Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 163-166

A 36-year-old patient with acute urinary retention due to an anterior midline prostatic cyst: A case report and review of the literature


Department of Urology, Naval Hospital of Athens, Athens, Greece

Date of Submission01-May-2020
Date of Decision25-May-2020
Date of Acceptance23-May-2021
Date of Web Publication13-Aug-2021

Correspondence Address:
Dimitrios Deligiannis
Department of Urology, Naval Hospital of Athens, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_21_21

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  Abstract 


During the years, there have been no more than a few reports (with ours being so far the sixth) of prostatic cysts prolapsing into the bladder and thus causing urinary obstruction. Most of those cystic formations are generally asymptomatic and are found during random controls. In our case, the cyst was located in the anterior midline of the prostate in a 36-years-old patient presenting at the E. R with severe suprapubic pain and urinary retention after 3 months of constantly deteriorating lower urinary tract symptoms. Transabdominal ultrasonography and magnetic resonance imaging revealed a projecting prostatic cyst that like a valve was blocking the bladder neck at 12 o'clock position. It was successfully removed by transurethral resection leaving the patient free of symptoms.

Keywords: Bladder obstruction, prostate, prostatic cyst, transurethral resection, urinary retention


How to cite this article:
Deligiannis D, Adamos K, Tselos A, Mavrikos S. A 36-year-old patient with acute urinary retention due to an anterior midline prostatic cyst: A case report and review of the literature. Hellenic Urology 2020;32:163-6

How to cite this URL:
Deligiannis D, Adamos K, Tselos A, Mavrikos S. A 36-year-old patient with acute urinary retention due to an anterior midline prostatic cyst: A case report and review of the literature. Hellenic Urology [serial online] 2020 [cited 2022 Jun 25];32:163-6. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/4/163/323797




  Introduction Top


Cysts of the lower male genitourinary tract are not a common feature and usually are found to be benign.[1],[2] Their discovery has been the result of the increasing use of transrectal ultrasound, computed tomography, and magnetic resonance imaging.

Embryology

Both sex embryos have two pairs of genital ducts: The paramesonephric ducts (Müllerian) and the mesonephric ducts (Wolffian). When it comes to the male genital tract development this is considered to be a result of the differentiation of the components on the Wolffian duct and the involution of the müllerian ones. Sometimes those remnants persist on adult males despite the degeneration of the müllerian ducts leading to the presence of certain formations or anatomic disorders.[3]

Classification

In the literature, prostatic cysts are usually classified as either median, paramedian, and lateral cysts, or intraprostatic and periprostatic cysts.[4],[5] Median cysts (prostatic utricle cysts and Müllerian duct cysts) are located in the midline behind the upper half of the prostatic urethra [Table 1].
Table 1: Cystic lesions of the lower male urogenital tract (source: Reference[18])

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Prostatic utricle cysts are an embryologic remnant of the Müllerian duct system, results of an incomplete regression of this structure during embryologic development. They are most commonly found in males under 20 years of age. Their reported occurrence in the general population is about 1%–5%.[6],[7] They are associated with various genitourinary abnormalities, including hypospadias, intersex disorders, cryptorchidism, and ipsilateral renal agenesis and they may manifest with various signs and symptoms, including urinary tract infection, pain, postvoiding incontinence, recurrent epididymitis, and hematospermia.[6],[8],[9] Since utricle cysts communicate with the urethra, they may result in postvoiding dribbling. Prostatic utricle cysts can become infected and may contain pus or hemorrhage, which can confuse imaging because their appearances overlap with those of abscesses and cystic tumors of the prostate.[4] Utricle cysts are pear-shaped structures that, unlike müllerian duct cysts, do not extend above the base of the prostate. They communicate freely with the prostatic urethra.[8] Utricle cysts are typically smaller than müllerian cysts and are usually 8–10 mm long. They contain fluid, which has high signal intensity on T2-weighted images.[4] At the transrectal US, they manifest as a midline anechoic cystic cavity posterior to the urethra.

Müllerian duct cysts result from focal failure of regression and focal saccular dilatation of the mesonephric duct. They are occasionally associated with renal agenesis, but external genitalia is normal.[9] The peak incidence of müllerian duct cysts is between the ages of 20 and 40 years. A few cases have been reported to occur in infancy.[10] According to an older autopsy series, the reported prevalence in men is 1%. However, the frequency of occurrence may be underreported, since some authors found a prevalence of 5% in urologic patients.[4] Müllerian duct cysts are usually asymptomatic but may manifest in early adulthood with urinary retention and urinary tract infection.[7] They may also cause ejaculatory impairment by obstructing the ejaculatory duct in the midline. Such as utricle cysts, Müllerian cysts can become infected; their imaging appearance resembles that of abscesses or cystic tumors of the prostate.[5] At aspiration, müllerian duct cysts never contain spermatozoa, but they do commonly contain calculi. There have been case reports of müllerian duct cysts and prostatic utricle cysts containing carcinoma.[5] Surgical excision of a müllerian duct cyst may be performed depending on the size and location of the cyst and the presence of clinical symptoms.[8] Transurethral resection and percutaneous aspiration are used to treat small müllerian duct cysts. The use of laparoscopic excision has also been reported. For a large pelvic or abdominal cyst, open surgical excision is the treatment of choice.[4] Müllerian duct cysts appear as teardrop-shaped midline cysts extending above the prostate. They do not communicate with the posterior urethra[10] [Table 2].
Table 2: Prostatic utricle cysts versus müllerian duct cysts (source: Reference[18])

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  Case Report Top


A 36-year-old patient presented at the E. R with severe suprapubic pain and urinary retention after 3 months of constantly deteriorating lower urinary tract symptoms including frequency, weak urinary stream, and a sensation of residual urine that became really important 1 week before. Our patient presented a form of coronal hypospadias [Figure 1] and besides that, he was a healthy male, free of other medical problems.
Figure 1: Coronal hypospadias

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The clinical examination revealed a dilated bladder. We performed a transabdominal ultrasound [Figure 2] and the volume of residual urine was >500 ml. At the same time, we noted the presence of a midline cystic formation elapsing from the prostate with an approximate diameter of 1,5 cm that projected on the bladder neck. The volume of the prostate was normal for the patient's age.
Figure 2: Ultrasound revealing a cyst at the level of the bladder neck and urinary retention

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A simple 16fr foley catheter was put in place and the patient was further controlled with an MRI [Figure 3] suggesting the presence of a ureterocele, or a cyst of prostatic origin such as a müllerian duct cyst. A preoperative cystoscopy revealed a cystic mass located in the anterior prostate, in the precise 12 o'clock position, closing the bladder neck like a checking valve [Figure 4]. There was not any other abnormality either from the bladder mucosa or the prostatic urethra.
Figure 3: T1 MRI image of the lower abdomen, revealing an anterior prostatic cyst

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Figure 4: Intra-operative cystoscopy with the anterior prostatic cyst, blocking almost completely the bladder neck opening

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The patient underwent transurethral surgery under general anesthesia and the cyst was excised with the transurethral resector [Figure 5]. No bleeding or other incidences were noted after the operation.
Figure 5: The channel created after minimal resection of the prostatic cyst

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  Discussion Top


Prostatic cysts are rather uncommon with a percentage of incidence varying from 0.5% to 7.9%. According to current classification, there can be intraprostatic cysts, extraprostatic, and mimics of prostatic and periprostatic cysts. Intraprostatic cysts can be either median (1%–5% prostatic utricle and 1%–5% müllerian duct cysts), either paramedian or lateral.[4],[6],[7] On studies among patients with symptomatic cysts up to 40% complained of obstructive urinary tract symptoms, while according to other studies patients with a medial prostatic cyst complained of prostatitis-like symptoms (77%), scrotal pain (62%), impaired micturition (32%), small volume ejaculation (35%), painful ejaculation (24%), hemospermia (24%), and infertility (12%).[2],[11] When it comes to the location of midline cysts these are mostly found posteriorly rather than anteriorly.[12] Most of the references so far have to do with posterior cysts or infravesical formations, while so far only a few cases with involvement of the bladder neck are presented including our case.[11],[12],[13],[14],[15],[16],[17],[18]

In our case, being the sixth on a series of similar cases so far, transurethral unroofing and excision of the cyst seem like the way to go.[11],[16],[17] No complications were noted including any level of erectile dysfunction and recession of LUTS. In our case, the patient mentioned a complete relief of his symptoms the first few hours since the removal of the postoperational catheter. The most important complication of transurethral resection includes injury of the urethra or bladder, which is located near the thin base of the cystic mass.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ishikawa M, Okabe H, Oya T, Hirano M, Tanaka M, Ono M, et al. Midline prostatic cysts in healthy men: Incidence and transabdominal sonographic findings. AJR Am J Roentgenol 2003;181:1669-72.  Back to cited text no. 1
    
2.
Dik P, Lock TM, Schrier BP, ZeijlemakerBY, Boon TA. Transurethral marsupialization of a medial prostatic cyst in patients with prostatitis-like symptoms. J Urol 1996;155:1301-4.  Back to cited text no. 2
    
3.
Sajjad Y. Development of the genital ducts and external genitalia in the early human embryo. J Obstet Gynaecol Res 2010;36:929-37.  Back to cited text no. 3
    
4.
McDermott VG, Meakem TJ 3rd, Stolpen AH, Schnall MD. Prostatic and periprostatic cysts: Findings on MR imaging. AJR Am J Roentgenol 1995;164:123-7.  Back to cited text no. 4
    
5.
Curran S, Akin O, Agildere AM, Zhang J, Hricak H, Rademaker J. Endorectal MRI of prostatic and periprostatic cystic lesions and their mimics. AJR Am J Roentgenol 2007;188:1373-9.  Back to cited text no. 5
    
6.
Paudel K, Kumar A. Unusually large prostatic utricle cyst. Kathmandu Univ Med J (KUMJ) 2009;7:73-5.  Back to cited text no. 6
    
7.
Jaidane M, Hidoussi A, Slama A, Hmida W, Sorba NB, Mosbah F. An acute urinary retention in an old man caused by a giant müllerian duct cyst: A case report. Cases J 2009;2:203  Back to cited text no. 7
    
8.
Parsons RB, Fisher AM, Bar-Chama N, Mitty HA. MR imaging in male infertility. Radiographics 1997;17:627-37.  Back to cited text no. 8
    
9.
Trigaux JP, Van Beers B, Delchambre F. Male genital tract malformations associated with ipsilateral renal agenesis: Sonographic findings. J Clin Ultrasound 1991;19:3-10.  Back to cited text no. 9
    
10.
Simpson WL Jr, Rausch DR. Imaging of male infertility: Pictorial review. AJR Am J Roentgenol 2009;192:S98-11.  Back to cited text no. 10
    
11.
Tambo M, Okegawa T, Nutahara K, Higashihara E. Prostatic cyst arising around the bladder neck-cause of bladder outlet obstruction: Two case reports. Hinyokika Kiyo 2007;53:401-4.  Back to cited text no. 11
    
12.
Nayyar R, Dogra PN. Anteriorly placed midline intraprostatic cyst. J Endourol 2009;23:595-7.  Back to cited text no. 12
    
13.
Issa MM, Kalish J, Petros JA. Clinical features and management of anterior intraurethral prostatic cyst. Urology 1999;54:923.  Back to cited text no. 13
    
14.
Yildirim I, Kibar Y, Sümer F, Bedir S, Deveci S, Peker AF. Intraurethral prostatic cyst: A rare cause of infravesical obstruction. Int Urol Nephrol 2003;35:355-6.  Back to cited text no. 14
    
15.
Tamaki M, Isogawa Y, Ohmori K. A case of prostatic cyst. Hinyokika Kiyo 1994;40:537-40.  Back to cited text no. 15
    
16.
Lee JY, Kang DH, Park HY, Park JS, Son YW, Moon HS, et al. An anteriorly positioned midline prostatic cyst resulting in lower urinary tract symptoms. Int Neurourol J 2010;14:125-9.  Back to cited text no. 16
    
17.
Diaz RR, Lee JY, Choi YD, Cho KS. Unroofed midline prostate cyst misled into a stricture with obliterative bladder neck contracture following a laser prostatectomy. Int Neurourol J 2013;17:34-7.  Back to cited text no. 17
    
18.
Shebel HM, Farg HM, Kolokythas O, El-Diasty T. Cysts of the lower male genitourinary tract: Embryologic and anatomic considerations and differential diagnosis. Genitourin Imaging 2013;33:1125-43. doi: 10.1148/rg.334125129.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]


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