Pathophysiological Mechanisms and Clinical Implications of Lower Urinary Tract Symptoms in Patients with Deep Endometriosis: A Narrative Review

Introduction and Hypothesis Endometriosis is a chronic inflammatory condition characterized by endometrium-like tissue outside the uterus. Deep endometriosis (DE) frequently involves the posterior pelvic compartment and can affect the urinary tract directly or indirectly, leading to a wide spectrum of lower urinary tract symptoms (LUTS). This narrative review aimed to synthesize current evidence on the mechanisms underlying LUTS in women with deep endometriosis, including direct urinary tract involvement, extra-urinary mechanisms, and postoperative dysfunction, and to discuss their diagnostic and therapeutic implications. Methods A structured, non-systematic literature search was conducted using PubMed/MEDLINE for English-language publications from 2000 to July 2026. Four thematic domains were considered: (1) prevalence and pathophysiological mechanisms of LUTS in endometriosis; (2) LUTS due to direct urinary tract involvement; (3) LUTS without direct urinary tract involvement; and (4) de novo LUTS after surgery for deep endometriosis. Results In women with DE undergoing preoperative urodynamic assessment, pooled estimates indicated voiding dysfunction in 21% and detrusor overactivity in 15%, with substantial heterogeneity. LUTS may reflect direct urinary tract involvement, neural dysfunction, inflammation, or surgical injury. Evidence for proposed neuroinflammatory and nociplastic mechanisms remains largely indirect or experimental. Conclusions Multiple pathophysiological mechanisms may contribute to LUTS in DE. Clinicians should be aware of the association between these two conditions and address treatment of both, which often requires a multidisciplinary approach. Where surgery is indicated, nerve-sparing techniques should be considered when technically feasible to reduce the risk of postoperative urinary dysfunction. Emerging mechanistic and phenotype-based approaches require further validation.