Urachal fistula in a 22 year male: a case report

Abstract

A patent urachus is one of the spectrums of congenital urachal anomalies. It has been termed as "urachal fistula" when the lumen of intra-embryonic portion of allantois persist abnormally. Persisting urachal fistula is a rare condition mostly diagnosed during childhood or in autopsies. Here we report a very rare case of urachal fistula of a young male. We present a case of 22 years male with intermittent periumbilical pain and sero-purulent discharge from umbilicus since birth. On examination sero-purulent discharging umbilical sinus with granuloma was present. Surgical excision of whole of the urachal fistulous tract was done with repair of bladder. Patient did well during post-operative period. Persisting urachal fistula in adult is rare entity and difficult to diagnose because of low incidence and non-specific symptoms. So a high index of suspicion is required in order to make the early diagnosis of urachal anomalies.

Full text

International Surgery Journal | September 2020 | Vol 7 | Issue 9 Page 3102
International Surgery Journal
Srivastava VK et al. Int Surg J. 2020 Sep;7(9):3102-3104
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Case Report
Urachal fistula in a 22 year male: a case report
Vipul Kumar Srivastava*, Shilpi Roy, Ram Niwas Meena, Rahul Khanna
INTRODUCTION
The urachus is a fibrous cord arising from the early fetal
anterior bladder wall to the allantois, extending cranially
to the umbilicus. It undergoes many developmental
changes during embryonic life and finally descends along
with the bladder in pelvis. This descent stretches the
urachus leading to the obliteration of its lumen and the
formation of a fibrous band known as the median umbilical
ligament.1 Failure of obliteration of this leads into
formation of various urachal abnormalities.
Congenital urachal remnants can be further subdivided
into five groups: patent urachus, umbilical-urachal sinus,
vesicourachal diverticulum, urachal cyst, and alternating
sinus.2 Mostly these anomalies remain asymptomatic
except for the patent urachus also known as urachal fistula
which is a rare condition to find. Even if they are found
then they are usually seen in newborns or often on
autopsies.
So we present this extremely rare case of a symptomatic
urachal fistula in a 22 year male.
CASE REPORT
A 22 year male presented to General Surgery OPD of Sir
Sunderlal Hospital, Institute of Medical Sciences, Banaras
Hindu University, Varanasi, Uttar Pradesh, India, with
intermittent peri umbilical pain and discharge from
umbilicus since birth. The pain was mild grade, dull aching
in nature not associated with any postural variation. On
examination a sero-purulent discharging sinus was found
in the umbilicus and induration was extending 2 cm below
umbilicus in midline. There was a 0.5×0.5 cm granuloma
protruding out from umbilicus below which sinus opening
was situated. The patient was given oral antibiotic
(amoxicillin and clavulanic acid) for seven days along with
anti-inflammatory drugs. After 1 week we planned for
surgical excision of granuloma and sinus.
Surgical excision under local anaesthesia was started and
during the surgery it was found to have communication to
the deeper plane. Since patient was complaining of pain so
spinal anaesthesia was given and procedure was restarted.
Layers of anterior abdominal wall were opened gradually
along the sinus tract and sheath was opened to expose the
ABSTRACT
A patent urachus is one of the spectrums of congenital urachal anomalies. It has been termed as "urachal fistula" when
the lumen of intra-embryonic portion of allantois persist abnormally. Persisting urachal fistula is a rare condition mostly
diagnosed during childhood or in autopsies. Here we report a very rare case of urachal fistula of a young male. We
present a case of 22 years male with intermittent periumbilical pain and sero-purulent discharge from umbilicus since
birth. On examination sero-purulent discharging umbilical sinus with granuloma was present. Surgical excision of
whole of the urachal fistulous tract was done with repair of bladder. Patient did well during post-operative period.
Persisting urachal fistula in adult is rare entity and difficult to diagnose because of low incidence and non-specific
symptoms. So a high index of suspicion is required in order to make the early diagnosis of urachal anomalies.
Keywords: Urachus, Urachal Fistula, Allantois, Umbilical sinus
Department of General Surgery, Institute of Medical Sciences, BHU, Varanasi, India
Received: 29 June 2020
Accepted: 06 August 2020
*Correspondence:
Dr. Vipul Kumar Srivastava,
E-mail: vipulsrivastava1992@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20203813

Srivastava VK et al. Int Surg J. 2020 Sep;7(9):3102-3104
International Surgery Journal | September 2020 | Vol 7 | Issue 9 Page 3103
peritoneum. Upon exploration of peritoneum and extra
peritoneal tissue it was found that this sinus was attached
to urinary bladder (Figure 1a and b). By now it was evident
to be a case of urachal fistula so to confirm that we did
methylene blue dye test. A Foley’s catheter was placed per
urethrally and methylene blue dye was injected into the
sinus opening at umbilicus. After sometime the dye was
seen in the catheter confirming the patent urachus. Now
distal part of fistulous tract attached to bladder was excised
and bladder rent was repaired in two layers. Specimen was
taken out and abdomen was closed. Catheter was left for 2
weeks. Patient did well during postoperative period.
Histopathology of the specimen did not show any
malignant pathology.
Figure 1: (a) and (b) Intraoperative photograph of
patient showing tubular structure connecting
umbilicus and urinary bladder-urachal fistula.
DISCUSSION
The persistence of the urachus was first described and
treated in 1550 by Cabrolius as mentioned by Begg.3 The
urachus is an embryological remnant situated in lower
midline of the abdomen within the retro pubic space of
retzius. It connects the anterior dome of the bladder to the
umbilicus but normally it is obliterated to form median
umbilical ligament. Collectively, the urachus is formed by
remnants of the cloaca and the allantois and so their
remnants are formed due to incomplete regression of the
intra-embryonic connection between them.4,5 Urachal
anomalies can be due to either congenital or acquired
causes. Congenital causes can be further subdivided into:
patent urachus, umbilical-urachal sinus, vesicourachal
diverticulum, urachal cyst, and alternating sinus.2 While
acquired urachal remnant diseases are classified into two
groups: infections and neoplasms.6 Among the congenital
urachal anomalies except patent urachus the remaining
four anomalies may close at birth but can reopen after
pathological conditions and therefore may be classified as
acquired urachal remnant diseases. The patent urachus is
purely congenital. It is frequently symptomatic pre- and
post natally.7 Most of the patients have urinary leakage
from the umbilicus.
The incidence of patent urachus is 3 in 1,000,000 live
births and is even rare in adults.8 Also patent urachus are
seen more commonly in men. In our case the patient had
presented in his adulthood which may be due to small
lumen of urachus which was patent.9 Mostly the patient
presents with umbilical discharge and its complications
like infection, urinary tract infection, umbilical cellulitis,
intraperitoneal rupture, bowel fistulae, bleeding and most
severe the neoplastic lesions due to chronic inflammation.
So any case of patent urachus or urachal fistula must be
taken care of as otherwise may lead to formation of
malignant tumors. Due to the low incidence and
heterogeneous presentation most often they are
misdiagnosed as appendicitis, Meckel’s diverticulitis,
urinary tract infection, pelvic inflammatory disease, and
bladder carcinoma.10 Computed tomography scan remains
the investigation of choice for suspected cases while
longitudinal ultrasound, indigocarmine dye discharge test
or fistulography are other means to diagnose the disease.11
In our case also the diagnosis was uncertain and we
operated the patient thinking that it was an infected
umbilical sinus but during the course of operation we came
to realize that it was a case of patent urachus. The standard
care of treatment in these disease must include removal of
whole of the tissue. This is due to the fact that inner layer
of urachal fistula or sinus contains transitional epithelium
which on prolonged inflammation has high chance of
transforming into adenocarcinoma.12
CONCLUSION
The congenital patent urachus is rare in adults. Further,
clinical diagnosis is delayed or ambiguous in these patients
due to low incidence and non-specific symptoms. So a
high index of suspicion is required in order to make the
diagnosis and to prevent subsequent complications. Early
detection of urachal anomalies can help optimize an
appropriate surgical approach if required and reduce the
risk of subsequent development of malignancy.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Srivastava VK, Roy S, Meena
RN, Khanna R. Urachal fistula in a 22 year male: a
case report. Int Surg J. 2020;7(9):3102-4.