A Forgotten Fetal Remnant in Adulthood: Vesicourachal Diverticulum: A Case Report

Jonathan Charles Lamptey: formal analysis. Dennis Awedam Achio: conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review and editing. Mary Monney‐Bortey: formal analysis, investigation. Gordia Adjoa Frimpomaa Amoako: writing – review and editing. Kofi Adutwum Appiah‐Kusi: writing – review and editing. Bernice Ahiadormey: writing – review and editing. Carl Christian Golightly: writing – review and editing. Rosing Namara Bainge: writing – review and editing. Theophilus Aboagye Aduama: writing – review and editing. Samuel Ofosu Agamah: writing – review and editing. Eunice Wilberforce A. Achio: writing – review and editing. Priscilla Mary Tetteh: writing – review and editing. Lawrence Jerry Akuaku: writing – review and editing. Richmond K. E. Buckner: writing – review and editing. Akana Allorkpe: writing – review and editing.

Ethical approval was not applicable. The study was conducted in accordance with the Declaration of Helsinki.

The authors have nothing to report.

A 38‐year‐old British woman presented with a 1‐year history of lower urinary tract symptoms, including urinary frequency, nocturia, and dysuria. These symptoms began shortly after the delivery of her second child and were associated with recurrent urinary tract infections (seven times in 6 months), which were treated with antibiotics. There was no history of hematuria, terminal dribbling, urinary retention, umbilical discharge, fever, chills, or headaches. Her past medical history was notable for ulcerative colitis and recurrent urinary tract infections. She is on Salazopyrin (three tablets morning and evening) and folic acid (5 mg daily). She reported a severe adverse reaction to non‐steroidal anti‐inflammatory drugs due to her ulcerative colitis. There was no significant family medical history. Socially, the patient is married and had been residing in Ghana for 8 years. She was a former smoker and alcohol consumer, both habits having been discontinued several years prior. She is a mother of two healthy children. Obstetric history revealed that her first delivery was a spontaneous vaginal delivery, whereas her second was an emergency caesarean section performed due to delayed labour and fetal heart decelerations. She reported no postpartum complications. On physical examination, the patient appeared comfortable, not pale, not jaundiced, and well‐hydrated. Her vital signs were stable. Chest examination revealed adequate air entry bilaterally with vesicular breath sounds and no added sounds. Cardiovascular examination had normal heart sounds with no murmurs. Abdominal examination revealed a soft, full, non‐tender abdomen, with no umbilical discharge or organomegaly; a healed Pfannenstiel incision was noted. The central nervous system examination was normal. A routine abdominopelvic ultrasound revealed an anterior bladder dome cystic lesion, with a differential diagnosis of urachal cyst/diverticulum Figure  1 . She was referred to the urology clinic for further evaluation. A computed tomography intravenous urogram showed a urachal remnant arising from the anterior/superior margin of the bladder and extending to the umbilical region, a length of 148 mm and a width of 3 mm, and with features consistent with an umbilical urachal sinus (Figures  2 , 3 , 4 ). Abdominopelvic ultrasound showing an anterior bladder dome cystic lesion suggestive of a urachal cyst. Computed tomography intravenous urogram (CT IVU) and pelvis sagittal plane showing urachal remnant (white arrows) coming from the anterior/superior margin of the bladder and extending to the umbilical region. Computed Tomography Intravenous Urogram (CT IVU) and pelvis sagittal plane showing urachal remnant length of 148 mm and a width of 3 mm. Axial image of computed tomography intravenous urogram (CT IVU) showing umbilical urachal remnant. Laboratory evaluation revealed normal renal function, with a serum creatinine of 54.6 μmol/L and an estimated glomerular filtration rate (eGFR) of 117 mL/min/1.73 m 2 . A mild normocytic anemia was noted (Hb 11.7 g/dL, MCV 91.8 fL, MCH 33.8 g/dL, HCT 34.6%), while electrolyte levels were within the normal range. Urinalysis showed hazy urine with 8 red blood cells per high‐power field, but no leukocytes or nitrites, and urine culture yielded no bacterial growth. During surgery, an intraoperative finding was a urachal tract extending from the umbilicus to the bladder dome with a clear communication with the bladder. The urachal tract was excised from the umbilical region and the bladder dome, and a bladder repair was done. There was no evidence of abscess formation or malignancy (Figures  5 , 6 , 7 ). Urachal sinus excised from the umbilical region. Urachal sinus excision from the bladder dome. Repair of the bladder. Histopathological findings revealed urothelial‐lined ducts consistent with a urachal remnant, with no evidence of dysplasia or malignancy. Postoperative recovery was uneventful, and the patient experienced no lower urinary symptoms or urinary tract infections at 2‐week, 6‐week, 3‐month, and 6‐month follow‐ups.

Vesicourachal diverticulum, a rare embryological remnant in adulthood, should be considered in patients presenting with persistent lower urinary tract symptoms that fail to respond to standard medical therapy. This case highlights the importance of maintaining a high index of suspicion, particularly when imaging reveals a cystic lesion at the bladder dome. Ultrasonography and contrast‐enhanced computed tomography play a pivotal role in establishing the diagnosis and delineating the extent of the anomaly. The patient underwent definitive surgical excision of the urachal remnant following appropriate antibiotic therapy. Histopathological examination confirmed a urachal remnant with no evidence of malignancy. Postoperatively, the patient had an uneventful recovery and remained symptom‐free during follow‐up.

The urachus is a vestigial embryologic structure derived from the allantois and cloaca, extending from the anterior dome of the bladder to the umbilicus and normally obliterating after birth to form the median umbilical ligament [ 1 ]. Urachal anomalies are broadly classified into congenital and acquired. Congenital urachal anomalies develop during embryogenesis and persist after birth. Normally, the urachus forms early in fetal life and subsequently obliterates before delivery. Around Day 13 postconception, the yolk sac develops, and by Day 16 it gives rise to the allantois and cloaca [ 3 ]. The allantois later contributes to the formation of the umbilical vessels, while the cloaca develops into the urinary bladder. Between 4 and 7 weeks of gestation, the allantois and cloaca remain connected by an epithelial tube known as the urachus [ 3 ]. As gestation progresses, the bladder descends into the pelvis, the umbilical cord matures, and the urachus becomes more distinct (Figure  8 ) [ 4 , 5 ]. Drawing illustrates the cloaca and allantois. The urachus measures approximately 30–100 mm in length and 8–10 mm in diameter [ 6 ]. By the third trimester, the urachus normally obliterates and becomes the medial umbilical ligament [ 7 ]. Failure of this process results in congenital urachal anomalies, which are more commonly diagnosed in the pediatric population and may present with abdominal complications [ 8 ]. Acquired urachal anomalies occur later in life and include infection and neoplasm [ 9 ]. These conditions arise when a previously closed urachal remnant becomes disrupted, inflamed, or reopens due to trauma, infection, or tumor formation [ 7 , 8 , 10 ]. Some reports describe sporting activities as precipitating factors that aggravate previously asymptomatic urachal cysts or reopen a closed urachus [ 8 , 11 ]. Acquired urachal anomalies are more commonly seen in adolescents and adults. Failure of complete involution results in a spectrum of urachal anomalies, including patent urachus (A), urachal sinus (B), vesico‐urachal diverticulum (C), and urachal cyst (D). Patent urachus results in persistent communication between the bladder and umbilicus; a urachal sinus is a blind‐ending tract communicating with the umbilicus; a vesico‐urachal diverticulum is an obliterated tract communicating with the bladder; and a urachal cyst represents a remaining double blind ending cavity of the urachal canal (Figure  9 ) [ 1 , 12 ]. Drawing illustrating the spectrum of urachal anomalies. Urachal anomalies occur in approximately 1 in 5000 children and are more common in males, with a male‐to‐female ratio of 3:1. However, they are uncommon in adults, with an incidence of roughly 2 per 100,000 hospital admissions and frequently pose diagnostic difficulties [ 2 ]. In adults, infection is the most common complication of urachal remnants and may manifest as recurrent urinary tract infections, suprapubic discomfort, umbilical discharge, or a midline infraumbilical mass. Chronic inflammation may predispose to epithelial metaplasia and, rarely, malignant transformation, most commonly urachal adenocarcinoma [ 12 ]. Because symptoms often mimic more common urological or gynecological conditions, a high index of suspicion is required, particularly in patients with persistent or recurrent lower urinary tract symptoms unresponsive to standard therapy. Imaging plays a central role in evaluation. Ultrasonography serves as a useful initial modality, while contrast‐enhanced computed tomography provides superior delineation of the tract, defines its relationship to the bladder dome and surrounding structures, and helps exclude malignancy. Magnetic resonance imaging may further characterize complex or infected lesions [ 13 , 14 ]. Definitive diagnosis is confirmed histopathologically following excision. Complete surgical removal of the urachal remnant, with or without a cuff of bladder tissue depending on the extent of involvement, remains the treatment of choice in symptomatic adults [ 15 ]. In the presence of infection, culture directed antibiotic therapy should precede or accompany surgical management. Early recognition and timely intervention not only resolve recurrent infections but also prevent serious complications such as abscess formation, fistulization, sepsis, and potential malignant transformation [ 16 ]. The patient expressed satisfaction in her quality of life, as she currently does not experience recurrent urinary tract infections.

The authors certify that written informed consent was obtained from the patient to publish this report.

Vesicourachal diverticulum. Urachal cyst. Urachal sinus. Cystic adenomyosis or endometriotic cyst. Bladder wall neoplasm. Vesicourachal diverticulum. Urachal cyst. Urachal sinus. Cystic adenomyosis or endometriotic cyst. Bladder wall neoplasm.

The urachus is a fibrous remnant of the allantois connecting the fetal bladder to the umbilicus, which normally obliterates before birth [ 1 ]. Persistence of this tract may lead to urachal anomalies such as cysts, sinuses, diverticula, or a patent urachus. These remnants are uncommon in adults and are often asymptomatic but may present with lower urinary tract symptoms (LUTS), recurrent urinary tract infections (UTIs), umbilical discharge, hematuria, or suprapubic pain. Delayed diagnosis can result in complications, including secondary infection, abscess formation, stone development, and rarely, urachal adenocarcinoma [ 2 ]. We present a case of an adult female with recurrent UTIs due to a vesicourachal diverticulum.

The authors declare no conflicts of interest.