Massive Prostatic Utricle Infection Mimicking Pelvic Abscess in a Child with Hypospadias

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Description

A six-year-old boy was admitted to a pediatric surgical unit because of persistent fever, painful urination, lower abdominal discomfort, and difficulty walking for five days. The child had undergone staged repair of proximal hypospadias at another institution during infancy. According to his parents, he had remained generally healthy afterward except for occasional urinary tract infections treated with oral antibiotics. Three days before admission, the patient developed high-grade fever associated with poor appetite and suprapubic pain. Local treatment with oral antimicrobial medication failed to improve symptoms. Progressive pelvic discomfort caused reluctance to stand upright or walk normally. There was no vomiting, diarrhea, or respiratory illness.

On examination, the child appeared febrile and ill-looking. Body temperature measured 39.2°C. Moderate suprapubic tenderness was present without signs of generalized peritonitis. External genital examination demonstrated a well-healed hypospadias repair with normal urinary stream during observed voiding. Digital rectal examination caused significant discomfort and revealed fullness anterior to the rectal wall. Laboratory investigations demonstrated leukocytosis, elevated C-reactive protein, and mild anemia. Urinalysis showed pyuria and microscopic hematuria. Urine culture later identified Enterococcus faecalis sensitive to ampicillin and vancomycin. Renal function remained within expected pediatric limits.

Pelvic ultrasonography revealed a large cystic structure posterior to the bladder measuring approximately 5 cm in diameter with internal debris and thickened walls. The lesion displaced the bladder anteriorly and compressed the rectum. Bilateral mild hydronephrosis was also noted secondary to bladder outlet compression. Initial radiological interpretation suggested a pelvic abscess or infected duplication cyst. Magnetic resonance imaging provided additional anatomical detail and demonstrated communication between the cystic cavity and the prostatic urethra, consistent with a markedly enlarged infected prostatic utricle. The cavity contained purulent material and inflammatory thickening extending toward surrounding pelvic tissues.

Intravenous broad-spectrum antibiotics and bladder catheterization were initiated immediately. Despite antimicrobial treatment, fever persisted and pelvic pain worsened over forty-eight hours. Surgical drainage was therefore recommended. Under general anesthesia, cystoscopy was performed initially. Endoscopic evaluation identified a large utricular opening within the posterior urethra. Purulent material drained spontaneously after gentle catheterization of the cavity. Because the utricle was extensive and multiloculated, complete drainage through endoscopy alone appeared insufficient. A combined transvesical approach was therefore undertaken.

Through a lower abdominal incision, the bladder was opened and the enlarged utricle identified posteriorly. Approximately 120 mL of thick purulent fluid was evacuated. The cavity walls were irrigated extensively, and partial excision of redundant utricular tissue was performed while preserving adjacent pelvic structures. A drainage catheter was left temporarily within the residual cavity. Microbiological culture from the drained fluid confirmed Enterococcus faecalis matching urine culture findings. Histopathological examination demonstrated chronically inflamed urothelial tissue without evidence of malignancy or ectopic mucosa.

The child improved substantially after surgery. Fever resolved within two postoperative days, and inflammatory markers normalized progressively. Follow-up ultrasonography demonstrated disappearance of hydronephrosis and reduction of the residual utricular cavity. The drainage catheter was removed after one week, and the patient was discharged in stable condition. During twelve months of follow-up, the patient remained free from recurrent infection or pelvic pain. Voiding pattern remained satisfactory, and repeat magnetic resonance imaging demonstrated only a small residual utricle without fluid accumulation.

The prostatic utricle represents a vestigial midline structure arising from incomplete regression of Müllerian duct tissue during embryological development. Small utricles may remain asymptomatic and undetected throughout life. Larger cavities, however, may predispose to urinary stasis, recurrent infection, stone formation, or voiding dysfunction. Radiological evaluation remains essential for anatomical characterization. Ultrasonography provides an effective initial assessment but may not identify communication with the urethra clearly. Magnetic resonance imaging offered superior delineation of the cavity and surrounding pelvic anatomy in this case, assisting surgical planning and exclusion of alternative diagnoses.

Endoscopic techniques may suffice for drainage of smaller infected utricles. However, giant cavities with thick inflammatory debris often require open or laparoscopic intervention for adequate evacuation and reduction of recurrence risk. Complete excision may prove technically difficult because of proximity to the vas deferens, pelvic nerves, ureters, and rectum. Partial excision combined with drainage therefore represented a safer strategy in this child. The transient hydronephrosis observed before surgery resulted from bladder outlet compression by the enlarged infected cavity. Delayed treatment could potentially have produced upper urinary tract deterioration or sepsis. Prompt recognition and drainage therefore played an important role in preserving urinary function.

Conclusion

Long-term follow-up remains advisable after treatment of enlarged prostatic utricles because recurrence of infection or progressive enlargement may occur. Rare malignant transformation has been described in adults with persistent Müllerian remnants, although such complications remain exceedingly uncommon during childhood. A giant infected prostatic utricle presenting as a pelvic abscess in a child with repaired proximal hypospadias. The case emphasizes the importance of considering Müllerian duct remnants in boys with recurrent urinary symptoms and pelvic cystic lesions. Combined endoscopic and transvesical drainage achieved complete clinical recovery and prevented further urinary complications in this patient.