|Year : 2022 | Volume
| Issue : 4 | Page : 253-256
Management of urethral cyst in children: A case series
Partha Chakraborty1, Pankaj Kumar Halder1, Debomita Das2, Avidip De3, Shreya Dutta4
1 Department of Pediatric Surgery, R G Kar Medical College, Kolkata, West Bengal, India
2 Department of Anesthesiology, R G Kar Medical College, Kolkata, West Bengal, India
3 Department of Surgery, Modern Diagnostic and Research Centre, Birbhum, West Bengal, India
4 Department of Pediatric Medicine, R G Kar Medical College, Kolkata, West Bengal, India
|Date of Submission||24-May-2022|
|Date of Decision||07-Aug-2022|
|Date of Acceptance||20-Aug-2022|
|Date of Web Publication||17-Oct-2022|
Dr. Pankaj Kumar Halder
Saroda Palli, Baruipur - 700 144, Kolkata
Source of Support: None, Conflict of Interest: None
The parameatal cyst (PMC) is a benign lesion that occurs primarily in male children, generally present after birth, but may also occur in girls and adults. Although expectant management, needle puncture, decapping, and marsupialization are described as different modalities of treatment, all are associated with recurrences. We present nine pediatric cases with PMC, their clinical presentation, treatment, and outcome along with a review of the literature.
Keywords: Cyst, excision, marsupialization, observation, parameatal, urethral
|How to cite this article:|
Chakraborty P, Halder PK, Das D, De A, Dutta S. Management of urethral cyst in children: A case series. Curr Med Issues 2022;20:253-6
| Introduction|| |
In 1956, Thompson and Lantin first illustrated the clinical entity of a parameatal cyst (PMC). It is a rare clinical condition, and about 50 cases have been described in literature till date. Patients with PMC are usually asymptomatic but, may produce obstructive urinary symptoms in long-standing cases. The pathogenesis was believed to be due to preputial delamination, blockage of the paraurethral duct, or a sequel of the infective process. Parents generally seek opinions from surgeons because of disfigurement and cosmetic issues. Close observation with a regular check-up, needle aspiration, de-capping, and marsupialization have all been reported but complete excision of the cyst along with its epithelial lining is the treatment of choice. Early surgical excision is imperative to avoid unnecessary complications (rupture/difficult micturition/splaying of urine/infection), prevent recurrence as well as to get a good cosmetic outcome. We here report a case series of nine children with PMC who were surgically treated with complete excision of the cyst and observed no recurrences with 6-month follow-up.
| Methodology|| |
Our clinical study is a case series that includes all eligible patients consecutively identified during the study registration period from March 2017 to February 2022. The study was conducted in the Department of Pediatric Surgery of a tertiary care hospital, Kolkata, India. It describes the experience of a group of nine patients (observational, descriptive research design), contains demographic and clinical information about them, and was conducted prospectively. The patients were treated in the order, in which they were identified, without a group control.
All patients (0–12 years of age) with a clear or whitish-blue cystic lesion at the tip of the glans or female urethra abutting the urethral meatus on its lateral side (with a clinical diagnosis of PMC) were included in this study.
Patients with evidence of smegma collection underneath the preputial skin resulting in cystic appearance, prolapsed urethra or ureterocele, and Bartholin cyst were excluded from the study.
The parents of all patients included in our study were informed about the management of these clinical conditions, including the different modalities of treatment. They signed a consent form in their own language for incorporating their children in this study and long-term follow-up.
| Case Series|| |
There were nine patients in our series with a male-to-female ratio of 8:1. The median age of presentation of the group was 5 years. All patients presented with cystic swelling over the glans penis or the female urethra near the external urethral meatus [Table 1]. The most common symptoms were splaying of urine during micturition and deformed meatus as perceived by the parents [Figure 1]. The cysts were nontender, very slowly progressive, and there was no history of difficulty in micturition or symptoms suggestive of urinary tract infection in any of the patients. The PMC was diagnosed by history and clinical examination and confirmed after surgery by biopsy of the cyst wall. Blood counts, blood biochemistry, urine analysis, and urine culture were completed in all patients before subjecting them to the surgery. All nine patients underwent complete surgical excision of the cyst under total intravenous anesthesia with penile block.
|Figure 1: Clinical pictures of parameatal cysts at different positions with urinary symptoms (presenting with splaying of urine.|
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Informed consent was taken from the parents before the administration of anesthesia. The patient was placed in the supine position, monitors attached and intravenous access was done. The patients were premedicated with injection glycopyrrolate, midazolam, and ondansetron. Sedation was administered with an injection of ketamine and propofol in titrated doses. Moreover, the dorsal penile nerve block was administered with an injection of bupivacaine (0.25).
Intraoperatively, no communication with the urethra was demonstrated in any of the cases. Utmost care was taken to remove all the lining epithelium and the edges were sutured with 6-0 or 5-0 Catgut suture. A urethral catheter was placed for 24 h. Postoperatively, all patients recovered well and were discharged on the same day or the next day. Histopathological examination of the cyst wall showed benign cyst with lining epithelium as pseudostratified columnar, tall columnar, and transitional epithelium. Good cosmetic results were observed in all patients without meatal stenosis/stricture and urine flow problems [Figure 2]. No recurrence was observed at 6 months of follow-up.
|Figure 2: Intraoperative and postoperative pictures of parameatal cyst at 5'o clock position in an 8-year-old boy.|
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| Discussion|| |
The PMC has been synonymously described as mucoid cyst, urethral cyst, and apocrine cystadenoma. It is an acquired condition but may present since birth. Its incidence is more in boys than in girls, as we see in our case series. Regarding its pathogenesis, several theories like delamination or separation of the foreskin from glans, occlusion of paraurethral ducts due to infection, presence of accessory sex glands in the penile urethra, and inadvertent estrogenic stimulation have been proposed. In our series, none of the patients had any suggestive history of such problems and, we did not observe any local abnormality corroborating the above-mentioned hypothetical issues claiming for the etiopathogenesis of the PMC.
The diameter of PMC generally varies from 1 mm to 10 mm. The cyst mainly occurs on the lateral aspect of the urethra. The parents of these children with PMC seek advice from the physicians mainly for cosmetic reasons. However, if the cyst attains a reasonable size, it causes deflection of the urinary stream, difficulty in retracting preputial skin, or pain due to obstructive urinary flow or traumatic rupture of the cyst or infection. Out of nine cases, four (36%) had symptoms of splaying of urine during urination. However, difficult micturition or infection episode was absent. The association of hypospadias with PMC has also been reported in the literature. The differential diagnoses of PMC are epidermal inclusion cyst, fibroepithelial polyp, dermoid cyst, Bartholin cyst, smegma pearls, prolapsed ureterocele, and juvenile xanthogranulomas. The dilemma in the clinical diagnosis appears in long-standing cases with spontaneous or traumatic rupture of the cyst along with bleeding and infection. However, it can be diagnosed by physical examination alone as we do in our cases, none of our patients had any complications before the surgery.
The management (surgical excision) should be initiated without any delay after the diagnosis to avoid any unwanted complications. On the contrary, Matsuyama et al. stated that conservative management with close observation is reasonable, as up to 25% of parameatal urethral cysts do self-resolve. We enquired parents about the duration of symptoms and any change in the cyst size since its first notification. The average duration of the symptoms was 6 months to 2 years, and none of the parents gave any convincing story of spontaneous resolution of the cyst. Close observation along with regular checkups with a pediatric urologist for several months (median age of follow-up 24 months) is recommended to monitor for cyst evolution (spontaneous resolution of the cyst), which is somehow difficult in developing countries, especially for patients from a poor socioeconomic status. The decision of the surgery depends on the presence of symptoms or the parents' choice. We counseled the parents about the management of this clinical condition (PMC), including the different modalities of treatment. The anxious parents did not take the risk of probable rupture/infection of the cyst and disagreed with prolonged follow-up. The treatment of choice is complete surgical excision of the cyst with the repair of the defect by a rapidly absorbable suture. Although cyst puncture, de-capping, and marsupialization of the cyst, etc., are all described in the literature as other forms of treatment, they are almost invariably associated with recurrence. We excised the entire cyst in all our cases and there were no recurrences at 6-month follow-up. The cyst wall lining varies from the columnar, cuboidal, squamous, or transitional epithelium. In our patients, the cysts were lined by tall columnar, transitional, and pseudostratified epithelium which further strengthened our clinical judgment.
| Conclusion|| |
PMC is a rare condition but, bothersome to the patients and parents. Awareness and knowledge of this condition are important for clinical diagnosis. From our small case series, we appraise that complete excision along with lining epithelium, and repair of the defect with the absorbable suture is the treatment of choice which also result in a cosmetically better outcome with no recurrence or complication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]