A diagnostic algorithm for urachal anomalies

Objective: Urachal anomalies are rare. Variable presentations can be a diagnostic challenge. We combine our series with a review of literature to delineate the most common presentations, highest yield diagnostic studies and a diagnostic algorithm. Methods: We reviewed records of 22 boys and 15 girls with the diagnosis of a urachal anomaly from 2000 through 2005. This revealed 19 cysts, seven patent urachuses, five sinuses, four patients with unspecified "urachal anomalies," and two patients with no urachal anomaly by surgical exploration. Ultrasound was the most common diagnostic study, followed by computed tomography (CT), voiding cystourethrogram and sinogram. Thirty-five of 37 patients underwent surgery. Results: Clinical presentation included periumbilical leakage in 54%, pain in 30%, periumbilical mass in 22% and irritative voiding symptoms in 14%. In many patients diagnosis was made on clinical examination alone. When an ultrasound was used it was diagnostic for 82% of cysts, 100% of sinuses and 100% of patent urachuses. A voiding cystourethrogram was diagnostic for 100% of patent urachuses, but less successful in the other anomalies. CT scans correctly diagnosed 71% of cysts. Overall complication rate was 9%, all wound infections. Conclusion: Reviewing the results of this and four other large series showed that the most common anomaly is the urachal cyst followed by urachal sinus and patent urachus. Periumbilical drainage is the most common presentation. Physical exam alone can be diagnostic. When this is not possible ultrasound is our recommended initial study, followed by a CT scan if unsuccessful.