Urachal Abscess: A Rare Etiology of Acute Abdominal Pain in Adults.

Abdominal pain is a common cause of emergency department visits. It often poses a diagnostic challenge for physicians given the broad spectrum of its possible medical and surgical etiologies. We report the case of a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. Abdominal examination revealed suprapubic mass and tenderness. Laboratory investigation revealed elevated leukocyte count and inflammatory markers. An abdominal ultrasound examination showed a collection with poorly defined borders. Additionally, CT demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus, conferring the diagnosis of a urachal abscess. The patient underwent successful management of the abscess with surgical excision. This case highlights the importance for clinicians to be aware of congenital urachal anomalies since early recognition of the urachal cyst is essential to determine the proper surgical management.

Introduction

Abdominal pain is a leading cause of emergency department visits. It is reported that abdominal pain accounts for approximately 5% of all such visits [1]. The condition often poses a diagnostic challenge for physicians due to the broad spectrum of its possible medical and surgical etiologies. While careful history taking and physical examination are crucial in making the diagnosis related to abdominal pain, imaging modalities are essential tools to make a definite diagnosis. In this report, we discuss the case of a young male patient who presented with abdominal pain and fever, which was found to be associated with a urachal abscess, which is an exceedingly rare clinical entity.

Case presentation

The patient was a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. His pain was persistent throughout the day and was stabbing in nature. He scored the pain as 7 out of 10 in intensity. It was associated with fever, nausea, and vomiting. There was no history of change in bowel motions or urinary symptoms. His past medical history was remarkable for a peptic ulcer disease. He had not undergone any surgical procedure previously. He was a non-smoker and did not drink alcohol. The family history was non-contributory. Of note, the patient did not have a history of diabetes mellitus, chronic steroid therapy, or any immunodeficiency disorders.

On examination, the patient looked tired and his vital signs revealed a low-grade fever and tachycardia. Abdominal examination showed tenderness in the lower abdomen with evidence of suprapubic mass. No overlying skin changes were noted. The abdomen was soft and lax with no signs of guarding or rigidity. Laboratory investigation revealed a leukocyte count of 14,200/𝜇L and erythrocyte sedimentation rate of 23 mm/hr. Other biochemical investigations, including renal and liver function tests, were within normal limits.

An abdominal ultrasound examination of the patient revealed a spheric collection with poorly defined borders. Subsequently, an abdominal CT scan was performed, which demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus (Figures 1, 2). Based on the clinical and radiological features, he was diagnosed as having a urachal abscess. A cystourethrogram was performed and revealed no communication with the bladder.

Figure 1

Axial CT image

Axial CT image of the pelvis showing a soft tissue mass (arrow) adjacent to the anterior abdominal wall

CT: computed tomography

Figure 2

Sagittal CT image

Sagittal CT image of the abdomen demonstrating the soft tissue mass (arrow) extending from the bladder to the umbilicus

CT: computed tomography

The culture from the obtained specimen of the abscess revealed growth of Staphylococcus aureus. The patient was administered a broad-spectrum intravenous antibiotic therapy, which resulted in clinical improvement with the resolution of the fever. He was then prepared for laparotomy, which confirmed the diagnosis of a urachal abscess. The mass was excised successfully without any injury to the bladder wall. The patient tolerated the operation well and did not develop any complications. He was discharged on the fourth postoperative day.

Discussion

We presented the case of a young man with a urachal abscess presenting with acute abdominal pain and fever. The urachus is a ductal embryological remnant extending from the bladder dome to the umbilicus. Failure to completely obliterate this duct results in congenital urachal anomalies that may result in abdominal or urinary symptoms. Congenital urachal anomalies are seen in one per 5,000 live births, but they are very rare in adults [2]. Owing to the increased number of radiological investigations, it is found that urachal anomalies are more prevalent than previously thought.

The urachal cyst develops when both ends of the urachus are obliterated. It usually develops in the lower third of the urachal tract. The size of the cyst varies, but it tends to be small in size. In most cases, the cyst is usually asymptomatic and gets detected incidentally by imaging. However, it may become symptomatic if it grows to a significant size or gets infected. Due to its rarity, congenital urachal anomalies may be confused with other clinical conditions [3].

Infection is the most frequent complication encountered in urachal cysts. The infection may be caused by a wide spectrum of gram-positive and gram-negative organisms that reaches the cyst by different routes, including hematogenous, lymphatic, or vesical. On rare occasions, the infected cyst may grow significantly and rupture, causing peritonitis. Complete excision of the cyst is crucial since the infection can recur even if it is successfully treated [4].

Malignant transformation of the urachal lining is another important complication of urachal remnant disease. While they are very rare, adenocarcinoma is the most common histopathological type of such tumors. Although that the normal lining of the urachus is transitional epithelium, most urachal neoplasms are not transitional cell carcinoma. These tumors are more common among men and often develop above the age of 40 years. Urachal tumors often have a poor prognosis because they present at late stages [5].

As in the present case, the clinical manifestation of a urachal cyst may mimic an acute abdomen [6]. The diagnosis of urachal anomalies may be delayed as it lacks specific signs and symptoms. Imaging modalities are essential to delineate the anatomic location of the cyst and its relationship to the bladder and umbilicus [7]. An ultrasound or CT scan is needed to make the diagnosis by demonstrating a fluid-filled cavity located along the lower abdominal wall.

Due to the rarity of the condition, an optimal management approach to it has not been established yet. The excision of the cyst may be done as a two-stage procedure involving incision and drainage followed by a delayed excision of the urachal remnant. Since the patient’s condition in the present case was stable, we undertook a single-stage approach. Postoperative care is essential because the procedure can be complicated by certain complications such as fistula formation, urinary leakage, and infections ranging from wound infection to severe sepsis.

Conclusions

The urachal cyst is a rare etiology of acute abdominal pain in adults. This case highlights the importance of being aware of congenital urachal anomalies since early recognition of the urachal cyst is essential to determine the proper surgical management. Physicians should take this condition into consideration when encountering a patient with acute abdominal pain and a palpable lower abdominal mass.