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| CASE REPORT |
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| Year : 2021 | Volume
: 33
| Issue : 1 | Page : 32-34 |
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An infected urachal cyst mimicking a lower urinary tract infection in a young adult
Kristiana Gkeka1, Georgios Tsampoukas2, Maria Tsimara3, Panagiotis Kartsaklis1
1 Department of Urology, General Hospital of Patras, Patras, Greece
2 Department of Urology, Princess Alexandra Hospital, Harlow, UK
3 Department of Radiology, General Hospital of Patras, Patras, Greece
| Date of Submission | 18-Jun-2021 |
| Date of Decision | 05-Jul-2021 |
| Date of Acceptance | 04-Aug-2021 |
| Date of Web Publication | 15-Feb-2022 |
Correspondence Address:
Kristiana Gkeka
53, Samothrakis Street, Patras
Greece
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/HUAJ.HUAJ_25_21
Urachus is an embryologic remnant of allantois, which in adults presents as medial umbilical ligament connecting the dome of the bladder to the umbilicus. Defective obliteration of the urachus results in various urachal abnormalities. An infected urachal cyst is one of the urachal abnormalities, all of which are rare in adult life. The clinical presentation of an infected urachal cyst in adults is heterogeneous, and therefore, the diagnosis may be occasionally challenging. We present and discuss a case of a 25-year-old man with an infected urachal cyst, mimicking a lower urinary tract infection.
Keywords: Abdominal pain, laparotomy, lower urinary tract infection, urachal cyst
How to cite this article:
Gkeka K, Tsampoukas G, Tsimara M, Kartsaklis P. An infected urachal cyst mimicking a lower urinary tract infection in a young adult. Hellenic Urology 2021;33:32-4 |
| Introduction | |  |
Urachus is an embryologic remnant, developed by the obliteration of the allantois. It forms the medial umbilical ligament, which connects the bladder dome to the umbilicus. If the obliteration fails, it will result in various urachal abnormalities: patent urachus, urachal cyst, urachal sinus, and vesicourachal diverticulum. Although those are quite rare, urachal cysts might be encountered in urological practice if they become complicated. In our paper, we present the case of a young man presenting with an infected urachal cyst, initially considered a lower urinary tract infection.
| Case Report | | |
A 25-year-old man was referred to the emergency department after several days of progressively worsening infraumbilical pain, dysuria, and fever. The diagnosis of lower urinary tract infection had been previously made in the community, and the patient had been treated with levofloxacin for 5 days with no response. On physical examination, a midline mass along with tenderness in the lower abdomen was noticed. The patient was tachycardic, body temperature was 38.5°C, and the blood pressure was 120/80 mmHg. Laboratory data showed a white blood cell count of 15.500/μL and a C-reactive protein level of 8.5 mg/dL. An urgent ultrasound illustrated a cystic-like mass (7.6 cm × 5 cm ×4.3 cm in diameter) located at the superior part of the bladder [Figure 1]. A computed tomography (CT) of the abdomen and pelvis showed a hypodense mass in the midline of the abdominal wall, with an indentation at the superior part of the bladder and a fibrous band ending up to the umbilicus, setting the diagnosis of an infected urachal cyst [Figure 2]. A decision for surgical intervention was made, and intravenous antibiotics (ciprofloxacin, amikacin) were administrated 24 h before the procedure. A laparotomy was performed, which revealed the urachal cyst as an extraperitoneal mass full of purulent fluid located at the superior part of the bladder. Firm adhesions between anterior abdominal wall and bladder were noticed; therefore, the cyst was extracted along with part of the bladder dome [Figure 3]. The postoperative course was uneventful, and the patient was discharged 7 days after surgery. The culture of the fluid of the mass revealed the growth of a Gram-negative bacterium (Citrobacter braakii). Pathological examination confirmed the histological characteristics of an infected urachal cyst [Figure 4]. | Figure 1: Ultrasound showing an irregular, lobulated, cystic lesion with content of mixed echogenicity located at the dome of the bladder
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 | Figure 2: Abdominopelvic computed tomography showing the infected urachal cyst, lying upon the dome of the bladder (sagittal view, white arrow)
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 | Figure 3: Intraoperative urachal cyst excision along with the dome of the bladder (white arrow: Urachal remnant)
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 | Figure 4: H and E image showing the duct lined by benign urothelium and cuboidal epithelium
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| Discussion | | |
The incidence of the congenital anomalies of the urachus is rather unknown, whereas the same applies for the complications. The presentation of an infected urachal cyst as acute abdominal pain is quite rare; a study reported that the urachal remnants were responsible for 0.03% of acute abdominal presentation in the emergency department. Examination of the ages revealed a trimodal distribution: in the neonatal period, the early 20s, and the mid-50s.[1]
The majority of urachal cysts remain asymptomatic unless get complicated. They present with a wide range of symptoms including abdominal pain, fever, umbilical discharge, midline mass, and dysuria. Usually, the diagnostic process focuses on other common conditions such as acute appendicitis, Meckel's diverticulitis, urinary tract infection, and tumors of the bladder. Due to the heterogeneous presentation, patients might be initially misdiagnosed, like in our case. However, urachal anomalies should be considered in the differential diagnosis of patients with atypical, abdominal pain or an abdominal mass in the midline presenting with acute abdomen, due to infection of the cyst, intracystic bleeding, intraperitoneal rupture, intestinal obstruction, obstructive uropathy, or bowel fistula.[2]
Secondary infection, rupture, fistula formation, hemorrhage, urinary or intestinal obstruction, and the development of cancer have been reported as long-term complications.[3] Regarding the latter one, the majority of urachal carcinomas are adenocarcinomas corresponding to 0.1%–0.3% of all bladder malignancies and 20%–39% of bladder adenocarcinomas, with a mean age of presentation of 61 years.[4],[5] Abdominal pain, a suprapubic mass, discharge of blood or pus from the umbilicus, and especially hematuria should raise the suspicion of urachal adenocarcinoma, whereas the presence of lower fatty infiltration of the retzius space in imaging is associated with benign disease.[6]
Multiple bacterial species have been isolated from the infected cysts, including Staphylococcus aureus, Streptococcus viridans, Escherichia coli, and Bacteroides species.[4] Like seen in our case, uncommon bacterial growth in the infected content of the cysts might reflect previous failed treatments.
Although the diagnosis of infected urachal cysts is primarily clinical, imaging is mandatory to confirm the diagnosis. Urachal cyst might be seen as a complex cystic mass in the midline above the bladder in ultrasonography, whereas CT with contrast illustrates the cyst as a supravesical heterogenous collection with enhancing irregular walls and a central nonenhancing low attenuation content. Magnetic resonance imaging might also assist. To our experience, CT should be considered the imaging of choice, as it is accurate and available in the emergency setting, excluding also other pathologies. However, imaging might not be able to differentiate benign from malignant urachal pathology. Although the majority of malignancies are solid, up to 27% can demonstrate a cystic component, and similarly, the “pathognomonic” of urachal cancer intrinsic calcification can also been seen in approximately 20% of urachal cysts.[7]
Should the surgical treatment have been decided, open or minimally invasive approaches can be considered with similar efficacy. A two-stage approach with preoperative antibiotic therapy and later intervention should be followed because of the shorter hospital stay and the lower complications rate. This approach was proven quite efficient in our case. Due to the high risk of recurrence and the future risk of malignancy, the complete resection of the cyst is preferred compared to the radiological drainage.[8] The traditional surgical technique is the open excision of urachal remnants with a midline infraumbilical incision, but laparoscopic excision can also be performed.[9] A robotically-assisted laparoscopic approach, if available, can also be followed with remarkable results.[10]
To sum up, urachal anomalies are a rare condition in adulthood but may result in severe illness necessitating surgical intervention. Although clinical presentation is nonspecific, the medical history, physical examination, and early imaging will result in the prompt diagnosis. When the surgical treatment is indicated, the excision of the cyst, open or laparoscopically, should be regarded as the treatment of choice.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials 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 | | |
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| 3. | Allen JW, Song J, Velcek FT. Acute presentation of infected urachal cysts: Case report and review of diagnosis and therapeutic interventions. Pediatr Emerg Care 2004;20:108-11. |
| 4. | Ashley RA, Inman BA, Routh JC, Rohlinger AL, Husmann DA, Kramer SA. Urachal anomalies: A longitudinal study of urachal remnants in children and adults. J Urol 2007;178:1615-8. |
| 5. | Hassanbhai DH, Ng FC, Koh LT. Is excision necessary in the management of adult urachal remnants? A 12-year experience at a single institution. Scand J Urol 2018;52:432-6. |
| 6. | Bi X, Wu Z, Han H, Zhou F. Clinical comparison of patients with benign urachal masses versus urachal carcinomas. Chin J Cancer 2017;36:2. |
| 7. | Das JP, Vargas HA, Lee A, Hutchinson B, O'Connor E, Kok HK, et al. The urachus revisited: multimodal imaging of benign and malignant urachal pathology. Br J Radiol 2020;93:20190118. |
| 8. | Yoo KH, Lee SJ, Chang SG. Treatment of infected urachal cysts. Yonsei Med J 2006;47:423-7. |
| 9. | Li Destri G, Schillaci D, Latino R, Castaing M, Scilletta B, Cataldo A Di. The urachal pathology with umbilical manifestation: Overview of laparoscopic technique. J Laparoendosc Adv Surg Tech 2011;21:809-14. |
| 10. | Madeb R, Knopf JK, Nicholson C, Donahue LA, Adcock B, Dever D, et al. The use of robotically assisted surgery for treating urachal anomalies. BJU Int 2006;98:838-42. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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