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Suspected deep endometriosis involving the urinary tract — MSRA MCQ

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HardHematuriaSuspected deep endometriosis involving the urinary tractMSRA

A 36-year-old woman presents with 9 months of severe dysmenorrhoea, deep dyspareunia and episodic dysuria. During each of the last 4 menstrual periods, she has had 1–2 days of visible haematuria occurring only while menstruating. She has no loin pain, fever, urinary frequency outside menstruation, weight loss or intermenstrual bleeding. During her most recent episode, urine dipstick showed 3+ blood, with negative nitrites and leucocytes. Three midstream urine cultures, including one taken before menstruation, showed no significant growth. eGFR is 92 mL/min/1.73 m², urine ACR is 1.4 mg/mmol and full blood count is normal. A pregnancy test is negative. Her symptoms significantly impair work and sexual relationships despite regular NSAID use. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Arrange a transvaginal ultrasound scan and refer to a specialist endometriosis service

Explanation lettering: D = shown as A · A = shown as D

The cyclical association of dysuria and visible haematuria with menstruation, alongside severe dysmenorrhoea and deep dyspareunia, should prompt suspicion of endometriosis, including possible deep disease involving the bladder or ureter. Repeated negative urine cultures and absence of pyuria make recurrent bacterial cystitis unlikely; normal ACR and renal function also make an intrinsic renal cause less likely. NICE recommends transvaginal ultrasound for all people with suspected endometriosis, including to identify deep endometriosis involving the bladder or ureter. It also recommends referral to a specialist endometriosis service when deep endometriosis involving the bladder or ureter is suspected. Investigation and referral should proceed in parallel. A is inappropriate because she is below the NICE age threshold for suspected-cancer-pathway referral based on visible haematuria alone, and the strongly menstrual pattern suggests a gynaecological cause. B disregards repeated sterile cultures. D is incorrect because CA125 should not be used to diagnose endometriosis, and pelvic MRI for suspected deep disease should be planned and interpreted by specialist imaging services. E is premature: ultrasound is first-line, and any laparoscopy should be considered within an appropriate specialist pathway rather than as the initial GP referral.

Reference: NICE NG73: Endometriosis: diagnosis and management — Recommendations (2017; amended 2024, updated 2026) — https://www.nice.org.uk/guidance/ng73/chapter/Recommendations NICE NG73: Endometriosis: diagnosis and management — Ultrasound and referral recommendations (2017; amended 2024, updated 2026) — https://www.nice.org.uk/guidance/ng73/chapter/Recommendations NICE NG73: Endometriosis: diagnosis and management — Referral to specialist endometriosis services (2017; amended 2024, updated 2026) — https://www.nice.org.uk/guidance/ng73/chapter/Recommendations