Cowper's syringocele: a classification of dilatations of Cowper's gland duct based upon clinical characteristics of 8 boys

Cowper's Syringocele: A Literature Review

Cowper's syringocele is a rare but underdiagnosed cystic dilatation of the main ducts of Cowper's gland. It is becoming more widely known in the adult population. Recent research proposes that syringoceles should be categorized according to the intraductal pressures causing ductal dilatation from mild to gross ultimately involving the gland itself. Although there may be some overlap in the clinical manifestations of different syringoceles, mildly dilated ducts are frequently asymptomatic. Moreover, moderate to gross duct dilatations can manifest as lower urinary tract symptoms (LUTS) or obstructive symptoms. A valid differential diagnosis is essential because these symptoms can be found in a wide range of severe illnesses. Syringocele can be diagnosed by ultrasonography in combination with voiding retrograde/antegrade cystourethrogram (VCUG), nevertheless, other procedures like cystourethroscopy, CT scan, and MRI scans can be helpful. Initially, conservative surveillance is advised, but if necessary, endoscopic marsupialization or surgical excision is the preferred treatment modality to address persistent problems.

Large, infected Cowper’s syringoceles: a rare cause of perineal sepsis in adult men

Urologists and general surgeons alike are familiar with assessing acute perineal pathology. A Cowper’s gland syringocele is a rare cystic dilatation of the male bulbourethral gland, typically seen in children. We report the diagnosis and emergency management of two adult cases of large, infected Cowper’s gland syringoceles. A comorbid 76-year old was diagnosed with sepsis and penile swelling, but there was no discrete superficial pathology. Magnetic resonance imaging (MRI) revealed a perineal collection communicating with the membranous urethra. A suprapubic catheter was inserted, and aspiration was attempted. Meanwhile, a 55-year-old diabetic presented with severe perineal pain. MRI revealed a deep perineal collection, involving the scrotum and proximal penis. He improved with antibiotics and aspiration of the collection. This rare diagnosis may be more common in older men than previously thought. Pelvic MRI is a key diagnostic tool. A minimally invasive approach is possible in those with considerable perioperative risk.

Imaging of the Bulbourethral (Cowper) Gland: Abnormalities and Differential Diagnosis

Normal Cowper glands and ducts are imperceptible at imaging. However, abnormalities of the Cowper glands and ducts are increasingly seen owing to increasing use of cross-sectional imaging. In this article, the authors present a comprehensive review of the normal anatomy of the Cowper glands and ducts and the clinical and imaging findings of conditions that affect them in an effort to help lead to appropriate diagnosis and management. A Cowper duct syringocele is a congenital or acquired dilatation of the Cowper duct in the bulb of the corpus spongiosum. Retrograde urethrography is the standard test to diagnose a communicating (open) Cowper duct syringocele, and MRI is used for further morphologic assessment. Cowperitis refers to inflammation of the gland and/or duct, and recurrent cowperitis is usually associated with an underlying syringocele, a urethral fistulous connection to the Cowper gland, or a perianal fistula. MRI allows detection of the underlying structural abnormality and the superimposed inflammation. Cowper stones are typically radiopaque and are found in both the Cowper gland and duct. A Cowper gland HHhemorrhagic cyst may be incidentally detected at MRI of the prostate, and follow-up MRI may be required to ensure evolution of hemorrhage and exclude an underlying neoplasm. Cowper gland carcinoma is rare and includes adenocarcinoma and adenoid cystic carcinoma subtypes. Transperineal US may be used for initial evaluation and CT and/or MRI are necessary for further characterization and staging. Cowper gland hyperplasia is a rare entity with few previous reports that may be incidentally detected at imaging and may mimic malignancy. ^©RSNA, 2022.

Cowper's Syringocele: A Rare Cause of New-Onset Voiding Dysfunction

Cowper's syringocele is a condition caused by dilatation of the main duct of Cowper's gland. It is a very uncommon cause of urethral obstruction. Closed type causes urinary obstruction. The aim of this article is to report a case of closed type syringocele causing new-onset urinary obstruction in a 10-year-old boy.

Syringoceles of Cowper's ducts and glands in adult men

Cowper's syringoceles are uncommon, usually described in children and most commonly limited to the ducts. We describe more complex variants in an adult population affecting with varying degrees of severity, the glands themselves, and the complications they may lead to. One hundred consecutive urethrograms of patients with unreconstructed strictures were reviewed. Twenty-six patients (mean age: 41.1 years) with Cowper's syringoceles who were managed between 2009 and 2016 were subsequently evaluated. Presentation, radiological appearance, treatment (when indicated), and outcomes were assessed. Of 100 urethrograms in patients with strictures, 33.0% demonstrated filling of Cowper's ducts or glands, occurring predominantly in patients with bulbar strictures. Only 1 of 26 patients with non-bulbar strictures had a visible duct/gland. Of 26 symptomatic patients, 15 presented with poor flow. In four patients, a grossly dilated Cowper's duct obstructed the urethra. In the remaining 11 patients, a bulbar stricture caused the symptoms and the syringocele was identified incidentally. Eight patients presented with perineal pain. In six of them, fluoroscopy and magnetic resonance imaging (MRI) revealed complex multicystic lesions within the bulbourethral glands. Four patients developed perineoscrotal abscesses. In the 11 patients with strictures, the syringocele was no longer visible after urethroplasty. In three of four patients with urethral obstruction secondary to a dilated Cowper's duct, this resolved after transperineal excision (n = 2) and endoscopic deroofing (n = 1). Five of six patients with complex syringoceles involving Cowper's glands were excised surgically with symptomatic relief in all. In conclusion, Cowper's syringocele in adults is more common than previously thought and may cause lower urinary tract symptoms or be associated with serious complications which usually require surgical treatment.

Persistent Dysuria in a Young Male

A Cowper's Duct syringocele is a rare diagnosis and currently there exists no clinical guidelines for evaluation and management. This clinical challenge illustrates the case presentation, evaluation, diagnosis, and treatment options for of a newly diagnosed Cowper's Duct syringocele.

Successful treatment of a rare Cowper’s bulbourethral gland syringocele in an adult with endoscopic laser deroofing using a rigid ureteroscope

Cystic dilatation of Cowper’s glands, also known as a syringocele, is a well-known condition of childhood, with increased recognition as a rare presentation of urinary tract symptoms in adults. Surgical techniques for its treatment vary, with several described in the literature. However, consensus on optimal treatment is unclear. We present a rare case of a Cowper’s gland syringocele successfully treated with laser deroofing with a previously undescribed method using a rigid ureteroscope, and we also review techniques in the literature.

Level of evidence:

Level 5.

Cowper's syringocele in the pediatric population: a retrospective study of 122 patients

INTRODUCTION AND OBJECTIVE

Syringocele is a rare cystic dilatation of the duct of Cowper's gland, afflicting mostly the pediatric population. Syringoceles have a wide range of symptoms and may cause urethral obstruction. The authors analyzed to clarify the clinical manifestation, diagnostic approach, management, and incidence in the pediatric population.

MATERIALS AND METHODS

All patients (122 cases) diagnosed with a syringocele at the department of Pediatric Urology in a tertiary referral university children's hospital between August 1991 and October 2016 were analyzed retrospectively by assessing medical charts.

RESULTS

The clinical manifestation, diagnostic findings, and follow-up are summarized in the table. Half of the patients (50.0%) also had typical posterior urethral valves (PUVs) and/or a single valve in the 12 o'clock position (flap-valve). The symptoms of open and closed syringoceles showed no significant difference. Treatment consisted of incision of the syringocele with a diathermia hook. The incidence of urinary tract infection (UTI) before and after surgery in the group that had a syringocele only was significant different. The overall incidence of syringoceles seen at urethrocystoscopy in this series was 3.0%.

DISCUSSION

This series suggests that the presenting age is strongly related to the consequences of syringoceles, as the youngest half of the patients had significantly more UTIs at presentation than older patients, who presented with significantly more obstructive voiding symptoms, postvoiding residuals, and incontinence. In addition, the younger group had a significantly higher incidence of vesicoureteral reflux and dilatation of the upper urinary tract. The found association between syringoceles and PUV may be due to overgrowth of epithelium, as possible origin in both anomalies.

CONCLUSION

With an incidence of 3.0%, syringoceles, in this tertiary referral series, should be considered in the differential diagnosis of obstructive urethral lesions. The presentation ranges between signs of severe obstructions in the prenatal and postnatal period to mild urinary incontinence problems at later age. Urethrocystoscopy proved to be useful in confirming the diagnosis and allows for immediate transurethral incision.

A Case of Symptomatic Cowper's Syringocele in an Adult Male: Diagnosis and Management

Background: Cowper's syringocele is cystic dilation of the excretory bulbourethral gland duct. This entity is common in the pediatric population but is rare or underdiagnosed in the adult population. Syringoceles are usually classified based on the configuration of the duct's orifice to the urethra with symptoms varying between irritative and/or obstructive accordingly. To the best of our knowledge, only few cases were reported in the literature. Case Presentation: We present the case of a 27-year-old male patient presenting with obstructive lower urinary tract symptoms. Pelvis MRI, retrograde urethrography, and flexible cystourethroscopy were performed and a diagnosis of imperforate Cowper's syringocele was made. Endoscopic unroofing with holmium:YAG laser was performed. The patient is free of symptoms 12 months postoperatively. Conclusion: Cowper's syringocele is a rare entity that should be considered in certain adult patients presenting with either storage or voiding symptoms. Ultrasonography is useful in detecting closed cystic lesions; however, antegrade urethrography and retrograde urethrography are gold standards to rule out communication with the urethra. Symptoms tend to resolve spontaneously and initial treatment is conservative. With persistent symptoms, endoscopic unroofing or marsupialization with cold knife or holmium:YAG laser is recommended as standard treatment.

Urethral syringocele: unseen but existing

BACKGROUND

Bulbourethral syringocele is an uncommon and under-diagnosed condition most commonly seen in the paediatric population, although there is increasing recognition in adults. Due to the difficulty in diagnosis, we report our experience of urethral syringocele in a quaternary paediatric hospital, with differing presentations, diagnosis and treatment.

METHODS

This is a retrospective review of seven cases of children over a period of 14 years, including their presentations, diagnosis, treatment and follow-up. A review of the current literature is presented.

RESULTS

The median age of these seven cases at presentation was 11 years (6 days to 16 years). Clinical features varied with age, with obstructive uropathy in a neonate, urinary tract infection in an infant, scrotal abscess in two children and lower urinary tract obstructive symptoms in three teenagers. Diagnostic voiding cystogram diagnosed the majority of syringoceles and two were seen on magnetic resonance imaging. Five boys underwent endoscopic transurethral deroofing and two children required transperineal marsupialization. Long-term follow-up showed all had complete resolution of symptoms.

CONCLUSION

Urethral syringocele presents from the neonatal period to late adolescence, with the presenting features reflective of age. Surgical management can be performed endoscopically or by open approach. Awareness of this condition and inclusion in the differential diagnosis, particularly in the setting of an atypical or recurrent scrotal abscess, could avoid a prolonged therapeutic course.

Current epidemiology and antenatal presentation of posterior urethral valves: Outcome of BAPS CASS National Audit

AIM

Posterior urethral valves (PUVs) are the most common cause of congenital bladder outlet obstruction (BOO) in boys and end-stage renal failure (ESRF) in childhood. In the 1980s, 1 in 4000 boys had PUV. Presentation was 1/3 antenatal/neonatally, 1/3 postnatal, 1/3 late (>1 year). This study aimed to describe the current proportions in a contemporary cohort.

METHODS

A national audit (BAPS CASS) of referrals in the UK and Ireland of boys diagnosed with suspected or confirmed PUV in a year was conducted. National registration data provided the male birth-rate. Data were presented as number (%), analysed by Mann-Whitney U-test and Chi-square test, with P < 0.05 taken as significant. The study was approved by a national ethics committee (NRES Committee South Central Oxford A (12/SC/0416)).

RESULTS

Data were collected from 1st October 2014 to 30th September 2015 from 25/26 centres on 121 cases of suspected bladder outlet obstruction (BOO), of which 113 (93%) were because of PUV. The male birth rate during the period was 432,806/year. The calculated incidence of BOO was 1/3580 and for PUV was 1/3800 per-annum. The proportion of PUV presenting according to age was: antenatally (n = 40, 35%), infancy (n = 47, 42%), and late (n = 26, 23%). Plasma creatinine was higher in antenatally-diagnosed BOO vs. postnatal, 54 (39.5-109.5) μmol/l vs. 34(21-47) μmol/l, P = 0.0005. Hydronephrosis and ureteric dilatation were significantly greater in antenatally diagnosed BOO vs. postnatal vs. late. Renal dysplasia (cortical thinning, poor corticomedullary differentiation, or renal cysts) was significantly more likely in antenatally diagnosed BOO.

CONCLUSION

Neither the incidence (~1/4000) nor the proportion antenatally diagnosed (~1/3) of boys with PUV appears to have changed in the past 30 years. Those boys who were antenatally diagnosed have significantly higher postnatal plasma creatinine, more hydroureteronephrosis, and renal dysplasia than those diagnosed in infancy or later. It may be hypothesized that this is the reason they are detected antenatally.

LEVEL OF EVIDENCE

Prognosis study - Level I - prospective national cohort study.

Dual Pathology Causing Congenital Bladder Outlet Obstruction

Anterior urethral syringocele is an uncommon congenital deformity characterized by cystic dilatation of bulbourethral gland ducts and is usually asymptomatic. We present a case on 4-day-old male neonate who presented with bilateral antenatal hydroureteronephrosis and renal impairment and found to have urethral syringocele and posterior urethral valves.

Cowper's Syringocele in Adolescent Male: Case Report

Background: Cowper's syringocele is a rare condition, uncommon in the adult population. It is more common in the pediatric population. Patients could be asymptomatic or present with irritative and/or obstructive symptoms. Ultrasonography (US) of perineal region, pelvis MRI, or urethrography are the most often used diagnostic modalities. Surgical treatment is indicated in all symptomatic patients. Endoscopic approach is preferred over open surgery. Unroofing of syringocele with cold knife or holmium yttrium aluminium garnet (YAG) laser is effective treatment.

Case Presentation: A 17-year-old Caucasian male presented at our emergency department with irritative symptoms. US of perineal region showed cystic formation near urethra. Pelvis MRI showed Cowper's gland syringocele. Endoscopic unroofing with holmium YAG laser was performed. Six months postoperatively the patient was asymptomatic and satisfied with the treatment.

Conclusion: Cowper's syringocele is a rare condition. Urologist should consider this condition in pediatric and adolescent patients with irritative and/or obstructive symptoms. Pelvis MRI and perineum US are the main diagnostic tools. Surgical treatment is effective. Endoscopic approach is preferred. Open surgery is indicated in complicated cases and in cases when endoscopic treatment fails.

Cowper's syringocele: A rare differential diagnosis of infravesical obstruction in boys and young adults

OBJECTIVE AND INTRODUCTION

Cowper's syringocele is a cystic dilation of the bulbourethral gland duct, initially defined by Maizels et al. in 1983. Although obstructive and non-obstructive types of this rare anomaly are described, clinical symptoms are highly unspecific. Therefore, we report 12 cases of children and young adults diagnosed with Cowper's syringocele to further clarify clinical course, comorbidity and treatment strategies.

STUDY DESIGN

We retrospectively collected clinical data of 12 children and young adults from birth to 18.5 years (median 7.2 years) who had been treated in four different institutes during a period of 16 years. The primary specific diagnostic work-up consisted of ultrasound, cystourethrography, and cystoscopy.

RESULTS

3Older patients with a median age of 11.8 years clinically presented with obstructive voiding pattern or gross hematuria; infants with a median age of 0.6 years presented with febrile urinary tract infections (UTIs). After cystoscopic confirmation in all patients, endoscopic treatment was possible in nine; open surgical resection was necessary in three patients. Because of intrauterine megacystis and chronic renal failure, one boy underwent suprapubic diversion with a cystostomy soon after birth. Owing to urological comorbidity or later complications, additional procedures were necessary, for example, resection of minor urethral valves, prophylactic circumcision for UTI, endoscopic or open antireflux procedures, and occasionally complex bladder reconstructions in the long term.

DISCUSSION

According to our data, the initial clinical symptoms of Cowper's syringocele were related to presenting age rather than the previously described type of syringocele according to Maizels et al. Infants presented with febrile UTIs; however, older boys and young adults had mainly voiding problems or nocturnal enuresis. Therefore, the clinical significance of the described syringocele types must be questioned. Eighty-three percent of our patients showed additional urological pathology such as vesicoureterorenal reflux, ureteropelvic junction obstruction, megaureter, or minor urethral valves. Thus, Cowper's syringocele hardly seems to be an isolated pathology.

CONCLUSION

Although rare, Cowper's syringoceles should be considered in differential diagnosis of infravesical obstruction in boys and young adults. Diagnostics are usually justified by presenting symptoms such as UTI or urinary flow impairment, which seem to be age dependent. Despite modern diagnostic tools, diagnosis is usually made by cystourethrography and sometimes accidentally by cystoscopy. Considerable urological comorbidities and consecutive bladder dysfunction need long-term follow-up.

Transurethral Unroofing of a Symptomatic Imperforate Cowper's Syringocele in an Adult Male

Cystic dilatation of bulbourethral gland ducts (Cowper's gland syringocele) is a rare abnormality. The condition has been described among pediatric populations, but it is uncommon in adults. It can be asymptomatic or present with obstructive and irritative urinary symptoms. We report a case of a symptomatic imperforate Cowper's syringocele in a young patient that was successfully managed with transurethral unroofing of the cyst.

A Case of Giant Cowper's Gland Syringocele in an Adult Male Patient

Cowper's gland syringocele is an uncommon, underdiagnosed cystic dilatation of Cowper's gland ducts showing various radiological patterns. Herein we report a rare case of giant Cowper's gland syringocele in an adult male patient, with description of MRI findings and management outcome.

Congenital urethral polyps in children: report of 18 patients and review of literature

BACKGROUND/PURPOSE

To evaluate the presentation, diagnosis and management of congenital urethral polyps (CUP) in children and to report the results of the endoscopic resection of polyp with long-term follow-up.

METHODS

Between April 1995 to March 2010, 18 children (14 boys, 4 girls) with CUP were treated. The most common presentation was urinary outflow obstruction/retention, hematuria or protruding polyp from the urethra meatus in girls. Six patients presented with vesicoureteral reflux (VUR). All children (except one) underwent a transurethral resection of the CUP.

RESULTS

Following the endoscopic resection of the polyps, there was no polyp recurrence, and all patients became symptom-free. The children exhibited no reflux, urinary retention, hematuria or urinary tract infection (UTI) following endoscopic management. Abnormal uroflowmetry patterns returned to normal following the resection of the polyp for one year after the operation.

CONCLUSIONS

Urethral polyps must be considered in every child with history of triad of recurrent intermittent urinary retention, hematuria and lower urinary tract symptoms. The cure can be achieved in all cases by an endoscopic approach. This type of tumor is always benign and very rarely recurs, unless the pedicle stalk is not resected. The endoscopic management of reflux is unnecessary in this group of patients due to their natural history of secondary reflux.

Posterior urethral valves and Cowper's syringocele: A rare association causing voiding dysfunction

Urethral syringoceles are cystic dilatations of paired bulbourethral glands of Cowper. They can cause voiding dysfunction in male children and usually occur in isolation. We report a rare association of Cowper's syringocele with posterior urethral valves in a 4-year-old child, which was successfully managed endoscopically.

Scrotal dermoid extending to the posterior urethra through a corpus cavernosum in a child

A 3-year-old boy presented with an asymptomatic intertesticular mass increasing in size. Plasma tumor markers (α-fetoprotein and β-human chorionic gonadotrophin) were negative. The mass had a pattern similar to testicular parenchyma but no discernable blood flow on scrotal Doppler ultrasound. Magnetic resonance imaging scan showed that it reached the posterior urethra after passing through the right corpus cavernosum with a progressive tapering extending into the pelvis. The mass was excised surgically and histologically found to be consistent with a dermoid cyst. Such rare benign lesions should be considered in the differential diagnosis of painless scrotal masses in children. Its anatomy was accurately defined by magnetic resonance imaging and was essential to minimize the risk to adjacent structures.

Epithelial Bmp (Bone morphogenetic protein) signaling for bulbourethral gland development: a mouse model for congenital cystic dilation

The bulbourethral gland (BUG) is a male-specific organ, which secretes part of the semen fluid. As the BUG is located in the deep pelvic floor, its developmental process is still unclear. Bone morphogenetic protein (Bmp) signaling plays pivotal roles in various organs. However, the function of Bmp signaling for BUG development is still unclear. The present study aimed to elucidate the role of Bmp signaling in the development of the BUG. We observed the prominent nuclear accumulation of phosphorylated (p) SMAD1/5/8, the downstream molecules of Bmp signaling, during BUG epithelial development. These results suggest that Bmp signaling contributes to BUG development. Bmp receptor1a (Bmpr1a) is known as the major type 1 signal transducer in some organogeneses. To analyze the Bmp signaling function for BUG development, we examined epithelial cell-specific Bmpr1a gene conditional mutant mice utilizing the tamoxifen-inducible Cre recombinase system. We observed cystic dilation and epithelial hyperplasia of the BUG in the Bmpr1a conditional knockout mice. The mutant cystic BUG specimens also showed inflammatory lesions. These BUG abnormalities resembled some of the BUG malformations observed in human congenital syndromes. The current study suggests that Bmp signaling possesses an essential role in BUG development and homeostasis. This would be the first report showing that the mutation of the Bmpr1a gene in the BUG epithelia phenocopied some abnormalities of human congenital syndromes affecting the BUG duct.

Endoscopic management of a type IV syringocele causing massive perirenal urinoma in an infant

The finding of a urinoma in the fetal and neonatal period is almost always related to an obstruction distal to the collection itself. Syringocele is a congenital or acquired dilation of a bulbourethral Cowper's gland. An exceedingly rare case of neonatal anterior urethral obstruction caused by a syringocele and manifesting itself with a dramatic clinical onset is presented. Clinical and radiologic findings are discussed and minimally invasive therapeutic strategies emphasized.

Variety of congenital urethral lesions in boys with lower urinary tract symptoms and the results of endoscopic treatment

OBJECTIVES

We described various types of congenital urethral anomalies seen in boys with LUTS such as refractory enuresis. Their urethrograpic and endoscopic finding were reviewed and the effect of trans-urethral incision (TUI) was analyzed.

PATIENTS AND METHODS

We evaluated 67 boys with lower urinary tract symptoms (LUTS, mean: 9 years old), in a period of three and a half years. A voiding cystourethrogram (VCUG) was performed in 37 patients and if we suspected a urethral abnormality, endoscopy was performed. Congenital urethral obstruction was diagnosed from VCUG and endoscopic findings and classified into Types 1, 3 and 4 posterior urethral valves (PUV) according to Douglas Stephens' description. Trans-urethral incision (TUI) was carried out for congenital urethral obstruction and the effect was judged three months later.

RESULTS

On VCUG, 17 patients (45.8%) had an abnormal urethral configuration. On endoscopy, nine patients (24.3%) were diagnosed as having PUV. The effect of TUI on PUV excluding Type 3 was 80%, while that on Type 3 was 25%.

DISCUSSIONS

The incidence of PUV compared to bulbar urethral narrowing was significantly different from that described in previous Japanese reports, but similar to other countries. The reason is thought to be the lack of standardized interpretations of VCUG images and endoscopic findings, resulting in the overestimation of the bulbar urethral lesion.

CONCLUSION

The incidence of PUV in Japanese boys with LUTS was higher than had ever been described. The improvement rate by TUI was high in PUV excluding Type 3, but low in Type 3. The ring like strictures at the bulbar urethra may be less important than has previously been thought.

The urethral valve of Guérin and lacuna magna: clinical presentations and urodynamic findings

We described the clinical presentations, radiological findings, urodynamic patterns and endoscopic management in a series of patients with symptomatic lacuna magna (LM). The medical records of 14 boys diagnosed as LM were reviewed, retrospectively. The presence of LM was first diagnosed based on clinical history, physical exam, and radiological findings; then confirmed by urethroscopy. Urodynamic study was performed in 10 boys before and after the procedure. Transurethral incision and fulguration of the valve was performed in all patients. The mean (range) age of patients was 3.1 years (6 months to 8 years). The boys presented with dysuria (n = 9), postvoid dribbling (n = 4), hematuria (n = 3), bloody spotting (n = 3), enuresis (n = 4), and glanular irritation and pain (n = 6). The post-operative period was uneventful in all patients. The symptoms were relieved and repeat radiological exam showed complete resolution of LM in all children by the 3rd post-surgical month. Before the procedure, main urodynamic abnormalities in children were high P(detmax) and detrusor instability that significantly improved within 3-6 months after treatment. Despite evidence suggesting that a LM is a frequent, normal anatomical variant, the valve may cause symptoms such as intermittent hematuria, dysuria, and bloody spotting of underwear. The lesion may be associated with obstructive urodynamic patterns in some children. Endoscopic treatment of patients effectively relieves the symptoms and corrects the urodynamic abnormalities.

Congenital anomalies of the male urethra

The spectrum of congenital anomalies of the male urethra is presented. The embryologic basis of each anomaly, when known, is discussed. Clinical and imaging features of each entity are presented.

Anterior urethral valves in children: A possible association between anterior urethral valves and Cowper’s duct cyst

To elucidate the pathophysiology of congenital obstruction of the anterior urethra and to investigate the association between anterior urethral valves and syringocele. Three boys with congenital obstruction of the anterior urethra diagnosed at our department between 1997 and 2004 were analyzed retrospectively. All three boys had congenital obstruction in the bulbar urethra. The presenting symptoms and age of each patient were varied. Whereas continuity between Cowper's duct and the diverticulum was not demonstrated radiographically in all of the boys, it was speculated endoscopically in all. Our series has suggested a possible association between anterior urethral valves (diverticulum) and syringocele. These congenital anomalies of the anterior urethra should be considered in the differential diagnosis of obstructive lesions of the urinary tract.

Cowper’s syringocele in an adult

Cowper's syringocele is cystic dilatation of the excretory bulbourethral gland duct. It is an uncommon condition and is usually reported in children. There are only ten previous case reports of late presentation in adulthood to the best of our knowledge. We present the imaging findings of such a case manifesting at 30 years of age.

Case Report: Cowper's Syringocele Treated with Holmium:YAG Laser

A syringocele is a cystic dilation of Cowper's duct. We report on a 15-year-old boy with persistent dysuria attributable to a syringocele, which was treated by endoscopic unroofing with the holmium:YAG laser. The classification, pathophysiology, and management options of Cowper's syringocele are briefly reviewed.

Cowper's syringocele--a rare malformation of the male urethra. Erlangen experience in two example cases

Cowper's syringocele is a cystic dilation of the male urethra which should be surgically treated when symptomatic. Two cases of syringocele, 1 adult and 1 juvenile, with obstructive micturition and microhematuria are reported. Both patients were treated using the transurethral surgical technique. The results are discussed with reference to the relevant literature.

Hematospermia: imaging findings

Hematospermia is an anxiety provoking but otherwise generally benign and self-limited condition that is infrequently associated with significant underlying pathology, and is most often considered to be idiopathic in nature. Management with routine clinical evaluation, watchful waiting, and reassurance generally suffice without further diagnostic workup or treatment. Noninvasive imaging may play an important role in the diagnostic workup of men with hematospermia, particularly in those who are >40 years old, have other associated symptoms or signs of disease, or have persistence of hematospermia. Many entities may be encountered in association with hematospermia at imaging, and specific therapeutic interventions may be used if certain treatable underlying pathologies are coincidentally detected. In this comprehensive review, we discuss the potential etiologies, diagnostic workup, imaging techniques, relevant male pelvic anatomy, imaging appearance of specific associated pathologies, and treatment for hematospermia.

Recent trends of genitourinary endoscopy in children

Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.

A neglected gland: a review of Cowper's gland

Cowper's glands are pea sized glands present inferior to the prostate gland in the male reproductive system. They produce thick clear mucus prior to ejaculation that drains into the spongy urethra. Though it is well established that the function of the Cowper's gland secretions is to neutralize traces of acidic urine in the urethra, knowledge regarding the various lesions and associated complications of this gland is scarce. This review provides a comprehensive report on the development, function and various lesions associated with Cowper's gland.

Anterior urethral valves and diverticula in children: a result of ruptured Cowper's duct cyst?

OBJECTIVE

To review a series of children with anterior urethral valves and diverticula, to elucidate the pathophysiology and optimal management of this entity.

PATIENTS AND METHODS

Nine cases (all boys; 1963 to 2003) were reviewed retrospectively.

RESULTS

Seven of nine boys had bulbar diverticula. Continuity between Cowper's duct and the diverticulum was noted endoscopically in two and confirmed radiographically in one. Initially, open surgery was curative but more recently endoscopic management has been the procedure of choice.

CONCLUSION

This series indicates that the distal lip of a ruptured syringocele may function as a flap-valve, leading to anterior urethral obstruction. Advances in imaging and endoscopic instruments have altered the mode of presentation and management of this entity.

Congenital urethral cysts in boys with vesicoureteric reflux

Four cases of congenital urethral cysts are reported. Diagnosis was made by endoscopy. The coincidence of urethral cysts and vesicoureteric refluxes seemed incidental in three cases. Fetal infravesical obstruction was provable in the fourth infant.

CONCLUSION

Urethral cysts should be considered in boys with vesicoureteric reflux. For the vast majority of cases it seems improbable that urethral cysts play a role in the pathogenesis of congenital vesicoureteric reflux.

Anterior urethral valves and diverticula

Obstructive lesions of the anterior urethra (valves, diverticula) are rare and can be difficult to diagnose. One recent case led us to review existing international reports; there are case histories for 260 patients over a 20-year period. The anatomical interpretation of these lesions is far from being unequivocal but many authors clearly distinguish between valves and diverticula, the basic difference being in the contiguity between the anomaly and the corpus spongiosum. Where the clinical presentation depends on age, the diagnosis depends essentially on voiding cysto-urethrography, which must image the whole urethra. Generally, the treatment for valves is simple, consisting of endoscopic resection. For diverticula it is not always necessary or desirable to remove the diverticulum; if there is a well-formed distal obstructing lip, removing it may be enough to cure the obstruction.

Imaging of male urethra

The male urethral imaging and pathology is not widespread in the radiology literature because this part of the urinary tract is easily studied by urologists with clinical or endoscopic examinations. Ultrasonography and MR imaging are increasingly being used in association with voiding cystourethrography and retrograde urethrography. The posterior urethra is being studied with voiding cystourethrography or voiding sonography which allows the detection of bladder neck pathology, post-surgical stenosis, and neoplasms. The functional aspects of the bladder neck and posterior urethra can be monitored continuously in patients with neuromuscular dysfunction of the bladder. The anterior urethral anatomy and pathology is commonly explored by retrograde urethrography, but recently sonourethrography and MR imaging have been proposed, distending the lumen with simple saline solution instead of iodinated contrast media. They are being used to study the urethral mucosa and the periurethral spongy tissue which can be involved in the urethral pathologies such as strictures, diverticula, trauma, and tumors. Imaging has an important role to play in the study of the diseases of the male urethra since it can detect pathology not visible on urethroscopy. The new imaging techniques in this area, such as sonography and MR, can provide adjunct information that cannot be obtained with other modalities.

Transforming growth factor-beta 2 heterozygous mutant mice exhibit Cowper's gland hyperplasia and cystic dilations of the gland ducts (Cowper's syringoceles)

Analyses of mutant mice with a deletion for the transforming growth factor beta 2 (Tgfbeta2) gene revealed cysts in the perineal/scrotal region of male mice. We present evidence from in situ, light and electron microscopy that the cysts observed in Tgfbeta2+/- heterozygous mice males derive from Cowper's gland tissue. The Cowper's glands of Tgfbeta2+/- heterozygous mutant mice display all steps of glandular hyperplasia and cystic dilation. TGF-beta isoforms and TGF-beta receptor (TbetaR-II) were localized immunocytochemically in sections of Cowper's glands. TGF-beta2 and TGF-beta3 were located predominantly in myoepithelial cells of the Cowper's gland whereas the TbetaRII was found in the plasma membrane of the acinar cells. TUNEL-assays revealed that apoptotic cell death is significantly reduced in Cowper's glands of TgfbetaB2+/- heterozygous mutant mice. The fact that Tgfbeta2+/- heterozygous mutant mice exhibit hyperplasia of Cowper's gland epithelium and Cowper's gland cysts suggests a disturbance of epithelial-stromal interaction most likely due to reduced TGF-beta2 level, accompanied by a significant decrease in apoptosis.

Cowper's syringocele causing voiding disturbance in an adult

BACKGROUND

A 21-year-old man presented with a sudden onset of miction pain and post-void dribbling. The diagnosis was Cowper's syringocele due to the findings of retrograde urethrography and urethroscopy.

METHODS/RESULTS

The patient underwent transurethral unroofing of the syringocele. The present case is of interest because Cowper's syringocele is usually diagnosed in male infants and children and is rarely found in adults.

CONCLUSION

This lesion should be included in the differential diagnosis of voiding disturbances in adults.