeit painful condition. It should elicit a clear, focused medical workup. Time for a very big wakeup call- there is no excuse for renal failure in endometriosis patients. We should be looking for red flags, following up symptoms, and referring patients on if we are not sure.

References

Armstrong, C. (2011). ACOG updates guideline on diagnosis and treatment of endometriosis. American Family Physician83(1), 84. Retrieved from https://www.aafp.org/afp/2011/0101/p84.html

Bailey, A. P., Schutt, A. K., & Modesitt, S. C. (2010). Florid endometriosis in a postmenopausal woman. Fertility and sterility94(7), 2769-e1. Retrieved from https://www.fertstert.org/article/S0015-0282(10)00665-5/fulltext?mobileUi=0&fbclid=IwAR2Z6KlNaoUVmZX_T6HQNIjvrzOJJ6whztpBa-bSkSa44Z2w6eZBMdjXTCs

Barra, F., Scala, C., Biscaldi, E., Vellone, V. G., Ceccaroni, M., Terrone, C., & Ferrero, S. (2018). Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. Human Reproduction Update24(6), 710-730. Retrieved from https://academic.oup.com/humupd/article/24/6/710/5085039

Carmignani, L., Vercellini, P., Spinelli, M., Fontana, E., Frontino, G., & Fedele, L. (2010). Pelvic endometriosis and hydroureteronephrosis. Fertility and sterility93(6), 1741-1744. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0015028208047341

Choi, J. I., Yoo, J. G., Kim, S. J., Lee, H. N., & Kim, M. J. (2015). Acute renal failure due to obstructive uropathy secondary to ureteral endometriosis. Case reports in obstetrics and gynecology2015. Retrieved from https://www.hindawi.com/journals/criog/2015/761348/

Langebrekke, A., & Qvigstad, E. (2011). Ureteral endometriosis and loss of renal function: mechanisms and interpretations. Acta obstetricia et gynecologica scandinavica90(10), 1164-1166. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0412.2011.01210.x

Nezhat, C., Paka, C., Gomaa, M., & Schipper, E. (2012). Silent loss of kidney seconary to ureteral endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons16(3), 451. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535807/

Palla, V. V., Karaolanis, G., Katafigiotis, I., & Anastasiou, I. (2017). Ureteral endometriosis: A systematic literature review. Indian journal of urology: IJU: journal of the Urological Society of India33(4), 276. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635667/

Ponticelli, C., Graziani, G., & Montanari, E. (2010). Ureteral endometriosis: a rare and underdiagnosed cause of kidney dysfunction. Nephron Clinical Practice114(2), c89-c94. Retrieved from https://www.karger.com/Article/FullText/254380?fbclid=IwAR0BIGigiHgowV4UYH6dnSctOJYWl8xHyFWu563PIoz-ozxvlcMgYfoRhQQ

Soriano, D., Schonman, R., Nadu, A., Lebovitz, O., Schiff, E., Seidman, D. S., & Goldenberg, M. (2011). Multidisciplinary team approach to management of severe endometriosis affecting the ureter: long-term outcome data and treatment algorithm. Journal of Minimally Invasive Gynecology18(4), 483-488. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465011002378

Wang, P., Wang, X. P., Li, Y. Y., Jin, B. Y., Xia, D., Wang, S., & Pan, H. (2015). Hydronephrosis due to ureteral endometriosis in women of reproductive age. International journal of clinical and experimental medicine8(1), 1059. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358548/