Endometriosis is an extremely underdiagnosed condition which can complicate the presentation of patients who seek care from urologists. By using validated questionnaires on clinic intake, it may become easier to differentiate patients whose underlying diagnosis is endometriosis and direct them to the appropriate providers for specialized care. It is hypothesized that there may be a difference in pelvic symptoms and psychological distress scores between patients with and without endometriosis.

A prospective database of 262 new patients to a Female Pelvic Medicine and Reconstructive Surgery (FPMRS) subspecialty clinic was queried for patients with diagnosed endometriosis. Male and transgender female patients were excluded from analysis. The PHQ 4 (Anxiety and depression screening tool for patients with serious illnesses) and PFDI 20 (Pelvic Floor Disability Index – composed of UDI 6 [Urinary distress Inventory], CRAD 8 [Colorectal anal distress inventory], POPDI 6 [Pelvic organ prolapse distress inventory]) validated questionnaire responses were analyzed between those with and without endometriosis using unpaired t-tests.

177 patients without endometriosis and 44 with endometriosis were included. Of the endometriosis patients, 52% had a score greater than 25 (i.e. clinically significant symptoms) on the CRAD subsection, 77% on the UDI subsection, and 45% on the POPDI subsection. Of participants without endometriosis, those numbers were 25%, 55%, and 44%, respectively. On unpaired t-tests, there were no significant differences between scores on the PHQ 4 (p = 0.485), UDI 6 (p = 0.375), or POPDI 6 (p = 0.531) questionnaires. There was a significant difference between CRAD8 scores (p = 0.025).

The odds of endometriosis was 2.8 (95% CI 1.4-5.6) in the presence of pelvic pain, (compared to the absence of pelvic pain), 3.7 (95% CI 1.6-8.9) in the presence of urinary symptoms (compared to the absence of urinary symptoms), 2.5 (95% 1.3-4.9) in the presence of bowel symptoms (compared to absence of bowel symptoms), 0.85 (95% CI 0.4-1.8) in the presence of sexual dysfunction (compared to the absence of sexual dysfunction), 2.8 (95% CI 1.4-5.8) in the presence of prolapse symptoms (compared to absence of prolapse symptoms), and 3.9 (95%CI 1.6-9.2) in the presence of autonomic symptoms (compared to the absence of autonomic symptoms).

Endometriosis is associated with a high prevalence of pelvic symptoms in patients presenting for subspecialty urogynecology and reconstructive pelvic surgery (URPS) / pelvic pain clinic evaluation. Within this subspecialty population with high urinary and pain symptomatology, only bowel symptoms distinguished those with endometriosis versus those without. However, in this dataset, we showed significant odds for pelvic pain, urinary, bowel, prolapse and autonomic nervous symptoms comparing each magnitude with other pelvic symptoms.

Endometriosis is commonly underdiagnosed, with patients often waiting over 10 years to receive appropriate treatment. Based on data from intake questionnaires alone, urologists and other pelvic health specialists should pay close attention to patients who report high multifactorial pelvic symptomatology, especially bowel symptoms, as part of their pelvic distress. Urologists and others at the front line of pelvic health can help reduce time to accurate diagnosis, overall healthcare costs, and patient dissatisfaction with their treatment pathway by asking screening questions (e.g. pain worse with periods), maintaining a high index of suspicion, and coordinating effective multidisciplinary care at the earliest possible encounter.