Festered Urachal Cyst in an Adult – An Odd Version

Background: Urachal anomalies are rare and result from incomplete obliteration of the urachal remnant. We report a 37-year-old male who came with complaints of lower abdominal pain and burning micturition for the past 1 week, who is a known case of type 2 diabetes mellitus under medication. Had a history of incision and drainage for a left ischiorectal abscess and open reduction and internal fixation of the left hip joint. On Ultrasonography (USG) of the abdomen, a heterogeneous collection measuring 4 x 3 x 3 cm was noted in the anterosuperior aspect of the urinary bladder, with inflammatory changes suggestive of infective etiology. He was managed with empirical antibiotics. Computer Tomography (CT) abdomen showed features suggestive of a urinary bladder wall abscess; USG-guided aspiration was done, and 40 ml of pus was drained and sent for culture; a sensitive antibiotic was started. His symptoms improved, and discharged. On follow-up, he had lower abdominal pain on and off and low-grade fever for 2 weeks, for which evaluated USG Abdomen showed Fatty liver/ Cystitis; appendix wall appeared thickened, measuring 4.2mm. There is an anechoic cystic collection of size 6.0 x 3.0 x 2.5 cm noted above the superior wall of the bladder with multiple septations and internal echoes suggestive of an infected urachal cyst. In Contrast Enhanced Computer Tomography (CECT) abdomen well defined heterogeneous collection of 4.7 x 2.9 x 2.7cm was noted in the perivesical space, with bilateral renal calculi. On cystoscopy, bilateral DJ stenting was done; with exploratory laparotomy, the perivesical abscess was drained, and tissue abutting the bladder was removed, along with an appendix. Due to its vague presentation, it required a high index of suspicion to make a timely diagnosis and appropriate management.

Keywords: Urachal anomaly, Urachal cyst, Perivesical abscess, Pyourachus, Urinary sepsis.