Bladder Endometriosis: Symptoms, Diagnosis, and Treatment Options

Bladder endometriosis can be confusing and frightening—especially when you have pelvic pain and urinary symptoms but repeated urine cultures come back “normal.” Many people are told it’s recurrent UTIs, interstitial cystitis, or “just endometriosis,” without a clear explanation of what’s happening in the bladder itself.

This article brings together findings from multiple recent studies (including large surgical-center experiences and a systematic review) to explain what bladder endometriosis is, how it’s typically diagnosed, what treatments actually look like in real-life practice, and what outcomes and risks you should know before deciding on a plan with your doctor.

What is bladder endometriosis (and why it can be missed)?

Bladder endometriosis usually refers to endometriosis that grows into the bladder wall muscle (the detrusor). It’s considered part of deep endometriosis, which often involves other pelvic organs too. That “deep” component matters: these nodules may grow from the outside of the bladder inward, which is one reason symptoms can be significant—and also why some diagnostic approaches can miss it.

A key challenge is that bladder endometriosis is uncommon in the general endometriosis population, but more likely in people with deep endometriosis. In one large single-center experience that reviewed over 11,000 endometriosis laparoscopies, only a small fraction were confirmed as bladder endometriosis. On the other hand, when you look specifically at people undergoing surgery for deep endometriosis, urinary tract involvement (bladder and/or ureter) becomes much more relevant; an expert-center cohort of deep endometriosis surgeries found urinary-tract lesions in roughly 1 in 10 surgical patients meeting their criteria.

In plain terms: bladder endometriosis is not the most common explanation for urinary symptoms—but when deep endometriosis is on the table, it becomes important to actively look for it.

Symptoms patients notice: what’s typical—and what’s not required

Many patients expect bladder endometriosis to cause obvious urinary signs like blood in the urine. But research and clinical reports repeatedly show that hematuria may be absent, even when disease is present.

Symptoms can include:

• Pain with urination (dysuria), bladder pressure, or suprapubic pain
• Urinary frequency/urgency (sometimes persistent even after treatment)
• Pelvic pain that may worsen cyclically
• Pain with sex (dyspareunia)—often because bladder disease coexists with deep endometriosis elsewhere

One detailed clinical case report illustrates a common pattern: severe pelvic pain plus urinary pain, normal routine urine testing, and delayed recognition until targeted pelvic imaging (ultrasound and MRI) made bladder involvement more likely.

How is bladder endometriosis diagnosed? (And why “normal urine tests” don’t rule it out)

Diagnosis usually relies on a combination of history, pelvic exam, targeted imaging, and sometimes cystoscopy, with final confirmation often coming from surgery and pathology.

Imaging: ultrasound and MRI are often complementary

Across studies, transvaginal ultrasound (TVUS) is frequently used first, especially in endometriosis-focused centers. It can sometimes identify a bladder nodule preoperatively, but it’s not perfect—results depend heavily on equipment and the sonographer’s endometriosis expertise. MRI is commonly used to better map disease depth and surrounding anatomy, particularly when surgical planning is needed.

A systematic review discussing surgical planning for bladder endometriosis reported that both ultrasound and MRI can be quite specific when positive, but sensitivity is modest, meaning imaging can miss some cases. Practically, that means a “normal” scan doesn’t always end the conversation if symptoms and the broader endometriosis picture still fit.

Checking the kidneys/ureters matters more than many patients realize

Bladder endometriosis sometimes coexists with ureter involvement, and ureter disease can be silent until it causes blockage and hydronephrosis (swelling of the kidney). In surgical cohorts of urinary-tract endometriosis, ureter procedures were common, highlighting why many centers include some form of upper-tract evaluation (often kidney ultrasound) when urinary tract endometriosis is suspected.

Cystoscopy: helpful in select cases, not always mandatory

Cystoscopy (looking inside the bladder) can be useful when lesions are suspected near the bladder lining, when there is bleeding, or to clarify lesion location relative to the ureter openings. But bladder endometriosis can be primarily within the bladder wall, so cystoscopy may or may not show classic findings.

Treatment options: medical therapy vs surgery

Medical (hormonal) therapy: often helps symptoms, but may not be enough

Hormonal treatment (such as progestins or GnRH analogs) may reduce inflammation and pain. Real-world reports show it can provide temporary or partial relief, but symptoms can return when medication is stopped or becomes less effective. Deep bladder nodules may also have a fibrotic/desmoplastic component, which can make them less responsive.

Medical therapy may be a reasonable first step when:

• Symptoms are manageable
• Imaging suggests limited disease
• Fertility plans or surgical risk make conservative care preferable
• There’s no concern for ureter obstruction or kidney risk

Surgery: the main “definitive” option when symptoms persist or anatomy is threatened

When pain persists despite medical therapy, or when lesion size/location raises concern for progression or urinary-tract obstruction, surgery becomes a common next step.

The core surgical goal is complete excision of the bladder lesion while protecting the ureters. Techniques generally fall into two categories:

1. Bladder shaving (partial-thickness excision)

Used when the lesion does not appear to involve the full bladder wall thickness. In one single-center series, shaving was presented as effective with very low complication rates in that experience, though numbers were small.

2. Partial cystectomy (full-thickness resection with bladder repair)

Used when disease involves deeper layers or approaches/enters the mucosa. This is more invasive than shaving but can be necessary for complete removal. In the same single-center experience, partial cystectomy was commonly performed and most followed patients reported symptom improvement—especially urinary pain.

A key point echoed across surgical literature: transurethral resection (TUR) alone is generally discouraged as a stand-alone “cure,” because bladder endometriosis often grows from outside the bladder inward, making it hard to remove fully from inside the bladder.

Laparoscopy vs robotic surgery vs open surgery: what should patients expect?

Most modern expert centers aim for minimally invasive surgery (laparoscopic or robotic), and large surgical cohorts show that the majority of urinary-tract endometriosis cases can be managed this way, with open conversion reserved for select situations (for example, severe bleeding or very complex anatomy).

Robotic surgery is increasingly discussed because it may help with:

• Fine dissection in tight spaces
• Suturing the bladder repair
• Operating near the trigone and ureter openings (high-stakes anatomy)

However, a systematic review of robotic surgery for bladder endometriosis found no randomized trials, and much of the published evidence is case reports and small retrospective comparisons. Overall, robotics appears feasible, but claims of clearly better outcomes than standard laparoscopy should be viewed as promising but not proven. In practice, surgeon experience and the center’s multidisciplinary setup often matter more than the platform.

Outcomes: how likely is symptom relief, and how fast?

Across studies, the direction is consistent: most patients report meaningful symptom improvement after surgery, especially for urinary pain. In one center’s follow-up of bladder endometriosis surgeries, nearly all followed patients reported improvement overall, and urinary pain (dysuria) improved in all followed patients who had it.

How quickly might you feel better?

• Some improvement can be early, but bladder healing takes time.
• In an expert-center cohort of urinary-tract endometriosis surgery (including many ureter cases), most patients reported not needing analgesics by 1 month, suggesting substantial short-term pain relief is possible—though individual recovery varies depending on the extent of surgery (bladder-only vs bladder + bowel/ureter procedures).

Risks and side effects: what are the real trade-offs?

It’s important to separate two realities:

1. These surgeries can be very effective, and many patients feel significantly better.
2. They are not “minor” surgeries, especially when disease is deep or close to the ureters.

Potential risks include:

• Bleeding (occasionally requiring return to the operating room)
• Bladder leakage or fistula (uncommon, but a serious complication)
• Ureter narrowing/stenosis or injury (may require urologic intervention)
• Temporary urinary catheter after full-thickness bladder surgery
• Persistent urinary frequency or bladder sensitivity in a subset of patients

In a deep endometriosis expert-center cohort that included many ureter operations, complications were common overall (reflecting how complex these combined surgeries can be), and a meaningful minority required reintervention. Prior endometriosis surgery was associated with higher serious-complication rates in that cohort—useful to know if you are considering repeat surgery.

Who benefits most from referral centers and multidisciplinary care?

The combined evidence strongly supports referral to an endometriosis-focused center when:

• Imaging suggests bladder deep endometriosis, especially near the trigone
• There is suspected ureter involvement or hydronephrosis risk
• You’ve had prior endometriosis surgeries
• You may need combined procedures (bowel + bladder/ureter)
• Your surgeon anticipates possible ureteral stenting or ureter reimplantation (ureteroneocystostomy)

Even in studies where gynecologic teams performed most surgeries, authors consistently emphasize involving urology when lesion location is “unfavorable” or ureter reconstruction might be necessary.

Practical takeaways (to bring to your next appointment)

• Ask your clinician to clarify whether your symptoms could fit bladder endometriosis even if urine cultures are normal and there’s no blood in the urine.
• If bladder endometriosis is suspected, discuss targeted TVUS by an endometriosis-experienced sonographer and whether MRI would change planning.
• Make sure someone has assessed kidney/ureter risk (often kidney ultrasound, sometimes additional imaging), especially if there’s any concern for ureter involvement.
• If surgery is on the table, ask whether your case should be handled in a multidisciplinary setting (gynecology + urology), and what approach is planned (shaving vs partial cystectomy).
• Clarify recovery details: catheter duration, bladder repair, and what symptoms should trigger urgent follow-up (fever, flank pain, inability to urinate, heavy bleeding).

What we still don’t know (and why results can vary)

Even though the overall picture supports surgery as an effective option for many patients, there are important uncertainties:

• Comparative evidence is limited. For robotic vs laparoscopic approaches, high-quality randomized trials are lacking, and many publications are small retrospective series or case reports.
• Long-term outcomes and recurrence rates are hard to pin down. Some cohorts report low recurrence in follow-up, but follow-up duration can be short and definitions vary.
• Symptom improvement doesn’t always equal “bladder normal.” Some patients may have persistent frequency/urgency or overlapping bladder pain syndromes even after successful excision—especially if there is long-standing sensitization or coexisting pelvic floor dysfunction.
• Disease extent matters. Outcomes and risks differ greatly between isolated bladder lesions and cases combined with ureter or bowel deep endometriosis, which is why individualized planning is essential.

Bladder endometriosis is treatable, and many patients improve substantially—especially when diagnosis is deliberate and surgery (if needed) is planned with the right imaging and the right team.