PARAMEATAL URETHRAL CYST IN A 20-YEAR-OLD MALE
PATIENT: A CASE REPORT
Fransiska Yofita Olga Wemona1, Putu Kurnia
Darma2, Rozaqy Ishaq3,
Taufik Indrawan4
RSUD dr. Mohamad
Soewandhie Surabaya, East Java, Indonesia
yofolga@gmail.com1, kurniadarmapratama@gmail.com2,
m.rozaqy.ishaq@gmail.com3,
tfkurologi@gmail.com4
KEYWORDS |
ABSTRACT |
parameatal urethral cyst, rare
anomaly, male patient, case report |
The
parameatal urethral cyst is a rare anomaly and appears as a small blister in
proximity to the urethral meatus. These cysts may result from occlusion of
paraurethral ducts or, in other cases, from faulty preputial separation from
the glans along the coronal sulcus. A 20-year-old male patient came to our
outpatient clinic at dr. M. Soewandhie General Hospital Surabaya with a
cystic lesion on the right side of the external urethral meatus. The patient
only found out about his situation one year ago, and he did not experience
any complaints except a branched urination. On physical examination, an 8 mm
cystic lesion was found on the right side of the external urethral meatus.
The patient consented to complete surgical excision of the cyst. The
procedure was performed under regional anesthesia. The cyst was completely
resected from the surrounding tissues. One month after surgery, there is no
post-operative pain and good urine flow, and the patient is also satisfied
with the post-operative condition. Histologic examination shows pieces of
tissue in the form of polypoid lined with squamous epithelium underneath,
stroma of fibrous tissue with proliferation of blood vessels and some
inflammatory cells of lymphocytes in between. There are no signs of
malignancy. Parameatal urethral cyst is an abnormal and rare case, usually
asymptomatic. However, sometimes dysuria, urinary retention, branching urine,
and cosmetic problems are the reasons that cause patients to seek a doctor's
help. It can be diagnosed just on physical examination and can be cured by
complete excision. |
DOI: 10.58860/ijsh.v3i1.148 |
|
Corresponding Author: Fransiska Yofita Olga Wemonal
Email: yofolga@gmail.com
INTRODUCTION
The parameatal urethral cyst is a rare anomaly and appears as a small
blister in proximity to the urethral meatus (Fischer, 2019; Zaontz & Long, 2022). It was
first reported in two cases in 1956 by Thompson and Lantin, so far 50 cases
have been published. These cysts may result from occlusion of paraurethral
ducts or, in other cases, from faulty preputial separation from the glans along
the coronal sulcus (Fahmy, 2015; Liu et al., 2018; Skrodzka et al., 2020).
Urethral
parameatal cysts are rare anomalies that appear as small vesicular lesions near
the urethral meatus but usually do not interfere with the urinary tract or sexual
function (Agrogiannis
et al., 2018; Partin
et al., 2021). This cyst usually appears at
birth or early childhood and usually appears in the ventral or lateral part of
the urethral meatus (Shaw
et al., 2018). Urethral parameatal cysts
are urethral lesions that can occur in children and young adults (Fahmy,
2015; Cha et
al., 2023). This condition is a rare
case report, only less than 50 cases have been reported. The first case was
reported by Thompson and Lantin in 1956 (Shaw
et al., 2018; Tavukcu
et al., 2017; Oktaviani
& Hoetama, 2020; Lal
& Ankur, 2013).
The largest
series was published by Willis et al. in 2011, which reported 18 pre-pubertal
boys. In addition to this series, Shiraki reported 9 cases in 1975 (Hodson
et al., 2012; Saki
et al., 2017; Tavukcu
et al., 2017). Shiraki (1975) interpreted
that this cyst may have formed from occlusion of the paraurethral duct or, in
other cases, derived from incomplete preputial separation of the gland along
the coronal sulcus (Yamada
et al., 2013; Patil
et al., 2015). Hill and Ashken refer to
obstruction that occurs as a result of an infection (Mahato
et al., 2014). The cyst wall can be
transitional and squamous or columnar epithelium (Partin
et al., 2021).
Urethral
parameatal cysts are usually an incidental finding on physical examination (Tsili
et al., 2023). They are mostly
asymptomatic, although sometimes accompanied by several symptoms, including
dysuria, frequency, distortion of urine flow, or urinary retention (Partin
et al., 2021; Yu et
al., 2022). Most cysts in the pediatric
population are less than 1 cm in size and do not cause urinary problems (Nuari
& Widayati, 2017). The differential diagnosis
includes epidermoid cyst, pilosebaceous cyst, fibroepithelial polyp and
juvenile xanthogranuloma (Shaw
et al., 2018).
The action that
can be performed is a surgical cyst excision procedure with the patient under
anesthesia. Surgical procedures must be carried out carefully so as not to
cause meatal stenosis, to prevent recurrence and obtain good cosmetic results (Partin
et al., 2021; Shaw
et al., 2018; Mahato
et al., 2014; Tavukcu
et al., 2017; Oktaviani
& Hoetama, 2020; Lal
& Ankur, 2013).
CASE
A 20-year-old
male patient came to our outpatient clinic at dr. M. Soewandhie General
Hospital Surabaya with a cystic lesion on the right side of the external
urethral meatus. The patient only found out about his situation one year ago,
and he did not experience any complaints except a branched urination. On
physical examination, an 8 mm cystic lesion was found on the right side of the
external urethral meatus. The patient consented to complete surgical excision
of the cyst. The procedure was performed under regional anesthesia. The cyst
was completely resected from the surrounding tissues. One month after surgery,
there is no post-operative pain and good urine flow, and the patient is also
satisfied with the post-operative condition. Histologic examination shows
pieces of tissue in the form of polypoid lined with squamous epithelium
underneath, stroma of fibrous tissue with proliferation of blood vessels and
some inflammatory cells of lymphocytes in between. There are no signs of
malignancy.
RESULTS AND DISCUSSION
Anamnesis and
physical examination were carried out autonamanesis on Monday, July 25th
2022, at 02.00 PM.
Patient identity
Name : Mr. AF
No.
MR : 690333
Gender : Male
Date
of birth/age : November 7th
2001/20 years old
Occupation
: Student
Religion : Islamic
Address
: Tambak Asri
Gading
Anamnesis
· Main complaint :
Lump on the right
side of the penis
· History of current illness :
The patient came to the urology
clinic at dr. M. Soewandhie General Hospital Surabaya with complaints of a lump
on the right side of the penis. The patient said he only found out about his
condition in the last year when he wanted to have a routine check-up. The
patient said that there was no lump when the patient was small. The patient did
not complain of anything other than branching of urine.
· Past medical history :
Hypertension (-), Diabetes mellitus (-)
· Family history of illness :
Hypertension (-), Diabetes mellitus (-)
· Treatment history :
There is not any
· Operation history :
Never had a history
of previous surgery
· Allergy history :
There is not any
Physical examination
· Generalist status
o
General condition :
sufficient
o
Consciousness :
composmentis
o
GCS : 4-5-6
o
TTV
§ Blood Pressure : 110/70 mmHg
§ Pulse :
88x/minute, regular, strong lift
§ Respiration : 20x/minute, regular
§ Temperature :
36.8 °C
§ SpO2 : 99%
spontaneous
o
Head
§ Conjunctiva :
anemic (-/-)
§ Sclera : icteric (-/-)
§ Cyanosis : (-)
§ Dyspnea : (-)
o
Neck
§ Lymph nodes : no lymph nodes enlargement
o
Thorax
§ Heart
·
Inspection :
ictus cordis was seen at the left midclavicular 5th ICS
·
Palpation :
ictus cordis is palpable at the 5th ICS of the left mid-clavicle
·
Percussion :
upper right border on the right parasternal 2nd ICS, lower right border on the
right parasternal 4th ICS, upper left border on the left parasternal 2nd ICS
and lower left border on the left midclavicular 4th ICS
·
Auscultation :
single S1/S2, murmur (-), gallop (-)
§ Lungs
·
Inspection :
symmetrical breathing movements, injury (-), mass (-)
·
Palpation : right
and left fremitus are the same
·
Percussion :
sonor/sonor
·
Auscultation :
vesicular (+/+), rhonchi (-/-), wheezing
(-/-)
o
Abdomen
§ Inspection : supple, mass (-), injury (-)
§ Auscultation : normal bowel sounds
§ Percussion : tympanic throughout the
abdominal area
§ Palpation : no tenderness was found
The entire abdominal area, liver and spleen are not palpable.
o
Extremities
§ Upper extremities : warm dry red, edema (-/-), CRT <2
seconds
§ Lower extremities : warm dry red, edema (-/-), CRT <2
seconds
·
Urological status
o
Right costovertebral region :
kidney ballottement not
palpable, tumor mass (-), knocking pain on costovertebral angle (-)
o
Left costovertebral region :
kidney ballottement not
palpable, tumor mass (-), knocking pain on costovertebral angle (-)
o
Suprapubic region :
flat, buldging (-), hematoma (-), tumor mass (-), tenderness
(-)
o
External genitalia region
§ Penis : a cyst appears on the external urethral
meatus dextra measuring 8 mm
§ Scrotum : tumor mass (-), tenderness
(-)
o
Perineal and anorectal regions
§ Rectal
Touche : Good anal sphincter tone, smooth
rectal mucosa, prostate not palpable, tenderness (-), mucus (-), feces (-)
·
Clinical Photo
Figure 1. Cystic mass formation in the right external
urethral meatus
Supporting investigation
·
Pre-OP complete blood &
urine (07-05-2022)
Table 1. Complete Blood & Complete Urine pre-OP
Inspection |
Results |
Reference
Value |
Complete
Blood |
||
Hemoglobin |
15.0
g/dL |
13.2-17.3 |
Erythrocyte Count |
5.79
10^6/uL |
4.40-5.90 |
Hematocrit |
45.8
% |
40.0-52.0 |
Leukocyte Count |
9.33
10^3/uL |
3.80-10.60 |
Count Types |
|
|
Eosinophils |
2.1
% |
2.0-4.0 |
Basophils |
0.3
% |
0-1 |
Neutrophils |
59.6
% |
50-70 |
Lymphocytes |
32.6
% |
20-40 |
Monocytes |
5.4
% |
2-8 |
Eosinophil # |
0.20
10^3/uL |
0.00-0.40 |
Basophil # |
0.30
10^3/uL |
0.00-10 |
Neutrophil # |
5.56
10^3/uL |
1.50-7.00 |
Lymphocytes # |
3.04
10^3/uL |
1.0-3.7 |
Monocytes # |
0.50
10^3/uL |
0.00-0.70 |
N/L Ratio |
1.83 |
<3.13 |
Platelet Count |
360
10^3/uL |
150-400 |
MCV |
79.1
fL (L) |
81.0-96.0 |
MCH |
25.9
pg (L) |
27.0-36.0 |
MCHC |
32.8g/L |
31.0-37.0 |
RDW-CV |
12.9
% |
10.0-15.0 |
RDW-SD |
36.2
fL (L) |
37-54 |
MPV |
8.6
fL |
6.5-11.0 |
HFLC |
0.1
% |
0-1.4 |
Random Blood Glucose |
99
mg/dL |
70-200 |
HBsAg (CMIA) |
0.33
Non-Reactive S/CO |
MRR |
Blood Potassium |
4.6
mg/dL |
3.5-5.0 |
Blood Creatinine |
0.8
mg/dL |
0.6-1.3 |
Blood Sodium |
146
mmol/L |
136-146 |
PT |
9.9
seconds |
9.7-13.1 |
INR |
0.87 |
|
APTT |
29.4
seconds |
24.5-32.8 |
BUN |
10
mg/dL |
7-22 |
SGOT |
19
U/L |
15-37 |
SGPT |
34
U/L |
12-78 |
Anti-HCV |
Negative |
Negative |
Complete
Urine |
||
Color |
Yellow |
Yellow |
Specific gravity |
1,015 |
1,000-1,030 |
pH |
6.5 |
4.5-8.0 |
Leukocytes |
Negative |
Negative |
Nitrite |
Negative |
Negative |
Proteins |
Negative |
Negative |
Glucose |
Negative |
Negative |
Ketones |
Negative |
Negative |
Urobilinogen |
Normal |
Normal
(<1.0) |
Bilirubin |
Negative |
Negative |
Erythrocytes |
Negative |
Negative |
Erythrocyte Sediment |
0-1/lpb |
0-2 |
Leukocyte Sediment |
0-1/lpb |
0-1 |
Epithelium |
0-1/lpb |
0-2 |
Cylinder |
- |
- |
Crystal |
Negative |
Negative |
Diagnosis
External Urethral Parameatal Cyst
Planning
·
Therapy :
Cyst excision
·
Monitoring :
Patient complaints (cosmetics, urinary tract problems improved)
·
Education :
Disease education, action plan, goals and risks of surgery, complications that
may occur, informed consent
Durante OP & Follow Up
On physical
examination, a cystic mass measuring ± 8 mm was found on the right side of the
external urethral meatus. The patient agreed to undergo surgical excision of
the cyst. This procedure is performed under regional anesthesia. The cyst is
resected from the surrounding tissue and then examined in the anatomical
pathology laboratory to determine the cell type of the cyst. After one week,
the patient came back to the clinic for control with complaints that had
improved. There is no pain, and the urination has not branched. One month
later, the patient was in control, there was no post-operative pain, urine flow
was good, and the patient was also satisfied with the post-operative condition.
Histological examination showed polypoid-shaped pieces of tissue lined with
squamous epithelium, beneath which fibrous tissue was visible with
proliferation of blood vessels and some lymphocytic inflammatory cells among
them. There were no visible signs of malignancy. This is in line with case
report discusses about a 5-year-old male with a cystic lesion around the
urethral meatus, which is a rare congenital condition. The patient underwent
complete excision of the cyst, and the management aligns with the findings in
the provided case, where the patient underwent surgical excision of the cyst,
leading to post-operative improvement and satisfaction (Oktaviani
& Hoetama, 2020). Urethral
parameatal cysts are urethral lesions that can occur in children and young
adults (Fahmy, 2015; Cha et al., 2023). This cyst usually appears at birth or
early childhood and usually appears in the ventral or lateral part of the
urethral meatus (Shaw et al., 2018).
Figure
2. Surgical procedure for cyst excision
Figure 3. Clinical photo 1
week post-op
Figure 4. Clinical photo 1
month post-op
Figure 5. Lab Results.
Anatomical Pathology
CONCLUSION
The research objective for
studying parameatal urethral cysts is to understand the clinical presentation,
diagnosis, and treatment outcomes of this rare condition. The conclusion drawn
from the research should provide clear insights into the management and
prognosis of parameatal urethral cysts, particularly focusing on the
effectiveness of complete excision as a curative treatment. The available
literature on parameatal urethral cysts indicates that this condition is rare
and often asymptomatic, but it can lead to issues such as dysuria, urinary
retention, and cosmetic concerns. Diagnosis can typically be made through
physical examination, and complete excision is reported to be an effective
treatment, with low recurrence rates. The main objective of treatment is to
achieve good cosmetic results and prevent recurrence.
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2024 by the authors. It was submitted for possible open-access publication
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