An Enlarged and Infected Prostatic Utricle as a Rare Cause o
A 13-year-old male presented to the pediatric emergency department (ED) of a community hospital with lower abdominal pain and pain with urination for 2 days. He had occasional vomiting and loose stools. He had a fever 1 day prior to the presentation. In the ED, he had a low-grade fever, a mildly distended abdomen, and lower abdominal tenderness. Urine was turbid with too numerous to count white blood cells (WBCs). He denied sexual activity. His past medical and surgical history was notable for a two-stage proximal hypospadias repair as an infant, which was complicated by the development of a urethrocutaneous fistula. The fistula was subsequently repaired at 3 years of age. He also had a history of mixed gonadal dysgenesis and had a left orchiectomy for a left streak gonad with fallopian tube remnants as an infant. A urine culture was sent, and he was discharged on oral cephalexin with a presumptive diagnosis of UTI.

He returned to the ED 2 days later for persistent pain at the end of urination and lower abdominal pain. There were no interval fever or chills, and diarrhea had resolved. He reported worsening suprapubic and right lower quadrant pain, dysuria, urinary urgency and frequency, and foul-smelling urine. He had decreased appetite and activity. Stools had been small and clumped recently, but he denied chronic constipation. His mother reported a small amount of urethral discharge seen on the toilet paper used for wiping after urination. In the ED, he was afebrile and had lower abdominal tenderness on palpation. Genitourinary exam was notable for a circumcised penis, absent left testis, and descended right testis that was mildly tender to palpation but had a normal lie and cremasteric reflex. Urine culture from the prior ED visit showed no growth, although repeat urinalysis at the current visit still showed too numerous to count WBCs. The peripheral WBC count was normal, and C-reactive protein was elevated at 20mg/dL.

Scrotal ultrasound showed a normal right testicle with normal flow and no concerning pathology. Abdominal ultrasound could not visualize the appendix in its entirety, but no secondary signs of appendicitis were seen. Retroperitoneal ultrasound showed normal bladder and kidneys. The radiologist reported circumferential wall thickening of the rectum with an air-fluid level. Further review of the patient's past medical history was revealing. Following penoscrotal hypospadias repair as an infant, he had recurrent UTI. Voiding cystourethrogram (VCUG) was performed and showed no vesicoureteral reflux. However, on the postvoid film, there was a round structure projecting over the lower right pelvis of uncertain etiology. In hindsight, this was likely the prostatic utricle. He developed an urethrocutaneous fistula following his hypospadias repair. At the time of urethrocutaneous fistula repair about 1 year later, a cystourethroscopy was performed, but the neck of the prostatic utricle was not visualized at the time.

He was admitted to the pediatric unit and started on IV ceftriaxone. Pediatric urology was consulted, and he was taken to the operating room the following day. Cystourethroscopy was performed and demonstrated debris within the bladder. A small utricular opening was visualized with efflux of debris. The utricular orifice was cannulated, and aspiration yielded 160mL of thick, mucinous, foul-smelling fluid that was sent for culture. A generous incision of the orifice was performed to allow for adequate drainage of the utricular contents per urethra. He tolerated the procedure well. Culture of the aspirated fluid grew multiple organisms, whereas intraoperative urine culture showed no growth. He was discharged on oral Augmentin. He did well, but symptoms recurred. Therefore, he underwent elective robotic-assisted laparoscopic excision of the prostatic utricle several months later at a tertiary-care center.