{"paper_id":"039693b1-bf28-45e0-9a80-b44c70aac060","body_text":"BioMed Central\nPage 1 of 3\n(page number not for citation purposes)\nJournal of Medical Case Reports\nOpen AccessCase report\nUrachal endometrioma: a case report\nKatherine M Browne*1, Stephen S Connolly1, Niamh Daly2, Tom Crotty3 and \nRobert J Flynn1\nAddress: 1Department of Urology, Adelaide and Meath Hospitals incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland, \n2Department of Gynaecology, Adelaide and Meath Hospitals incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland and \n3Department of Histopathology, Adelaide and Meath Hospitals incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland\nEmail: Katherine M Browne* - katheribrowne@rcsi.ie; Stephen S Connolly - sconnolly@rcsi.ie; Niamh Daly - niamh.daly@amnch.ie; \nTom Crotty - tom.crotty@amnch.ie; Robert J Flynn - robert.flynn@amnch.ie\n* Corresponding author    \nAbstract\nIntroduction: We discuss a rare presentation of an unusual case of endometrioma.\nCase presentation: A 40-year-old Caucasian woman presen ted with subacute abdominal pain\nand a suprapubic mass. A final diagnosis was made after the mass was resected and histopathology\nconfirmed an endometrioma originating from an urachal remnant. Select imaging studies and\nhistopathology are presented in this case report.\nConclusion: While endometriomata are well known to arise from abdominal scars, the condition\ndescribed in this case report is a rare example of an endometrioma arising from the urachus. A\nreview of the pathological complications of the urachus is also included.\nIntroduction\nEndometriosis is defined as the presence of endometrial\ntype glands and stroma outside the uterus. The areas usu-\nally affected are the fallopian tubes, ovaries, uterine liga-\nments, ureters and bladder [1]. The term endometrioma is\nused when endometriosis appears as a circumscribed\nmass. The most common involvement outside of the pel-\nvis occurs within the lower abdominal wall, caesarean sec-\ntion scars and less commonly the umbilicus. The\nincidence of endometriosis within an abdominal scar for\nhysterectomy is estimated at only 1% [2].\nCase presentation\nA 40-year-old Caucasian woman presented to the emer-\ngency room with a six-month history of progressive lower\nabdominal pain. She had failed to visit a doctor sooner for\nfear that she may have a malignancy. Her medical history\nwas notable for hysterectomy and unilateral salpingo-\noophorectomy five years prior to presentation to treat\nendometriosis. Her obstetric history was remarkable for\nthree lower segment caesarean sections, all via a suprapu-\nbic (Pfannenstiel) incision. Hormone replacement ther-\napy had been instituted four years previously following\nthe onset of symptoms of oestrogen insufficiency.\nA physical examination at the emergency room revealed a\n3-cm poorly defined, tender suprapubic mass extending\nto her umbilicus. The overlying skin was normal and the\nmass appeared to be tethered to the abdominal wall. No\nurinary symptoms were present and her urine analysis was\nclear. Contrast computed tomography of her abdomen\nand pelvis demonstrated a 3.3-cm lower abdominal mass\nintimately related to the dome of the bladder in a position\nthat was typical of urachus (Figure 1). Flexible cystoscopy\nPublished: 1 December 2009\nJournal of Medical Case Reports 2009, 3:9310 doi:10.1186/1752-1947-3-9310\nReceived: 12 October 2009\nAccepted: 1 December 2009\nThis article is available from: http://www.jmedicalcasereports.com/content/3/1/9310\n© 2009 Browne et al; licensee BioMed Central Ltd. \nThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), \nwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.\n\nJournal of Medical Case Reports 2009, 3:9310 http://www.jmedicalcaser eports.com/content/3/1/9310\nPage 2 of 3\n(page number not for citation purposes)\nreported the appearance of an extrinsic mass indenting\nthe dome of the bladder, but no mucosal abnormality was\nfound.\nA percutaneous trucut (16G) biopsy, which only showed\nthe presence of fibromuscular tissue, proved to be of no\nhelp. An open exploration of this urachal mass was per-\nformed through a laparotomy incision. No technical\nproblems were experienced intraoperatively. The fibrous\nmass was distinct and easily separated from the bladder.\nWide local excision was performed, but removal of a cuff\nof bladder was found unnecessary. Histopathological\nanalysis concluded the mass to be a benign endometri-\noma arising from the urachus. The patient's recovery has\nbeen excellent without any recurrence of the pain she pre-\nviously experienced.\nDiscussion\nAn embryologic structure, the urachus is the canal joining\nthe fetal urinary bladder to the allantois. The urachus,\nwhen obliterated normally, forms the median umbilical\nligament. Persistent remnants are uncommon but may\nstill manifest clinically as a vesicocutaneous fistula,\nurachal cyst or umbilical sinus. The presence of urothe-\nlium within the persistent urachus has been reported to\nresult in malignant transformation.\nA recent article in the American Journal of Surgery retro-\nspectively examined abdominal wall endometriomas and\nfound that the mean age of presentation was at 29.4 years.\nPresenting symptoms were noted to include abdominal\nmass, cyclical and non-cyclical pain with dysmenorrhea\n[3,4]. Although rather uncommon, endometriosis can\noccur in the postmenopausal (oestrogen-deprived) state\n[5], and usually occur in women who undergo unopposed\noestrogen replacement therapy [6]. Previous case reports\nhave described umbilical endometriosis with periodic\nbleeding from the umbilicus without prior pelvic or\nabdominal surgery [7].\nAs demonstrated in our patient, however, endometriosis\nmay masquerade as a tumour arising from the urachus\nSelected computed tomography images showing urachal endometriomaFigure 1\nSelected computed tomography images showing urachal endometrioma.\n \n\nPublish with BioMed Central   and  every \nscientist can read your work free of charge\n\"BioMed Central will be the most significant development for \ndisseminating the results of biomedical research in our lifetime.\"\nSir Paul Nurse, Cancer Research UK\nYour research papers will be:\navailable free of charge to the entire biomedical community\npeer reviewed and published immediately upon acceptance\ncited in PubMed and archived on PubMed Central \nyours — you keep the copyright\nSubmit your manuscript here:\nhttp://www.biomedcentral.com/info/publishing_adv.asp\nBioMedcentral\nJournal of Medical Case Reports 2009, 3:9310 http://www.jmedicalcaser eports.com/content/3/1/9310\nPage 3 of 3\n(page number not for citation purposes)\n[8]. Endometriosis can display local aggression, with uri-\nnary bladder endometriosis previously reported to extend\ninto the adjacent bowel [9]. Endometriosis of the abdom-\ninal wall scars is rare, especially in postmenopausal\nwoman. However, it must be considered as a possible\ncause of any abdominal wall mass in a woman who has\nhad previous pelvic surgery and who is of reproductive age\nor taking exogenous hormones. Malignant transforma-\ntion has been described in abdominal wall endometriosis,\nwith clear cell carcinoma and endometrial carcinoma\nbeing the most common reported variants. As such, radi-\ncal surgery is the most common treatment applied [10].\nConclusion\nThis case report illustrates a rare presentation of urachal\nendometrioma. Accurate final diagnosis can only be\naccomplished after surgical excision and histopathologi-\ncal examination of the mass. Malignant transformation\nhas been described in abdominal wall endometriosis and\nradical excision is the mainstay of treatment.\nConsent\nWritten informed consent was obtained from the patient\nfor publication of this case report and any accompanying\nimages. A copy of the written consent is available for\nreview by the Editor-in-Chief of this journal.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthors' contributions\nKB, SC and RF wrote and proofread the manuscript. ND\nand TC performed pathological work and research. They\nalso contributed in writing the manuscript. All authors\nread and approved the final manuscript.\nReferences\n1. Clement PB: Pathology of endometriosis.   Pathol Annu  1990,\n25:245-295.\n2. Chatterjee SK: Scar endometriosis: a clinicopathologic study\nof 17 cases.  Obstet Gynaecol 1980, 56:81-84.\n3. Bianco RG, Parithivel VS: Abdominal wall endometriomas.  Am J\nSurg 2003, 185(6):596-598.\n4. Dwivedi AJ, Agrawal SN, Silva YJ: Abdominal wall endometrio-\nmas.  Dig Dis Sci 2002, 47(2):456-461.\n5. Habuchi T, Okagaki T: Endometriosis of bladder after meno-\npause.  J Urol 1991, 145(2):361-363.\n6. Goodman HM, Kredentser D: Postmenopausal endometriosis\nassociated with hormonal replacement therapy.  J Reprod Med\n1989, 34(3):321-323.\n7. Zollner U, Girschick G: Umbilical endometriosis without previ-\nous pelvic surgery: a case report.   Arch Gynecol Obstet  2003,\n267(4):258-260.\n8. Crotty K: Endometriosis manifesting as urachal tumour.  South\nMed J 1994, 87(4):539-540.\n9. Stewart WW, Ireland GW: Vesical endometriosis in a postmen-\nopausal woman: a case report.  J Urol 1977, 118(3):480-481.\n10. Sergent F, Baron M, Le Cornec JB: Malignant transformation of\nabdominal wall endometriosis.  J Gynecol Obstet Biol Reprod (Paris)\n2006, 35(2):186-190.","source_license":"CC0","license_restricted":false}