Case Report Aditya - Jurnal Vancover

Infected Urachal Cyst in Adult : A Case Report
Krnia Penta Seputra, Aditya Airlangga Ekaputra, Besut Daryanto
Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang
Abstract
The urachus, or median umbilical ligament, is a midline tubular structure that extends upward
from the anterior dome of the bladder toward the umbilicus. The urachus is a vestigial
fibromuscular structure situated between the transversalis fascia anteriorly and the
peritoneum posteriorly. Persistence of an embryonic urachal remnant can give rise to various
clinical problems. Because urachal remnant diseases are uncommon and manifest with
nonspecific abdominal or urinary signs and symptoms, definitive presurgical diagnosis is not
easily made. Ultrasound (USS), computed tomography (CT) and magnetic resonance imaging
(MRI) will all assist in making this important diagnosis. A 32 year old female was referred to
Saiful Anwar General Hospital after presenting history of pain abdomen since two months,
radiated to perineum. History of dysuria and nausea since 1 month previously, there was no
history of fever or change in bowel habit. Abdominal ultrasound showed abscess at anterior
bladder, MRI showed infected cyst mass in suprapubic pointing to left umbilical. Partial
cystectomy and uterus biopsy was performed. From histopathologic result showed chronic
inflammation tissue and no malignancy was found.
Keywords: Urachus, urachal remnants, urachal cyst, infection
Introduction:
The urachus, or median umbilical ligament, is a midline tubular structure that extends upward
from the anterior dome of the bladder toward the umbilicus. It is a vestigial remnant of at
least two embryonic structures: the cloaca, which is the cephalic extension of the urogenital
sinus (a precursor of the fetal bladder), and the allantois, which is a derivative of the yolk sac.
Persistence of an embryonic urachal remnant can give rise to various clinical problems, not
only in infants and children but also in adults. Because urachal remnant diseases are
uncommon and manifest with nonspecific abdominal or urinary signs and symptoms,
definitive presurgical diagnosis is not easily made 1.
The urachus is a vestigial fibromuscular structure situated between the transversalis fascia
anteriorly and the peritoneum posteriorly. It usually involutes in early childhood to form the
median umbilical ligament. Partial involution can give rise to a number of pathologies 2.
Ultrasound (USS), computed tomography (CT) and magnetic resonance imaging (MRI) will all
assist in making this important diagnosis 3.
The persistence of urachal remnants was reported in 61.7% of patients 16 years, 49.0% of
those 16 to 35 years, 20.4% of those 36 to 55 years, and 3.7% of those 56 years of age. These
findings concur with those in an autopsy study in which urachal remnants were found on
microscopic examination in 32% of cases.The data support the suggestion that the urachus is
a regressive structure that undergoes involution during a normal lifespan and is often present
in normal adults 4.
The treatment of urachal cysts involves primary excision of the cyst. However, the traditional
treatment of an infected urachal cyst is composed of a two-stage approach, an incision and
then drainage of the infected cyst followed by secondary excision. The single-stage excision
involves a primary excision of the infected urachal cyst and bladder cuff, whereas the two-
stage procedure involves a primary incision and drainage, a delay to ensure that the infection
has cleared, and then a later excision of the urachal remnant and bladder cuff 5. In adults, the
commonest variety is urachal cyst, with infection being usual mode of presentation. The route
of infection is haematogenous, lymphatic, direct or ascending from the bladder. The
commonly cultured microorganisms from the cystic fluid include Escherichia coli,
Enterococcus faecium, Klebsiella pneumonia, Proteus, Streptococcus viridans and
Fusobacterium 6.
Case report:
A 32 year old female was referred to Saiful Anwar General Hospital after presenting history
of pain abdomen since two months, radiated to perineum. History of dysuria and nausea since
1 month previously, there was no history of fever or change in bowel habit. On examination
she was alert, with normal vital sign. She had completed a course of antibiotics prescribed by
his General Practitioner. From ultrasound we found abscess at anterior bladder.
Figure 1: Abdominal ultrasound showed hypoechoic lesion with irregular margin,with echoic
shadow at posterior lession.
From MRI found we found infected cyst mass in suprapubic pointing to umbilical at left
paracentral, pressing bladder at superoanterior, presenting an infected urachal cyst.
Figure 2: MRI showed cystic mass with clear margin, irregular, in lower abdominal midline
suprapubic.
During operation we found cystic urachus mass attached to bladder and uterus.
Figure 3: Partial cystectomy and uterus biopsy was performed.
We diagnosed the patient with infected urachal cyst and undergone partial cystectomy.
Histophatologic examination showed chronic inflammation tissue and no malignancy was
found.
Figure 5: Fibrous connective tissue with infiltration of lymphocyte inflammatory cells

Discussion:
The urachus is derived from two embryologic structures: the caudally invaginating allantois
from the yolk sac and the ven- trally invaginating cloaca from the urogenital sinus 2. Descent
of the bladder from the 5th month of development into the foetal pelvis pulls the urachus
with it resulting in the formation of the urachal canal. The lumen of this canal progressively
obliterates during foetal life, with eventual formation of a fibrous tract in early adult life 6.
Incomplete obliteration of the urachal lumen allows formation of a urachal cyst, which
accounts for approximately 30 per cent of all urachal disorders 7.
At the end of development, the urachus lies between the transversalis fascia anteriorly and
the peritoneum posteriorly (space of Retzius), surrounded by loose areolar tissue and
attaches the umbilicus to the dome of the bladder. Histologically, it is composed of 3 layers;
an innermost layer of modified transitional epithelium similar to the urothelium, the middle
layer of fibroconnective tissue and outer most layer of smooth muscle continuous with the
detrusor 6. Radiographic evaluation of urachal anomalies by USG, CT and or MRI is essential
for confirming diagnosis. The optimal treatment for a urachal remnant is surgical excision. A
staged approach of therapy, with initial medical management followed by delayed surgical
excision, appears appropriate for patients with septic signs.
Infected urachal remnants have occasionally been treated with drainage alone, but it has
been reported that the persistence of epithelium leads to a recurrence rate of 30% if excision
does not follow 8. The sonographic appearance of urachal cyst is a fluid-filled anechoic
structure, which lies between the skin and anterior abdominal wall in the midline of the
abdomen, below the umbilicus 9.
Infected urachal remnants often present with local signs and symptoms of infection
(erythema, pain, warmth, purulent drainage), with or without systemic or laboratory
evidence of an infectious process. Urinalysis and urinary culture also are unreliable indicators
of an urachal anomaly, whether infected or noninfected 10. Abdominal symptoms vary. Pain
at or below the umbilicus may be acute or chronic, continuous or intermittent.
Gastrointestinal and urinary symptoms are minimal or absent. with gentle palpation,
tenderness usually can be elicited and a mass felt. If there is infection and peritoneal
involvement, muscle guarding may be noted. Antibiotic therapy preoperatively and
postoperatively is an important adjunct to prevent peritonitis, especially if the cyst is infected
11. Traditional surgical excision ofa urachal remnant involves a transverse or midline
infraumbilical incision. To minimize the morbidity of surgery, for example postoperative pain
and prolonged convalescence, others have reported single cases using a laparoscopic
approach 12.
Conclusion:
Urachal anomalies are rare in adults. Presentation is atypical; therefore, a high index of
suspicion is required in order to achieve a diagnosis. MRI confirms the diagnosis and defines
the surrounding anatomical relationship. Complete surgical excision is the treatment of
choice due to the risk of malignant transformation.
Reference:
1. Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim MJ. Urachal remnant diseases: spectrum
of CT and US findings. Radiographics. 2001;21(2):451–61.
2. Moazzam AA, Wagle N, Shiroishi MS. Malignant transformation of DNETs: a case
report and literature review. 2018;(May):1–2.
3. Qureshi K, Maskell D, McMillan C, Wijewardena C. An infected urachal cyst presenting
as an acute abdomen - A case report. Int J Surg Case Rep [Internet]. 2013;4(7):633–5.
Available from: http://dx.doi.org/10.1016/j.ijscr.2013.02.026
4. Jackson M, Cusano A, Murphy G, Haddock P, Meraney A, Wagner J. Infected Urachal
Cyst Following Laparoscopic Cholecystectomy. :1–4.
5. Yoo KH, Lee SJ, Chang SG. Treatment of infected urachal cysts. Yonsei Med J.
2006;47(3):423–7.
6. Ekwueme KC, Parr NJ. Infected urachal cyst in an adult: a case report and review of
the literature. Cases J. 2009;2:6422.
7. Goldman IL, Caldamone AA, Gauderer M, Hampel N, Wesselhoeft CW, Elder JS.
Infected urachal cysts: A review of 10 cases. J Urol [Internet]. 1988;140(2):375–8.
Available from: http://dx.doi.org/10.1016/S0022-5347(17)41612-0
8. Chaithanya J, Srinivas BK, Hanumanthaiah KS, Rajagopalan S. Urachal Diverticulum
presenting as abdominal pain : a surprise at surgery. 2017;4(8):2833–5.
9. James V, Seguin J, Kwan C. Urachal Cyst Diagnosed by Point-of-care Ultrasound. Clin
Pract Cases Emerg Med [Internet]. 2017;1(4):374–6. Available from:
https://escholarship.org/uc/item/1nt223w0
10. McCollum MO, MacNeily AE, Blair GK. Surgical implications of urachal remnants:
Presentation and management. J Pediatr Surg. 2003;38(5):798–803.
11. Constantian HM, Amaral EL. Urachal cyst: case report. J Urol [Internet].
1971;106(3):429–31. Available from: http://dx.doi.org/10.1016/S0022-
5347(17)61310-7
12. Okegawa T, Odagane A, Nutahara K, Higashihara E. Laparoscopic management of
urachal remnants in adulthood. Int J Urol. 2006;13(12):1466–9.

Case Report Aditya - Jurnal Vancover

Uploaded by

Copyright:

Available Formats

Case Report Aditya - Jurnal Vancover

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Report Aditya - Jurnal Vancover

Uploaded by

Copyright:

Available Formats

Infected Urachal Cyst in Adult : A Case Report

Krnia Penta Seputra, Aditya Airlangga Ekaputra, Besut Daryanto

Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang

Figure 5: Fibrous connective tissue with infiltration of lymphocyte inflammatory cells

You might also like