Title: Single Stage Management of an Infected Urachal Cyst in a 21-year-old male
Author(s): Aleks Lane, DO
Email: sxlane@mercy.com
Introduction: Urachus is a developmental connection between the umbilicus and the bladder that normally involutes during development and only persists in normal development as the median umbilical ligament. Remnants of the urachus can result in a spectrum of anomalies including a patent urachus, umbilical polyp, bladder diverticulum, and urachal cyst. Studies have shown that asymptomatic remnants have been present in up to 1 percent of patients undergoing abdominal imaging at pediatric centers with most patients being diagnosed by the age of 6. A common presentation has been that of a urachal cyst which may present as a bulge near the umbilicus without a patent connection to the umbilicus or bladder. These urachal cysts may also present as infected with erythematous/tender changes over the preexisting bulge. Urachal cysts can be confused with umbilical hernias based off physical exam alone but are differentiated on imaging Urachal remnants identified in adults have been associated with underlying adenocarcinoma within the remnant however reported rates have been low but have been cited as reason for resection.
Case Report(s): Patient is a 21-year-old male that initially presented to his primary care physician office secondary to 2 days of worsening periumbilical pain associated with overlying erythematous skin changes. The patient was sent to the emergency department due to concern of strangulated umbilical hernia. General surgery was consulted, and the patient underwent CT of the abdomen which demonstrated at 3 cm x 2.5 cm fluid collection at the umbilicus without evidence of herniated intra-abdominal contents. The patient was taken for diagnostic laparoscopy with obliteration of urachal remnant and excision of infected urachal cyst with umbilectomy due to concern of ischemic changes of the overlying skin. Final pathology demonstrated squamous epithelial lined urachal abscess.
Discussion: Urachal cysts are uncommon developmental remnants of a urachus. There is a spectrum of remnants of the urachus that are named based upon the proximal or distal connection or in the case of a urachal cyst, a walled off persistent cyst at the midportion of the urachus. According to a retrospective analysis of imaging findings confirming the presence of urachal anomalies by Gleason et al., the general prevalence of urachal remnants in the pediatric population undergoing abdominal imaging was found to be around 1%. Most of these anomalies were urachal remnants (bladder diverticulum or umbilical polyp) at 89% with urachal cysts only making up 9% of these identified on imaging.[1] Urachal cysts may present either as asymptomatic bulges inferior to the umbilicus or may present as tender and erythematous skin changes indicating infected urachal cyst contents. Classically, a two staged approach has been described in management of these lesions with incision and drainage of the abscess with subsequent interval resection after the infection has improved. However, in this case the patient was successfully managed with good outcomes with primary cyst excision at the time of initial presentation.
