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Cowper Gland Syringocele
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Cowper Gland Syringocele A 15-year-old boy with Crohn disease presented with perineal pain and focal tenderness, suggesting an initial clinical diagnosis of a perianal abscess. He also reported a 1-year history of dysuria and difficulty initiating urination, and denied urinary frequency, urgency or urinary incontinence. Urinalysis was negative for signs of infection and renal ultrasound was normal. Magnetic resonance imaging (MRI) of the pelvis to evaluate the extent of the suspected abscess showed a well defined, uniformly T2 hyperintense, nonenhancing 2.7 ⫻ 1.6 cm lesion at the left base of the penis with impression on the adjacent bulbar urethra (fig. 1). There was a thin track of fluid signal extending from the lesion posteriorly to the Cowper gland. There was no perianal abscess or fistula. Voiding cystourethrography showed extrinsic compression of the bulbar urethra (fig. 2). The prostatic, membranous and penile urethral segments were normal. The MRI and voiding cystourethrography findings were consistent with an imperforate Cowper syringocele (type III).
Cowper glands are paired structures that reside within the urogenital diaphragm, and gland secretions provide urethral lubrication. A Cowper gland syringocele is cystic dilatation of the main duct of the gland. The 4 types of syringocele are type I—a simple syringocele with mild dilatation of the duct, type II—a perforated syringocele with dilated distal (downstream) duct that communicates with the urethra via a patulous ostium, type III—an imperforate syringocele that does not communicate with the urethra and type IV—a ruptured syringocele in which a fragile membrane that was previously part of the dilated distal duct remains in the urethra after the distal duct has ruptured.1 Functionally and radiographically, types I, II and IV are considered “open” lesions and are more likely to cause symptoms such as post-void dribbling and hematuria. Type III lesions can be thought of as “closed” lesions and are more likely to cause obstructive symptoms such as dysuria and urinary retention.2 Radiographic diagnosis can start with transperineal ultrasound, although voiding or retrograde ure-
Figure 1. MRI of lower pelvis. A, sagittal T2-weighted sequence shows well defined T2 hyperintense lesion at base of penis indenting bulbar urethra (white arrow). Linear track (black arrow) extends posteriorly to Cowper gland. B, sagittal T1-weighted image following gadolinium shows a uniformly low signal lesion without enhancement (white arrows).
0022-5347/13/1902-0713/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2013.04.079 Vol. 190, 713-714, August 2013 Printed in U.S.A.
www.jurology.com
713
714
RADIOLOGY PAGE
Figure 2. Voiding cystourethrogram shows eccentric impression narrowing bulbar urethra (black arrows). There was no communication between urethra and lesion.
thrography is the gold standard for diagnosis of syringocele. On transperineal ultrasound closed syringoceles will appear as well circumscribed, thin walled cystic lesions parallel to the urethral canal.3 Fine internal echoes may be present. Open lesions will appear as cystic outpouchings when the urethra is distended with normal saline.2 On direct urethrography type I syringoceles appear as reflux of contrast from the bulbar urethra posteriorly into a minimally dilated Cowper gland duct, type II as cystic dilatation of the distal portion of the duct and type IV as cystic dilatation of the distal duct with a linear filling defect in the bulbar urethra representing the ruptured membrane.4 For closed syringoceles, MRI is especially helpful because they do not communicate with the urethra. Type III syringoceles appear as homogenous T2 hyperintense and T1 hypointense ovoid le-
sions with smooth borders and a tract leading posterior to the Cowper gland.3 Differential diagnosis of Cowper gland syringocele varies with the type of syringocele and symptoms. For type III syringocele, the differential diagnosis includes other causes of obstructive symptoms such as tumor of the bulbourethral gland, abscess and posterior urethral valves.5 If the lesion is asymptomatic and diagnosis was made incidentally, surveillance is appropriate. If the lesion is symptomatic, treatment is often transurethral marsupialization.6 Our patient subsequently underwent cold knife unroofing of the Cowper gland syringocele with initial near complete resolution of symptoms, reporting only intermittent dysuria at 1-year followup. Repeat cystoscopy at 1 year did not show recurrence and symptoms were attributed to urinary crystals secondary to methotrexate use and perianal disease related to Crohn disease. Fangbai Wu, Ellen Park and Unni Udayasankar Cleveland Clinic Children’s Hospital Cleveland, Ohio 1. Maizels M, Stephens FD, King LR et al: Cowper’s syringocele: a classification of dilatation of Cowper’s gland duct based upon clinical characteristics of 8 boys. J Urol 1983; 129: 111. 2. Melquist J, Sharma V, Sciullo D et al: Current diagnosis and management of syringocele: a review. Int Braz J Urol 2010; 36: 3. 3. Kickuth R, Laufer U, Pannek J et al: Cowper’s syringocele: diagnosis based on MRI findings. Ped Rad 2002; 32: 56. 4. Tanga M, Manchia A, Dolezalova H et al: Syringocele of the Cowper’s gland: report of two cases in the childhood. Eur J Radiol Extra 2004; 49: 111. 5. Volders W, Degryse H and Oyen R: Imperforated Cowper’s syringocele. JBR-BTR 2005; 88: 160. 6. Bevers RFM, Abbekerk EM and Boon TA: Cowper’s syringocele: symptoms. J Urol 2000; 163: 782.
Cowper Gland Syringocele A 15-year-old boy with Crohn disease presented with perineal pain and focal tenderness, suggesting an initial clinical diagnosis of a perianal abscess. He also reported a 1-year history of dysuria and difficulty initiating urination, and denied urinary frequency, urgency or urinary incontinence. Urinalysis was negative for signs of infection and renal ultrasound was normal. Magnetic resonance imaging (MRI) of the pelvis to evaluate the extent of the suspected abscess showed a well defined, uniformly T2 hyperintense, nonenhancing 2.7 ⫻ 1.6 cm lesion at the left base of the penis with impression on the adjacent bulbar urethra (fig. 1). There was a thin track of fluid signal extending from the lesion posteriorly to the Cowper gland. There was no perianal abscess or fistula. Voiding cystourethrography showed extrinsic compression of the bulbar urethra (fig. 2). The prostatic, membranous and penile urethral segments were normal. The MRI and voiding cystourethrography findings were consistent with an imperforate Cowper syringocele (type III).
Cowper glands are paired structures that reside within the urogenital diaphragm, and gland secretions provide urethral lubrication. A Cowper gland syringocele is cystic dilatation of the main duct of the gland. The 4 types of syringocele are type I—a simple syringocele with mild dilatation of the duct, type II—a perforated syringocele with dilated distal (downstream) duct that communicates with the urethra via a patulous ostium, type III—an imperforate syringocele that does not communicate with the urethra and type IV—a ruptured syringocele in which a fragile membrane that was previously part of the dilated distal duct remains in the urethra after the distal duct has ruptured.1 Functionally and radiographically, types I, II and IV are considered “open” lesions and are more likely to cause symptoms such as post-void dribbling and hematuria. Type III lesions can be thought of as “closed” lesions and are more likely to cause obstructive symptoms such as dysuria and urinary retention.2 Radiographic diagnosis can start with transperineal ultrasound, although voiding or retrograde ure-
Figure 1. MRI of lower pelvis. A, sagittal T2-weighted sequence shows well defined T2 hyperintense lesion at base of penis indenting bulbar urethra (white arrow). Linear track (black arrow) extends posteriorly to Cowper gland. B, sagittal T1-weighted image following gadolinium shows a uniformly low signal lesion without enhancement (white arrows).
0022-5347/13/1902-0713/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2013.04.079 Vol. 190, 713-714, August 2013 Printed in U.S.A.
www.jurology.com
713
714
RADIOLOGY PAGE
Figure 2. Voiding cystourethrogram shows eccentric impression narrowing bulbar urethra (black arrows). There was no communication between urethra and lesion.
thrography is the gold standard for diagnosis of syringocele. On transperineal ultrasound closed syringoceles will appear as well circumscribed, thin walled cystic lesions parallel to the urethral canal.3 Fine internal echoes may be present. Open lesions will appear as cystic outpouchings when the urethra is distended with normal saline.2 On direct urethrography type I syringoceles appear as reflux of contrast from the bulbar urethra posteriorly into a minimally dilated Cowper gland duct, type II as cystic dilatation of the distal portion of the duct and type IV as cystic dilatation of the distal duct with a linear filling defect in the bulbar urethra representing the ruptured membrane.4 For closed syringoceles, MRI is especially helpful because they do not communicate with the urethra. Type III syringoceles appear as homogenous T2 hyperintense and T1 hypointense ovoid le-
sions with smooth borders and a tract leading posterior to the Cowper gland.3 Differential diagnosis of Cowper gland syringocele varies with the type of syringocele and symptoms. For type III syringocele, the differential diagnosis includes other causes of obstructive symptoms such as tumor of the bulbourethral gland, abscess and posterior urethral valves.5 If the lesion is asymptomatic and diagnosis was made incidentally, surveillance is appropriate. If the lesion is symptomatic, treatment is often transurethral marsupialization.6 Our patient subsequently underwent cold knife unroofing of the Cowper gland syringocele with initial near complete resolution of symptoms, reporting only intermittent dysuria at 1-year followup. Repeat cystoscopy at 1 year did not show recurrence and symptoms were attributed to urinary crystals secondary to methotrexate use and perianal disease related to Crohn disease. Fangbai Wu, Ellen Park and Unni Udayasankar Cleveland Clinic Children’s Hospital Cleveland, Ohio 1. Maizels M, Stephens FD, King LR et al: Cowper’s syringocele: a classification of dilatation of Cowper’s gland duct based upon clinical characteristics of 8 boys. J Urol 1983; 129: 111. 2. Melquist J, Sharma V, Sciullo D et al: Current diagnosis and management of syringocele: a review. Int Braz J Urol 2010; 36: 3. 3. Kickuth R, Laufer U, Pannek J et al: Cowper’s syringocele: diagnosis based on MRI findings. Ped Rad 2002; 32: 56. 4. Tanga M, Manchia A, Dolezalova H et al: Syringocele of the Cowper’s gland: report of two cases in the childhood. Eur J Radiol Extra 2004; 49: 111. 5. Volders W, Degryse H and Oyen R: Imperforated Cowper’s syringocele. JBR-BTR 2005; 88: 160. 6. Bevers RFM, Abbekerk EM and Boon TA: Cowper’s syringocele: symptoms. J Urol 2000; 163: 782.