[A case report of Cowper's syringocele in an adult treated with transurethral unroofing]

We present an adult case of Cowper's syringocele. A 19-year-old male presented with the chief complaint of persistent post-voiding dribbling 5 months after onset. Urethroscopy demonstrated a thin membrane with a small orifice on the ventral aspect distal to the external sphincter. Magnetic resonance imaging showed a restiform shadow on the left side of the corpus spongiosum. Retrograde urethrogram showed filling of diverticulum-like structure in the region of urethral bulb terminating in the urogenital diaphragm. Considering the results mentioned above, we diagnosed the patient with Cowper's syringocele. Transurethral unroofing of the Cowper's syringocele was performed with a cold knife, and the excessive tissue on the edge of syringocele was electroresected to avoid recurrence. His post-voiding dribbling resolved completely after the procedure and has not recurred in 13 months postoperatively. Cowper's syringocele is typically diagnosed presenting with hematuria, urinary tract infection, and disuria in male infants and children. Adult cases of Cowper's syringocele are rare, and only 32 cases including the present case have been reported. Proper awareness of this entity and careful evaluation are important if patients present with persistent adult-onset voiding dysfunction.

[Syringocele in children: an unusual presentation as scrotal mass]

Syringocele is a cystic dilation of the excretory bulbourethral Cowper gland duct, and is a rather uncommon finding in pediatric age. It is frequently asymptomatic but sometimes may cause voiding symptoms and urinary tract infection (UTI). This case report describes an unusual manifestation of syringocele presenting with hydrocele. The case concerns a 2-year-old boy who was referred to our Clinic with a diagnosis of hydrocele. The patient underwent hydrocelectomy through a bilateral inguinal incision, but no clear communication with the patent peritoneal vaginal ducts could be demonstrated. The histology evidenced an epidermoid cyst. One year later the scrotal mass relapsed. Sonography, voiding cistography (VCG), computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed. VCG, CT scan and MRI demonstrated the communication between the urethra and the scrotal mass. A surgical excision of the syringocele with endoscopic resection of the collar were performed. Syringocele is a rare entity in pediatrics. To this authors' knowledge there are no reports in the literature describing cases presenting with scrotal mass.

Management of "open" syringocele based on urodynamic findings

INTRODUCTION

Depending on the type and size of the syringocele and the age of the patient, syringocele is treated medically or surgically, with endoscopy or open surgery. We report our experience in 10 "open" consecutive cases of syringocele, propose a clinical classification and discuss the management.

MATERIAL AND METHODS

In all patients (pts), diagnosis was achieved through voiding cystourethrography. All pts performed multichannel urodynamic studies. Pts with impaired compliance and/or detrusor instability (4 pts out of 10) underwent endoscopic unroofing. They were followed up until to 24 months after the endoscopic procedure. Pts with normal urodynamic findings were treated medically and followed with clinical examination. All pts performed an urinalysis every 2 weeks for the first three months and monthly for an year.

RESULTS

In endoscopic treated pts, voiding cystourethrography showed a normal profile of the urethra at 3 months follow-up. Pts with UTI, but with normal urodynamic parameter were treated with antibiotic therapy. At serial follow-up, all pts were completely symptom-free. Urinalysises were normal, negative for infection or haematuria.

DISCUSSION

In the literature to date, there isn't accordance if and when treated "open" syringoceles. In our opinion, it is useful to classify "open" syringocele based on urodynamic findings. Syringocele needs endoscopic surgical treatment if it is obstructed or a cause of dysfunctional alteration of the bladder, in order to avoid unnecessary surgery in syringocele without urodynamic abnormality.

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.

William Cowper and his decorated copperplate initials

William Cowper was an 18th-century London surgeon/anatomist who made important contributions to several medical disciplines. He achieved lasting fame for describing the bulbourethral glands and lasting infamy for pirating plates for his anatomical atlas, the Anatomy of Humane Bodies. Cowper wrote the books and papers that taught the forerunners of today's surgeons and anatomists. His most famous pupil, the great surgeon William Cheselden, was one of the teachers of John Hunter, the founder of modern surgery. Cowper's magnificent atlas of human myology, the Myotomia Reformata, is a showcase for exquisitely rendered illustrations of muscles and bones. Cowper populated his masterwork with dozens of delightfully decorated initial letters depicting anatomical scenes. This article introduces readers to the long-forgotten William Cowper and exhibits his stunning historiated letters in all their glory.

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.

Does preejaculatory penile secretion originating from Cowper's gland contain sperm?

PURPOSE

To determine if spermatozoa are present in the preejaculatory penile secretion, originating from Cowper's gland.

METHODS

DESIGN

Prospective clinical and laboratory study.

SETTING

Andrology and Sex Counseling Unit, Department of Obstetrics and Gynecology, Academic Teaching Hospital.

PATIENTS

Five patients referred for premature ejaculation, three for excessive fluid secreted during foreplay and four normal healthy volunteers.

INTERVENTION

Glass slide smears of preejaculatory Cowper's gland secretion obtained during foreplay from at least two different occasions, and semen samples after masturbation.

MAIN OUTCOME MEASURES

Microscopic examination of air-dried smears, and routine semen analyses.

RESULTS

None of the preejaculatory samples contained sperm. All the patients had sperm in routine sperm analyses.

CONCLUSIONS

Preejaculatory fluid secreted at the tip of the urethra from Cowper's gland during sexual stimulation did not contain sperm and therefore cannot be responsible for pregnancies during coitus interruptus.

[Syringocele of the Cowper's gland]

OBJECTIVE

To report an additional case of syringocele of Cowper's glands and briefly review its etiopathogenesis, diagnosis and treatment.

METHODS/RESULTS

A 26-year-old male consulted for a recent voiding syndrome and chronic postvoid dribbling. A voiding cystourethrogram demonstrated a syringocele, which was confirmed during endoscopic treatment.

CONCLUSIONS

Syringocele or cystic dilatation of Cowper's gland duct usually has a congenital etiology. There are four morphological types: simple, perforated, imperforate and ruptured. Diagnosis is made by voiding cystourethrography and confirmed by endoscopy. Transperineal ultrasound was also utilized for the diagnosis. Treatment is by endoscopic incision.

[Simple syringocele of Cowper's glands]

OBJECTIVE

To describe an additional case of simple syringocele of Cowper's glands and review the literature.

METHODS

An additional case of simple syringocele of Cowper's glands is presented and the literature over the last 10 years is reviewed.

RESULTS/CONCLUSIONS

The treatment most commonly utilized is marsupialization to the urethra by endoscopy. The foregoing was performed in our patient with satisfactory results.

Cobb's collar and syringocele with stone

We report a case of unusual syringocele with a stone and Cobb's collar. Tubular or cystic dilatation of Cowper's gland duct has been called a syringocele. Congenital urethral narrowing is known as Cobb's collar. This paper presents a rare case of adult syringocele with stone and Cobb's collar. We analysed the clinical, radiological and therapeutic aspects of this entity.

[Diseases of the glandulae bulbourethrales Cowperi in the man]

The history of Cowper Gland is described. Next the clinical, radiological and endoscopical findings in 172 patients (age 18 to 82) are evaluated with regard to the importance of these alterations in clinical practice. There was no tumor. In three cases, only the bulbourethral gland showed inflammation. Out of 169 syringoceles 9 were closed (3 perineal, 6 bulbar). Only one case of the urethral (bulbar) type of closed syringocele showed obstruction. There were 56 patients with various forms of dilatation and opening into the urethra. Only one case showed obstruction. Thirty-one out of 104 patients with so-called simple syringocele had mild dilatation of the duct, mainly normal gland and mild symptoms. Alterations of the urethral wall as well as clinical symptoms were noted in the remaining 73 men with irregular ducts and alterations of the gland; all of them had local urethral signs; in 42 there were extensive urethral strictures.

Altered expression of transforming growth factor betas during urethral and bulbourethral gland tumor progression in transgenic mice carrying the androgen-responsive C3(1) 5' flanking region fused to SV40 large T antigen

We demonstrate that targeted expression of SV40 large T antigen (TAg) to the urethral (periurethral) and bulbourethral gland epithelium leads to adenocarcinoma formation in these tissues after 7 months of age, which are extremely rare sites for spontaneous tumor formation in humans. The development of proliferative lesions in the urethral gland predictably follows a temporal course of progression with approximately one third of male animals developing urethral tumors by 1 year of age. Tumor progression in these organs correlates to the level of TAg and p53 expression. Immunoprecipitation confirmed that SV40 TAg protein was bound to p53 and Rb p110 in vivo. Expression of transforming growth factor beta (TGFbetas) was evaluated during tumor progression of urethral gland carcinomas. Elevations of intracellular and extracellular TGFbeta1 and extracellular TGFbeta3 were found in preneoplastic and neoplastic lesions, suggesting that increased TGFbetas may augment tumor growth. c-Met expression showed a tendency for increased expression in the urethral gland carcinomas. We speculate that the directed expression of SV40 TAg by the hormone responsive C3(1) gene and subsequent tumor formation in these organs is influenced by androgens, since these tissues and carcinomas express androgen receptor (AR) and arise only in male transgenic mice. Several cell lines established from the urethral carcinomas were also shown to express AR, but are not androgen dependent in culture. To our knowledge, this is the first transgenic animal model for urethral and bulbourethral carcinomas. This transgenic mouse model and the cell lines derived from it may provide a unique opportunity for dissecting molecular mechanisms involved in the tumorigenesis of these organs which otherwise rarely develop cancer.

Anterior urethral diverticulum produced by Cowper's gland duct cyst

A case of congenital urethral diverticulum is presented. The patient was a 16-year-old boy with the chief complaint of dribbling urine since he was 14 years old. A retrograde urethrogram revealed a diverticulum of the bulbar urethra, which had been produced by a cystic dilation of the Cowper's gland duct. The walls of the diverticulum were resected endoscopically.

Adenoid cystic carcinoma of Cowper's gland

We report an additional case of primary adenoid cystic carcinoma of Cowper's gland in an otherwise healthy asymptomatic 66-year-old man. Based on a review of similar lesions presenting in the head and neck, our treatment plan entailed pelvic exenteration followed by radiation therapy. Whether adenoid cystic carcinoma of Cowper's gland behaves as aggressively as it does in the head and neck remains unclear. However, in view of the extensive local invasion in our patient and a previously successful outcome, a combined surgical and radiation approach appears to be the most appropriate therapy.

[Syringocele of the Cowper's glands in adults: presentation of a case]

Enlargement of Cowper gland ductus (syringocoeles) is an uncommon lesion, normally found in children and young adults. The paper presents a case of one adult syringocoele, treated through transurethral route, and reviews the lesion's etiology, clinic, radiology and therapy.

[Syringocele of Cowper's gland]

The dilatation of the duct of Cowper's gland is known as Cowper's Syringocele, a rarely occurring pathology, usually of a congenital origin. We offer two new cases corresponding to a perforated Syringocele and a non-perforated Syringocele. We analyse the clinical, radiological and therapeutic aspects of this entity.

Cystic dilatation of Cowper's gland duct--an overlooked cause of urethral symptoms?

Dilatation of Cowper's gland duct was diagnosed in four men with symptoms including post-voiding dribbling, frequency of micturition, dysuria and hematuria. Cystourethrography gave the correct diagnosis in all cases. Treatment consisted of transurethral incision of the cystic excretory duct, providing marsupialization into the urethra. Investigation of longstanding or recurrent episodes of urethral symptoms in men should include cystourethrography with this lesion in mind. It seems to be less rare than was previously assumed.

Urethral cyst in a man

We report a case of a bulbous urethral cyst in a man. This rare lesion, probably arising from Cowper's gland, was treated successfully by endoscopic excision of the cyst wall.

[Syringocele or cystic diagnosis of Cowper's gland ducts]

Cystic dilatation of bulbo-urethral gland ducts (Cowper's syringocele) is an uncommon abnormality, frequently asymptomatic, showing various radiographic patterns. The lesion is more commonly seen in children, but it may be found in adults too, and may cause dysuria, pollakiuria, stranguria and posturinary dribbling. Fourteen patients with syringocele were observed: 6 of them were asymptomatic, while in 8 the most common symptoms were posturinary dribbling and stranguria. X-ray examination showed 7 cases of perforated syringocele, 4 cases of ruptured syringocele, 2 cases of simple syringocele and 1 case of imperforate syringocele. Various theories are reported to explain how the lesion forms and the differences are analyzed which characterize different kinds of urethral lesions.

[Ventral diverticula of the bulbous urethra]

We report 5 male patients with ventral diverticula of the bulbous urethra. There was urinary infection in 4 cases, urethral obstruction in 1 and voiding disturbances in 1. Urethral catheterism had been performed previously for various reasons in three patients. Urethroscopic evaluation was successfully completed with endourethral resection in four instances. Based on our morphologic findings we believe that the relationship between these diverticula and dilatation of Cowper's gland ducts is beyond doubt. The cause of this dilatation remains unclear, but mechanical factors, like catheterism, can play a role.

Urethral obstruction and prostatitis

Urethral destruction is only occasionally the reason for prostatitis and Cowperitis and prostatitis is only demonstrated occasionally to complicate urethral stricture. It is a dependence of prostatitis and spastic urethral obstruction in the neuropathic bladder.

Urethral valves as a cause of dilated Cowper's glands and perineal pain

Symptoms of lower urinary tract obstruction are the most frequent manifestation of congenital posterior valves. A case is presented in which the initial symptom was perineal pain. Diagnosis was delayed because of a false diagnosis of prostatitis. Urethrography and cystography showed posterior urethral valves and dilated Cowper's glands. Bilateral incisions of the valves with the knife electrode resulted in disapperance of the pain and regression of the dilated Cowper's glands.

Cysts of the ducts of Cowper's glands

We describe 4 patients, 3 of whom were children, with cysts in the ducts of Cowper's glands. Presenting symptoms were testicular pain and urethritis. Voiding urethrography with dilute contrast medium is the best diagnostic aid short or urethroscopy. The cysts were effectively treated by avulsion with a bent wire.

Carcinoma of Cowper's gland, report of the eleventh case

Images

Observations on the development of the seminal vesicles, prostate and bulbourethral glands in the ram

Images