Submitted:
29 May 2026
Posted:
01 June 2026
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Abstract
Background: Endometriosis is a chronic inflammatory disease commonly associated with pelvic pain and infertility. Increasing evidence suggests that women with endometriosis may also experience lower urinary tract symptoms (LUTS), even without direct urinary tract involvement. Aim: This study aimed to evaluate LUTS in women with endometriosis and determine whether these symptoms are associated with urethral ultrasonographic parameters or the localization of endometriotic lesions. Materials and Methods: This prospective case–control study included 166 women aged 17–49 years: 83 with confirmed endometriosis and 83 controls without endometriosis. Endometriosis was confirmed laparoscopically, except in patients with cesarean scar endometriosis, where diagnosis was based on imaging and histopathological confirmation. Clinical assessment included standardized questionnaires and transvaginal pelvic floor sonography. Urinary symptoms were assessed using the Urogenital Distress Inventory short form (UDI-6). Urethral length and mobility were evaluated at rest, during contraction, and during the Valsalva maneuver. Results: Women with endometriosis demonstrated significantly higher total UDI scores than controls (27.8 vs. 16.7; p = 0.002), with the greatest differences in pain/discomfort and urine leakage symptoms. No significant differences in urethral anatomy were observed. Among symptomatic patients, urethral mobility during Valsalva was significantly lower in the endometriosis group (p = 0.041). Lesion localization was not associated with symptom severity. Conclusions: Women with endometriosis experience a greater burden of LUTS, particularly bladder storage dysfunction and pain, likely related to functional and neuroinflammatory mechanisms rather than structural abnormalities.
Keywords:
endometriosis
; pelvic floor ultrasonography
; lower urinary tract symptoms
1. Introduction
Endometriosis is a chronic, estrogen-dependent inflammatory disease affecting approximately 10% of women of reproductive age, with symptom onset occurring primarily during the reproductive years [1]. The most common clinical manifestations include dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility, all of which significantly impair quality of life [1,6,7,8]. In addition to gynecological symptoms, women with endometriosis frequently present with coexisting conditions such as depression, anxiety disorders, migraine, irritable bowel syndrome, and interstitial cystitis/painful bladder syndrome [2,3,4,5].
Increasing evidence suggests that lower urinary tract symptoms (LUTS) are also common in women with endometriosis, even in the absence of overt urinary tract involvement [9,10,11,12]. Reported urinary complaints include urgency, dysuria, urinary frequency, nocturia, and a sensation of incomplete bladder emptying [9,10,11,12]. These symptoms may substantially contribute to disease burden and reduced quality of life, yet they remain underrecognized in routine gynecological care [13,14].
Previous studies suggest that urinary dysfunction in endometriosis may differ from classical pelvic floor disorders. Gabriel et al. demonstrated that women with endometriosis more frequently reported urinary urgency, difficulty voiding, incomplete bladder emptying, and dysuria, whereas no significant association was found with stress urinary incontinence symptoms [10,12]. Similar observations have been reported in studies focusing on urinary tract endometriosis and deep infiltrating disease, suggesting that bladder storage dysfunction and altered sensory symptoms may be more relevant than mechanical stress-related incontinence [9,11,15,16,17].
However, the mechanisms underlying LUTS in women with endometriosis remain poorly understood. It is unclear whether these symptoms reflect true pelvic floor dysfunction with altered urethral support and mobility, or whether they are primarily functional manifestations related to chronic pelvic inflammation, neuroangiogenesis, visceral hypersensitivity, cross-organ sensitization, and central pain sensitization associated with endometriosis [17,18,19,20].
Although urinary symptoms in endometriosis have been increasingly recognized, objective assessment of urethral anatomy and mobility in this population remains limited. Moreover, it is not known whether the severity of urinary symptoms is influenced by the anatomical localization of endometriotic lesions.
Therefore, the aim of this study was to determine whether women with laparoscopically confirmed endometriosis experience a greater burden of lower urinary tract symptoms compared with controls, and whether these symptoms are associated with objective urethral ultrasonographic parameters or with the localization of endometriotic lesions.
2. Materials and Methods
2.1. Study Design
This prospective study was conducted at the Department of Reproduction and Gynecology, Gynecological and Obstetric Clinical Hospital of Poznan University of Medical Sciences, Poznań, Poland. Written informed consent was obtained from all participants, and the study protocol was approved by the Ethics Committee of the Poznan University of Medical Sciences (12/26). All procedures were performed in accordance with relevant guidelines and regulations.
2.2. Characteristics of the Study Group
A total of 166 women aged 17–49 years were enrolled in the study, including 83 women with confirmed endometriosis and 83 controls without evidence of endometriosis following surgical evaluation.
All participants presented with clinical symptoms suggestive of endometriosis, including dysmenorrhea, chronic pelvic pain, and dyspareunia. Women with suspected pelvic endometriosis underwent laparoscopic evaluation according to clinical indications, whereas patients with suspected cesarean scar endometriosis underwent surgical excision of the lesion.
The inclusion criteria for the endometriosis group were:
- surgically confirmed endometriosis established laparoscopically in patients with pelvic disease or histopathologically following excision in patients with cesarean scar endometriosis,
- clinical symptoms suggestive of endometriosis, including dysmenorrhea, pelvic pain, and dyspareunia.
Diagnosis of cesarean scar endometriosis was based on characteristic clinical history, dedicated ultrasound findings, and histopathological confirmation after lesion excision.
2.3. Clinical Assessment
A detailed medical history was obtained from all participants using a standardized questionnaire developed by the Polish Society of Gynecologists and Obstetricians (PTGiP). The questionnaire included demographic and anthropometric characteristics, gynecological and obstetric history, menstrual characteristics, previous surgical procedures, and symptoms potentially associated with endometriosis.
Pain-related symptoms, including dysmenorrhea, chronic pelvic pain, dyspareunia, urinary complaints, and gastrointestinal symptoms, were graded according to patient-reported severity.
Validated questionnaires were used to assess urinary symptoms, including the Urogenital Distress Inventory short form (UDI-6).
2.4. Ultrasonographic Assessment
Before surgery, all patients underwent comprehensive transvaginal ultrasound examination dedicated to endometriosis assessment.
Sonographic evaluation was performed according to internationally accepted standardized protocols, including the International Deep Endometriosis Analysis (IDEA) consensus and the Morphological Uterus Sonographic Assessment (MUSA) criteria. The examination included systematic assessment of pelvic anatomy, localization of ovarian and extraovarian endometriotic lesions, evaluation of the anterior and posterior pelvic compartments, assessment of organ mobility using the sliding sign, and screening for deep infiltrating endometriosis.
Pelvic floor sonography using transvaginal ultrasound was additionally performed to assess urethral morphology and mobility. Measurements included urethral length and urethral mobility at rest, during pelvic floor muscle contraction, and during the Valsalva maneuver.
Urethral mobility was assessed dynamically relative to the inferior margin of the symphysis pubis. Negative values of urethral mobility reflected posterior displacement of the urethra during dynamic maneuvers.
Due to the non-normal distribution of the ultrasonographic parameters, results were presented as medians and ranges or interquartile ranges, as appropriate.
2.5. Statistical Analysis
Statistical analysis was performed using SigmaPlot version 11.0 (Systat Software, USA). A p-value <0.05 was considered statistically significant.
Due to the non-normal distribution of the data, non-parametric tests were used. Quantitative variables were compared using the Mann–Whitney U test, whereas qualitative variables were analyzed using Fisher’s exact test or the chi-square test.
Correlation analysis was performed using Spearman rank correlation coefficients.
To identify factors associated with urinary symptom severity, linear regression analysis was performed using total UDI score as the dependent variable. Independent variables included age, BMI, endometriosis status, urethral length, history of vaginal delivery, and cesarean section.
3. Results
Among the 158 women undergoing laparoscopy, endometriosis was confirmed intraoperatively in 75 patients, whereas no evidence of endometriosis was identified in 83 women, who constituted the control group. Additionally, 8 women were diagnosed with cesarean scar endometriosis based on characteristic imaging findings and histopathological confirmation following lesion excision.
Within the endometriosis group, adenomyosis was identified in 6 patients, endometriotic lesions involving the Retzius space in 18 patients, and peritoneal endometriosis in other pelvic locations in the remaining 51 patients.
3.1. Baseline Characteristics
Baseline clinical and obstetric characteristics are presented in Table 1.
Women with endometriosis were significantly younger compared with controls (30.0 [24.0–35.0] vs 32.0 [29.0–38.8] years; p=0.013). Body weight was also lower in the endometriosis group (61.0 [55.5–69.5] vs 65.5 [57.2–77.5] kg; p=0.042), whereas no significant differences were observed regarding BMI or height. Women with endometriosis were more frequently nulliparous (72.3% vs 55.4%; p=0.036), while multiparity was more common in controls (44.6% vs 27.7%; p=0.035). No significant differences were observed regarding cesarean section history, vaginal delivery rates, or miscarriage prevalence.
3.2. Lower Urinary Tract Symptoms and Urethral Ultrasonographic Parameters
Results are presented in Table 2.
Women with endometriosis demonstrated significantly higher total UDI scores compared with controls (27.8 [11.1–33.3] vs 16.7 [5.6–22.2]; p=0.002).
Item-level analysis revealed significantly higher scores for pain/discomfort symptoms (UDI-6) and urine leakage drops (UDI-4) in the endometriosis group. No significant differences were observed for the remaining questionnaire items.
No significant differences were found regarding urethral length or urethral mobility between the groups.
3.3. Regression Analysis
Linear regression analysis demonstrated a significant association between previous cesarean section and higher UDI scores (β = 24.85; 95% CI: 4.69–45.02; p=0.017), Table 3.
The remaining variables, including age, BMI, and endometriosis status, were not independently associated with urinary symptom severity.
The model reached statistical significance (p=0.049) with moderate explanatory capacity (R2=0.168).
3.4. Influence of Endometriosis Localization
No significant association was found between lesion localization and total UDI scores, urethral length, or urethral mobility parameters.
Similarly, patients with bladder endometriosis did not demonstrate greater urinary symptom severity compared with women with other lesion locations.
Table 4.
Association between UDI6 and urethral parameters (urethral length [mm], urethral mobility during constriction [mm], and urethral mobility during Valsalva [mm]) and the presence of endometriotic lesions. 0- peritoneal endometriosis 1- peritoneal endometriosis in the Retzius space 2- Adenomiosis 3- endometriotic lesion in a cesarean scar.
Table 4.
Association between UDI6 and urethral parameters (urethral length [mm], urethral mobility during constriction [mm], and urethral mobility during Valsalva [mm]) and the presence of endometriotic lesions. 0- peritoneal endometriosis 1- peritoneal endometriosis in the Retzius space 2- Adenomiosis 3- endometriotic lesion in a cesarean scar.
| Endometriotic lesion | 0; (n=40) | 1; (n=18) | 2; (n=6) | 3; (n=8) | p-value Kruskal – Wallis ANOVA on ranks |
|---|---|---|---|---|---|
| Mediana (min.-max.) | |||||
| UDI6 | 2 (0-3) | 1 (0-3) | 2 (0-3) | 1 (0-3) | 0.399039 |
| Length of the urethra [mm] | 34 (20-41) | 32 (27 -41) | 37 (25-39) | 31 (27-38) | 0.322415 |
| Urethral mobility (constriction) [mm] | 2 (-5 - 10) | 2 (-5 - 11) | 1 (0-3) | 2 (-2 - 6) | 0.779239 |
| Urethral mobility (Valsalva) [mm] | -8 (-58 - 4) | -11 (-58 - (-4)) | -5 (-14 - (-3)) | -11 (-18 (-6)) | 0.058179 |
3.5. Symptomatic Patients Analysis
Additional analysis was performed exclusively in symptomatic patients (UDI ≥1), including 71 women with endometriosis and 71 controls.
- Ultrasonographic urethral parameters
No significant differences were observed regarding urethral length or urethral mobility during contraction. However, women with endometriosis demonstrated significantly lower urethral mobility during the Valsalva maneuver compared with controls (5.0 [3.0–8.0] vs 7.0 [4.0–10.0]; p=0.041), Table 5.
- 2.
- Correlations between LUTS and ultrasonographic parameters
Correlation analysis demonstrated weak but significant associations between selected urinary symptoms and urethral ultrasonographic parameters.
In women with endometriosis, stress urinary incontinence symptoms positively correlated with urethral mobility during the Valsalva maneuver (rho = 0.30; p=0.013). Furthermore, positive correlations were observed between urinary frequency (UDI-1) and urethral length (rho = 0.27; p=0.023), as well as between symptoms of urine leakage drops (UDI-4) and urethral length (rho = 0.25; p=0.035).
No significant correlations were observed in the control group.
4. Discussion
The present study demonstrated that women with laparoscopically confirmed endometriosis had significantly higher total UDI scores compared with women without endometriosis, indicating a greater burden of lower urinary tract symptoms. The most pronounced differences concerned pain/discomfort symptoms and urine leakage drops, whereas no significant differences were observed in stress urinary incontinence symptoms or urethral anatomical parameters.
These findings are consistent with previous reports suggesting that women with endometriosis more frequently experience irritative and bladder storage symptoms rather than classical stress-related urinary complaints. Gabriel et al. demonstrated that patients with endometriosis more frequently reported urinary urgency, difficulty voiding, incomplete bladder emptying, and dysuria, whereas no significant association was observed for stress urinary incontinence symptoms [10,12]. Similar observations have been reported in studies focusing on urinary tract endometriosis and deep infiltrating disease [11,15,16,17].
Importantly, our study did not demonstrate significant differences in urethral length or urethral mobility between women with and without endometriosis. Furthermore, no association was found between urethral ultrasonographic parameters and the localization of endometriotic lesions. These findings suggest that urinary symptoms in women with endometriosis may not primarily result from structural pelvic floor abnormalities or impaired urethral support.
Interestingly, additional analysis restricted to symptomatic patients (UDI ≥1) revealed significantly lower urethral mobility during the Valsalva maneuver in women with endometriosis compared with symptomatic controls. This finding was not observed in the overall study population, suggesting that subtle alterations in pelvic floor dynamics may become apparent only in women who already present with clinically relevant urinary symptoms. Reduced urethral mobility in symptomatic patients may reflect increased pelvic floor muscle tone, chronic pelvic floor guarding, or altered neuromuscular function associated with chronic pelvic pain rather than classical urethral hypermobility observed in stress urinary incontinence. These observations support the hypothesis that LUTS in endometriosis may be linked more closely to functional pelvic floor dysfunction and pain sensitization mechanisms than to overt anatomical abnormalities.
One possible explanation for the observed findings is pelvic floor overactivity associated with chronic pelvic pain. Women with endometriosis frequently demonstrate increased pelvic floor muscle tone and myofascial dysfunction, which may contribute to urinary urgency, pain, and bladder hypersensitivity despite the absence of major anatomical abnormalities [20,21]. Reduced urethral mobility observed in symptomatic patients with endometriosis may therefore reflect chronic pelvic floor guarding and altered neuromuscular function rather than classical pelvic floor weakness.
Another important mechanism may involve neuroinflammatory and central sensitization processes. Endometriosis is characterized by chronic inflammation, neuroangiogenesis, and increased density of sensory and autonomic nerve fibers within endometriotic lesions [17,18]. Chronic pelvic inflammation may induce cross-organ sensitization between pelvic organs, including the bladder, bowel, and reproductive tract [19,22]. This mechanism may explain why urinary frequency, bladder discomfort, and urgency-related symptoms are common even in women without direct bladder infiltration.
Interestingly, no significant relationship was observed between lesion localization and urinary symptom severity. Patients with bladder endometriosis did not demonstrate greater UDI scores compared with women with other lesion locations. These findings support the hypothesis that LUTS in endometriosis may be associated more strongly with systemic inflammatory and functional mechanisms than with local anatomical lesion burden [10,12,22,23,24].
An interesting observation of the present study was the association between cesarean section history and higher UDI scores in regression analysis. Women with previous cesarean section demonstrated significantly higher symptom burden. Although this finding should be interpreted cautiously because of the relatively small sample size, it may suggest a possible contribution of postoperative adhesions, scar-related pain, altered pelvic innervation, or cesarean scar endometriosis to urinary symptom development [25,26].
Importantly, although women with endometriosis demonstrated significantly higher UDI scores in univariate analysis, the association did not remain statistically significant in the multivariable regression model. This finding may be related to the relatively limited sample size, overlap between obstetric and clinical variables, and heterogeneity of urinary symptom presentation.
From a clinical perspective, the present findings emphasize the importance of routinely assessing urinary symptoms in women with endometriosis, even in the absence of overt urinary tract involvement. Symptoms such as urinary frequency, urgency, dysuria, and incomplete bladder emptying may significantly impair quality of life and remain underrecognized in routine gynecological practice. The use of validated questionnaires such as UDI-6 may facilitate early identification of patients requiring further urogynaecological evaluation and individualized multidisciplinary management.
The strengths of the present study include its prospective design, inclusion of women with laparoscopically confirmed endometriosis, and the combination of validated symptom questionnaires with objective pelvic floor ultrasonography.
Several limitations should also be acknowledged. First, the sample size was relatively limited, particularly in subgroup analyses concerning lesion localization. Second, urodynamic studies were not performed, and therefore functional bladder abnormalities such as detrusor overactivity could not be directly assessed. Third, detailed information regarding hormonal treatment, pain severity, and endometriosis staging was limited and may influence urinary symptom severity. Finally, the cross-sectional design does not allow causal interpretation.
Future studies should include larger cohorts, detailed pain phenotype assessment, urodynamic evaluation, and longitudinal follow-up after surgical or hormonal treatment to better characterize the mechanisms underlying LUTS in women with endometriosis.
5. Conclusions
- Women with endometriosis demonstrated a significantly greater burden of lower urinary tract symptoms, particularly symptoms related to bladder discomfort and pain.
- In the overall study population, urinary symptoms were not associated with significant differences in urethral anatomy or lesion localization. However, symptomatic women with endometriosis demonstrated reduced urethral mobility during the Valsalva maneuver, suggesting the presence of subtle functional pelvic floor alterations.
- The findings support the hypothesis that neuroinflammatory mechanisms, chronic pelvic pain, and functional pelvic floor dysfunction may contribute substantially to lower urinary tract symptoms in women with endometriosis.
- Routine assessment of lower urinary tract symptoms should be considered in the multidisciplinary management of women with endometriosis.Women with endometriosis demonstrated a significantly greater burden of lower urinary tract symptoms, particularly symptoms related to bladder storage dysfunction and pain.
Author Contributions
Conceptualization, K.T..; methodology, K.T., M.Kę..; formal analysis, K.T. and M.K..; investigation, K.T., M.K., K.K., and M.A.; data curation, K.T., M.K., K.K.,M.A.; writing—original draft preparation, K.T.; writing—review and editing, M.K., M.A., K.K., and M.Kę.; visualization, K.T.; supervision, M.Kę. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Poznan University of Medical Sciences (approval no. 12/26).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data presented in this study are available from the corresponding author upon reasonable request.
Acknowledgments
Not applicable.
Conflicts of Interest
The authors declare no conflict of interest.
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Table 1.
Baseline characteristic of the study group.
| Variable | Endometriosis group | Control group | p - Mann-Whitney rank sum test |
|---|---|---|---|
| Age (years) | 30.0 (24.0–35.0) | 32.0 (29.0–38.8) | 0,013* |
| Body weight (kg) | 61.0 (55.5–69.5) | 65.5 (57.2–77.5) | 0.042* |
| Height (cm) | 168.0 (164.0–172.0) | 167.0 (162.0–170.0) | 0.284* |
| BMI (kg/m2) | 21.5 (19.8–24.0) | 23.0 (20.5–26.5) | 0.091* |
| Nulliparous | 60/83 (72,3%) | 46/83 (55,4%) | 0,036** |
| Multiparous | 23/83 (27,7%) | 37/83 (44,6%) | 0,035** |
| Natural births | 19/23 (82,6%) | 32/40 (80,0%) | 1,000** |
| Cesarean section | 4/23 (17,4%) | 8/40 (20,0%) | 1,000** |
| Miscarriages | 8/83 (9,6%) | 9/83 (10,8%) | 1,000** |
Table 2.
UDI-6 results and urethral ultrasonographic parameters in women with endometriosis and controls.
Table 2.
UDI-6 results and urethral ultrasonographic parameters in women with endometriosis and controls.
| Variable | Endometriosis group | Control group | p-value |
|---|---|---|---|
| Total UDI score | 27.8 (11.1–33.3) | 16.7 (5.6–22.2) | 0.002 |
| UDI-1 | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 0.861 |
| UDI-2 | 0.0 (0.0–1.0) | 0.0 (0.0–0.0) | 0.114 |
| UDI-3 | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.943 |
| UDI-4 | 0.0 (0.0–1.0) | 0.0 (0.0–0.0) | <0.001 |
| UDI-5 | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.239 |
| UDI-6 | 1.0 (0.0–2.0) | 0.0 (0.0–1.0) | <0.001 |
| Urethral length [mm] | 34.0 (30.8–36.0) | 33.5 (29.0–36.0) | 0.832 |
| Urethral mobility during contraction [mm] | 2.0 (-5.0 to 11.0) | 2.0 (-15.0 to 14.0) | 0.254 |
| Urethral mobility during Valsalva maneuver [mm] | -8.0 (-54.0 to 4.0) | -9.0 (-35.0 to 7.0) | 0.321 |
Data are presented as median (interquartile range) or median (range). Comparisons were performed using the Mann–Whitney U test.
Table 3.
Linear regression model for the UDI score.
| Variable | β | 95% CI | p- |
|---|---|---|---|
| CC | 24.85 | (4.69; 45.02) | 0.017 |
| Age | 0.38 | (-0.37; 1.14) | 0.310 |
| BMI | -0.22 | (-1.32; 0.88) | 0.690 |
| Endometriosis group | -7.08 | (-18.67; 4.51) | 0.226 |
Table 5.
Comparison of ultrasonographic urethral parameters in symptomatic patients with endometriosis and the control group.
Table 5.
Comparison of ultrasonographic urethral parameters in symptomatic patients with endometriosis and the control group.
| Parameter | Endometriosis | Control group | p |
|---|---|---|---|
| Urethral length – resting | 27.0 (24.0–30.0) | 27.0 (25.0–30.0) | 0.701 |
| Urethral length – contraction | 26.0 (23.0–29.0) | 27.0 (24.0–30.0) | 0.446 |
| Urethral length – Valsalva maneuver | 25.0 (22.0–28.0) | 26.0 (23.0–29.0) | 0.391 |
| Mobility – contraction | 2.0 (1.0–4.0) | 3.0 (1.0–5.0) | 0.172 |
| Mobility – Valsalva maneuver | 5.0 (3.0–8.0) | 7.0 (4.0–10.0) | 0.041 |
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