International Scholarly Research Network
Volume 2011, Article ID 820924, 3 pages
UrachalSinusPresenting with AbscessFormation
JalalEddineElAmmari,YounessAhallal, OussamaElYazami Adli,
Mohammed JamalElFassi,andMy Hassan Farih
Department of Urology, University Hospital Center Hassan II Fes, Morocco
Correspondence should be addressed to Jalal Eddine El Ammari, firstname.lastname@example.org
Received 13 January 2011; Accepted 17 February 2011
Academic Editor: M. A. Salah
Copyright © 2011 Jalal Eddine El Ammari et al.Thisisanopenaccessarticledistributed undertheCreativeCommonsAttribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Urachalaffectionsarerare. Theirvariablewaysofpresentationmayrepresent adiagnosticchallenge. Urachalsinusesareararetype
of these abnormalities. They are usually incidental findings and remain asymptomatic unless a complication (most commonly
the infection) occurs. Infection of the urachal sinus would clinically present as purulent umbilical discharge, abdominal pain,
and periumbilical mass. We report herein a case of infected urachal sinus in male adult. The diagnosis was suspected clinically
and confirmed with ultrasonography and computed tomography scan. A preoperative cysto-fibroscopy showed normal aspect of
the bladder and excluded sinus communication. An initial broad spectrum antibiotic therapy followed by complete excision of
the sinus and fibrous tract without cuff of bladder has been therefore performed. The postoperative course was uneventful. No
recurrence was observed after 18 months of followup. Histological examination did not reveal any sign of malignancy.
Since the first description by Cabriolus in 1550, few cases of
urachal sinuses have been reported in literature. Urachal
abnormalities result from incomplete obliteration of the
foetal urachus. They are rare in adults comparing to children
. Various types of remnants have been described and
urachal sinus is the little common variety. The usual
presenting symptom of this anomaly is umbilical discharge
. Diagnosis remains challenging due to the rarity of this
lesion and the nonspecific nature of its symptomatology.
This paper aims at reminding the diagnostic and therapeutic
features of urachal sinus.
A 22-year-old male patient, with no relevant past medical
history, presented with a three days history of fever, abdom-
inal pain, and umbilical discharge without digestive nor
urinary symptoms. Physical examination revealed an initial
temperature of 38.9◦C, purulent umbilical discharge with
erythema, and tender umbilical mass (Figure 1). Laboratory
tests revealed marked leucocytosis of 24,000/mm3and
elevated C-reactive protein (42mg/L). The urinalysis and
renal function were within normal values. Culture of the
umbilical discharge grew Klebsiella pneumonia, and blood
culture was negative. Abdominal ultrasonography showed
echoic collection in a midline cavity within the anterior
abdominal wall. Computed tomography scan confirmed the
diagnosis of infected urachal sinus showing a heterogeneous
collection with calculus and gas formation communicating
with the umbilicus (Figures 2(a) and 2(b)).
The patient was initially treated with intravenous antibi-
otics(ceftriaxone and gentamycine). Two daysafterapyrexia,
cystoscopy and excision of the infected urachal sinus were
performed simultaneously. Cystoscopy confirmed no evi-
dence of a bladder anomaly. An infraumbilical midline inci-
sion was used to excise the sinus and fibrous tract (Figure 3).
The postoperativecourse wasuneventful.Histological exam-
inationdidnotrevealany signsofmalignancy. Norecurrence
was observed after 18 months followup.
The urachus is a vestigial remnant of at least two embryonic
structures: the cloaca, and the allantois. The tubular urachus
2 ISRN Urology
Figure 1: Purulent umbilical discharge with erythema and umbili-
normally involutes before birth, remaining as a fibrous cord
between the transversalis fascia anteriorly and the peritone-
um posteriorly and attaches the umbilicus to the bladder
Histologically, it presents with 3 layers: an innermost
layer of modified transitional epithelium similar to the
urothelium, a middle layer of fibro-connective tissue, and an
outermost layer of smooth muscle continuing the detrusor
lies occur in a 2:1 male to female ratio with 2% ratio
reported in adults .
Urachal abnormalities result from incomplete oblitera-
tion of the foetal urachus. There are five types of urachal
structure fails to close (50%); (2) urachal cyst, in which
both ends of the canal close leaving an open central portion
(30%); (3) urachal sinus, which drains proximally into the
umbilicus (15%); (4) vesicourachal diverticulum, where the
distal communication to the bladder persists (3–5%); and
(5) alternating sinus, which can drain to either bladder or
umbilicus [4, 5].
nous secretion via the umbilicus. The commonly cultured
microorganisms from the pus are Escherichia coli, Entero-
coccus faecium, Proteus, Streptococcus viridans and Fuso-
bacterium [4, 5]. In our case, Klebsiella pneumonia was cul-
The clinical signs and symptoms are nonspecific, as ura-
chal sinus is largely asymptomatic until they become infect-
a tender midline infraumbilical mass, umbilical discharge
and sepsis should arouse suspicion of urachal sinus .
Differential diagnosis of this condition includes anoma-
lies of the vitelline ducts (such as Meckel’s diverticulum),
Figure 2: (a) and (b): heterogeneous urachal collection with calcu-
lus and gas formation communicating with the umbilicus.
patent omphalomesenteric duct, infected umbilical vessel,
appendicitis, or omphalitis .
Ultrasonography could help in establishing the diagnosis
in 77% of patients. In our case, ultrasonography was not
specific and computedtomographyscan was usedtoconfirm
the diagnosis and analyse the connection to surrounding
Urachal sinus can be complicated by stone and gaseous
formation as was seen in our patient. Other reported com-
plications include rupture into the peritoneal cavity leading
to peritonitis, uracho-colonic fistula, and neoplastic trans-
formation . The risk of urachal malignancy in adults is
high and the prognosis is poor .
Although the innermost layer of the urachus is mainly
transitional cell, adenocarcinoma (mostly mucinous) is the
predominant histological type. This is probably due to met-
aplasia arising from chronic inflammation.
Figure 3: Infra-umbilical midline incision was used to excise the
sinus and fibrous tract.
Urachal cyst treatment depends on the presence of com-
plications or associated conditions. Noninfected urachal
sinus are usually removed in a single-step radical excision
of the remnant which removes the entire lesion with or
without a bladder cuff via open or laparoscopic surgical
approach . This intervention is performed to ovoid recur-
rence following simple drainage and to prevent developing
malignant transformation . In case of infection, a single-
stage procedure backed with appropriate antibiotic therapy
or 2-stage procedure involving initial incision and drainage,
followed bylaterexcisionoftheurachal remnant are adopted
with uneventful postoperative course.
Infected urachal sinus is rare in adults. Presentation is atyp-
ical; therefore, a high index of suspicion is required in
order to achieve a diagnosis. A triad of infraumbilical mass,
umbilical discharge, and sepsis is suggestive. Ultrasound and
computed tomography scan confirm the diagnosis and anal-
yses the surrounding anatomical connections. An antibiotic
regimen according to bacterial sensitivity is recommended
prior to the surgical intervention. In order to prevent
recurrence and malignant transformation, complete surgical
excision with or without a bladder cuff is the standard treat-
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