Endocervicosis of the urinary bladder is a very rare benign condition characterized by mucinous endocervical epithelium within the detrusor muscle of the bladder [3
]. It is believed to be a lesion of Müllerian origin, arising from Müllerian rests after their differentiation to intracervical tissue [4
]. This hypothesis has been supported by the following lines of evidence: main occurrence in women of reproductive age, location in the posterior bladder wall and coexistence with endometriosis and endosalpingiosis [5
]. When immunohistochemical phenotype of a case of endocervicosis was compared with four normal uterine endocervices, endocervicosis glands displayed stronger expression of uterus reactive antibodies such as HBME-1, estrogen receptor (ER) and progesterone receptors (PR) [7
]. These findings confirmed the endocervical nature of endocervicosis and constituted further arguments for the Müllerian origin hypothesis. The aetiology and pathogenesis of this entity remain unknown. There is evidence to suggest that it is hormone and age-related. However, although it is thought to be seen in women of child bearing age [8
] in our case it has been diagnosed in a post menopausal woman; the occurrence in post menopausal women is intriguing and possibly disconnects its aetiology and pathogenesis from the hormonal mechanisms.
Among several predisposing factors proposed to have an association with the development of endocervicosis, history of previous Caesarean section seems to be the most questionable [11
]. It is however interesting that in our case, as in all previous reports, a background of Caesarean sections was present [1
]. On the other hand, since the proliferative index of endocervicosis cells was found to be within the normal range established for endocervical glands [7
], it is plausible that there is no evidence of a distinct proliferative aetiopathogenetical background. Therefore, a background of uterine endocervical migration during previous surgery cannot be excluded.
To the best of our knowledge, there are less than twenty five cases reported so far. Although it is usually an incidental histologic finding, it may cause non-specific symptoms such as urinary complaints and pelvic pain, while rare cases involving pelvic nodes have been reported in the past [13
]. Due to nonspecific symptoms and clinical presentation, the differential diagnosis of endocervicosis is difficult: since it is commonly associated with a mass, it may be confused with a malignant tumor and therefore it must be clinically distinguished from an invasive carcinoma. Cystoscopy, which is still the gold standard investigation for the differential diagnosis of bladder cancer, invariably shows a mural lesion covered by intact epithelium. The definitive diagnosis relies on careful histopathological examination of the resected tissues. The histological differential diagnosis of endocervicosis includes several benign and malignant conditions such as cystitis glandularis, cystitis cystica nephrogenic adenoma and well-differentiated adenocarcinoma of the bladder [3
]. The final pathological diagnosis is based on architectural pattern and cytological features of the lesion.
According to Rodriguez et al
, partial cystectomy represents the best therapeutic option for patients with endocervicosis of the bladder [12
]. A successful laparoscopic excision of endocervicosis of the urinary bladder has also been reported [14
]. Less invasive therapeutic approaches have also been suggested [13
], while other authors, due to the benign condition of the lesion, proposed an even less invasive approach, rejecting the complete transurethral resection [15
]. According to the author's point of view, symptomatic endocervicosis can be managed with complete transurethral resection in order to reduce the burden of symptoms.
Fewer than 25 cases of endocervicosis of the bladder have been reported and therefore the natural history of the disease is unknown. However, there is no documented case of recurrence in a 14-year follow-up interval [2
]. According to the perspective of the authors, the rarity of the condition and the sparse information on long term follow up, dictates that the follow-up should be continued indefinitely.