BJR © 2020 The Authors.

Published by the British Institute of Radiology

https://​doi.​org/​10.​1259/​bjr.​20190118
Received: Revised: Accepted:
31 January 2019 17 November 2019 10 February 2020

Cite this article as:

Das JP, Vargas HA, Lee A, Hutchinson B, O'Connor E, Kok HK, et al. The urachus revisited: multimodal imaging of benign & malignant
urachal pathology. Br J Radiol 2020; 93: 20190118.

Pictorial Review

The urachus revisited: multimodal imaging of benign &

malignant urachal pathology

Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024

1,2,3
Jeeban Paul Das, MD, 2Hebert Alberto Vargas, MD, 3Aoife Lee, MD, 1Barry Hutchinson, MD,
4
Eabhann O'Connor, MD, 5Hong Kuan Kok, MD, 5William Torreggiani, MD, 1Joe Murphy, MD,
1
Clare Roche, MD, 1John Bruzzi, MD and 1,6Peter McCarthy, MD
1
Dept. of Radiology, Galway University Hospital, Co., Galway, Ireland
2
Dept. of Oncologic Imaging, Memorial Sloan Kettering Cancer Centre, New York, USA
3
Dept. of Radiology, Beaumont Hospital, Dublin 9, Ireland
4
Dept. of Urology, St. Vincent's University Hospital, Dublin, Ireland
5
Dept. of Radiology, Adelaide & Meath Hospital, Dublin, Ireland
6
School of Medicine, Clinical Science Institute, National University of Ireland, Galway, Ireland

Address correspondence to: Dr Jeeban Paul Das

E-mail: ​jeeban.​paul.​das@​gmail.​com

ABSTRACT:
The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates
at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete
obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus,
urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with
lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe
imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT,
positron emission tomography CT and MRI.

Introduction Imaging of urachal remnants

Urachal embryology
A urachal remnant occurs due to maldevelopment of the
allantois and cloaca. The allantois arises from the postero-
inferior yolk sac after the second week of embryonic devel-
opment. The urinary bladder initially extends to the level
of the umbilicus descending into the pelvis by month 5 of
gestation. The apical portion of the descending bladder,
derived from the cloaca, degenerates into an extraperitoneal
fibrous cord within the Retzius space, eventually becoming
the median umbilical ligament. This structure extends from
the bladder dome to the umbilicus. The vestigial remnant of
this is known as the urachus1,2 (Figure 1).
Epidemiology of urachal anomalies
A persistent urachus has an incidence of 1/5000 in the
adult population, occurring more frequently in males. The
most common urachal anomalies are urachal cysts, urachal
sinus, patent urachus and vesicourachal diverticulum
(Figure 2). Infection is the most common benign compli-
cation of urachal remnant pathology occurring in children
and adults whereas malignant complications have been
described exclusively in adults to date.1–3
Urachal cysts account for up to 54% of urachal remnant
anomalies, arising from the lower third of the urachus
and are often asymptomatic and incidentally discovered.
Sonography can demonstrate an extraluminal midline
fluid-­filled structure that does not communicate with the
umbilicus. CT following intravenous contrast usually reveal
a fluid-­attenuation supravesical lesion (Figure 3). On MRI,
urachal cysts usually demonstrate a thin, non-­enhancing
wall with intrinsic T1 hypointense and T2 hyperintense
signal.1–4
A urachal sinus is a tubular dilatation of the umbil-
ical portion of the urachus that occurs three times more
frequently in children than adults. Clinical presentation
is most commonly with periumbilical inflammation and
purulent discharge. On ultrasound, a urachal sinus may
appear tubular and hypoechoic communicating with the
umbilicus only. Fluoroscopic sinography can show a tube-­
like cul-­de-­sac. CT may better delineate infective complica-
tions. MRI can better evaluate for superimposed infection
or developing malignancy.1,3
 BJR Das et al

Figure 1. Schematic diagram (a) showing a normal urachus. Saggital (b) and axial (c) CT images following intravenous contrast
demonstrating a normal urachus extending into Retzius space.

Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024

The patent urachus is a fistulous communication occuring
between the urinary bladder and umbilicus, most commonly
presenting with umbilical urine leak. Ultrasound may demon-
strate a tube-­shaped anechoic structure communicating with
the antero superior bladder and umbilicus. Diagnosis can be
confirmed on voiding cystourography or fluoroscopic sinogram
with instilled contrast media defining the umbilical-­vesical tract.
CT and MRI can better demonstrate air, fluid or calculi within
the patent urachus, and evaluate for potential infective complica-
tions on post-­contrast imaging.1–3
A urachal diverticulum is a rare clinical entity accounting for
3–5% of urachal remnant pathology occurring when the urachus
communicates with the bladder dome only. Sonographic evalua-
tion of a urachal diverticulum shows a blind-­ending supravesical
hypoechogenic structure arising from the bladder dome. CT can
demonstrate an out-­pouching from the superior aspect of the
bladder (Figure 4) without umbilical communication, and may
demonstrate intraluminal calcification, present in up to 50% of
cases. In children, VCUG can show contrast reflux into the diver-
ticulum and help delineate the extent of the involvement of the

Figure 2. Schematic diagrams showing common urachal remnant pathology. (a) Urachal cyst; (b) Urachal sinus; (c) Patent ura-
chus; (d) Urachal diverticulum.

2 of 6 birpublications.org/bjr Br J Radiol;93:20190118
 Imaging of Urachal Pathology
Figure 3. 38-­year-­old male with a lower urinary tract symp-
toms. Axial (a) and saggital (b) CT images after intravenous
contrast showing a supravesical cystic structure without defi-
nite communication with the bladder or umbilicus confirmed
as a urachal cyst following image-­guided aspiration.
urachus. On MRI, a protruding midline soft-­tissue tract can be
seen, demonstrating variable signal intensity and post-­contrast
enhancement.1–3
Imaging of benign urachal pathology
Infection of a persistent urachus is the most common benign
complication occuring in patients with a urachal remnant, usually
due to Staphylococcus aureus. Patients with infected urachal cysts
may be asymptomatic with leukocytosis or present with recur-
rent urinary tract infections, abdominal pain or fever.1,2,4
Infected urachal cysts may be difficult to differentiate from non-­
infected cysts or other pelvic pathology on initial sonographic
evaluation in the absence of clinical signs and symptoms.5
Ultrasound is often the first-­line modality for imaging a child
presenting with symptoms of abdominal pathology. Greyscale
ultrasound reveals a midline extraperitoneal structure extending
from the bladder dome to the umbilicus containing internal
echoes (Figure 5) and may mimic other pelvic pathology, such
as haematoma. On CT, infected urachal cysts can appear thick-­
walled and irregular with peripheral enhancment and underlying
bladder wall thickening (Figure 6). On MRI, infected urachal
cysts can appear as irregular thick-­walled supravesical struc-
tures demonstrating variable signal intensity and heterogenous
contrast enhancement. MRI may delineate the infected urachal
Figure 4. 70-­year-­old male with back pain. Saggital (a) and
axial (b) CT images following intravenous contrast showing a
urachal diverticulum (arrows) detected as an incidental find-
ing.
3 of 6 birpublications.org/bjr
BJR
Figure 5. 5-­ year-­
old child with fever and urinary retention.
Longitudinal (a) and transverse (b) greyscale ultrasound
images demonstrating a lesion containing internal echoes
(arrows) anterosuperior to the urinary bladder (*). Surgical
excision following intravenous antibiotics confirmed diagnosis
of an infected urachal cyst.
Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024
cyst from adjacent pelvic structures and identify possible rupture
and abscess formation.1,3–5
Urachal abscess can develop if an infected cyst is left untreated.
Infected urachal cysts usually discharge into the umbilicus or
urinary bladder but may rarely rupture intraperitoneally from
their extraperitoneal location causing sepsis and peritonitis.
Given the lack of direct communication with either bladder
or umbilicus, clinical asessment may result in misdiagnosis of
more commonly encountered caused of acute abdomen, such
as appendicitis or bowel perforation.5,6 Ultrasound may show a
complex cystic mass in the midline above the urinary bladder.
CT following intravenous contrast can demonstrate a supraves-
ical heterogenous collection with a thick enhancing irregular
wall and central non-­ enhancing low attenuation (Figure 7),
that may abut or communicate with the abdominal wall.1,3,5,6
On MRI, a urachal abscess can appear as a thick-­walled, multi-
loculated predominantly T2 hyperintense mass extending into
Retzius space demonstrating heterogenous enhancement on
post-­contrast imaging. (Figure 8)
Benign urachal tumours are rare clinical and radiological entities
and include fibroadenomatous lesions, lipoatous tumours and
hamartomas.1,3
Figure 6. 49-­year-­old male with recurrent urinary tract infec-
tions. Saggital (a) and axial (b) CT images following intra-
venous contrast demonstrating an irregular cystic structure
anterosuperior to the urinary bladder demonstrating periph-
eral enhancement, confirmed as an infected urachal cyst fol-
lowing surgical excision.
Br J Radiol;93:20190118
 BJR
Figure 7. 21-­year-­old male with 2-­week history of fever and
tender suprapubic mass. Axial CT image after intravenous
contrast showing an irregular, mixed attenuation lesion
anterosuperior to the bladder dome (arrow) with surrounding
inflammatory change. Image-­guided aspiration yielded puru-
lent material. Subsequent surgical excision confirmed diagno-
sis of a urachal abscess.
Imaging of malignant urachal pathology
Malignant transformation of a urachal remnant is rare,
accounting for <0.5% of bladder cancer and develops twice as
often in males, most commonly between the ages of 46 and 56.
Adenocarcinoma accounts for 80–90% of cases with up to 75%
producing mucin. Sarcomatous neoplasms, squamous cell and
transitional cell urachal cancers have also been reported.1,3,7,8
Clinical presentation is variable and patients may be asymptom-
atic until local spread or development of metastases. Haematuria
is the most common symptom, present in up to 80% of cases.
Mucinuria can occur in up to 25% of patients, a rare symptom
that should raise suspicion and prompt further investigation for
a urachal cancer.3,7–9
On ultrasound, urachal malignancy can appear as a hypere-
chogenic soft-­tissue lesion between the urinary bladder and
Figure 8. 28-­year-­old female with pelvic pain and fever. Axial
(a) and sagittal (b) T2 weighted images showing a multiloc-
ulated heterogenously T2 hyperintense collection antero-
superior to the bladder (*), confirmed as a urachal abscess
following surgical intervention.
4 of 6 birpublications.org/bjr
Das et al
Figure 9. 32-­year-­old female with abdominal swelling and
lower urinary tract symptoms. Axial CT image following
intravenous contrast showing a solid-­ cystic mass (arrow)
containing a focus of curvlinear calcification (arrowhead)
anterosuperior to the urinary bladder (*). Histopathology
confirmed the diagnosis of urachal adenocarcinoma, follow-
ing surgical excision.
Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024
anterior abdominal wall demonstrating internal vascularity
on colour doppler imaging. Urachal cancer can demonstrate a
variable appearance on cross-­sectional imaging. On CT urachal
malignancy can appear as a solid-­cystic mass extending toward
the umbilicus with an irregular, enhancing wall (Figure 9). Up
to 90% of cases arise from the juxtavesical urachus, extending
cranially into the space of Retzius. Urachal cancer may also
appear as a predominantly cystic mass (Figure 10) or as a
midline or paramidline enhancing nodule arising from the
anterosuperior aspect of the urinary bladder (Figure 11).
Urachal cancer appears low attenuation in 60% of cases due to
the presence of mucin or necrosis. CT can also identify central
or peripheral calcification, present in almost 75% of urachal
cancers.1,3,8–10 Urachal malignancies may be predominantly
Figure 10. 39-­year-­old female with abdominal bloating and
mucosuria. Axial CT image demonstrating a well-­ defined
cystic structure with mural thickening and peripheral calcifi-
cation (arrowhead) anterosuperior to the urinary bladder (*).
Image-­guided aspiration and histopathology confirmed muci-
nous urachal adenocarcinoma.
Br J Radiol;93:20190118
 Imaging of Urachal Pathology
Figure 11. 41-­year-­old male with haematuria. Axial CT image
showing an enhancing soft-­tissue nodule (arrow) arising from
left anterosuperior wall of the bladder (*). Histopathology fol-
lowing cystoscopy and biopsy confirmed diagnosis of urachal
adenocarcinoma.
cystic demonstrating high T2 signal (Figure 12) or multilobu-
lated with solid and cystic components demonstrating interme-
diate and high T2 signal representing mucin, cystic change and/
or necrosis (Figure 13). On post-­contrast T1 weighted imaging,
urachal cancers may demonstrate inhomogenous enhancement.
MRI may provide addional value by defining local invasion of
adjacent soft-­tissue and visceral structures, as well as identifying
local nodal metastases.1,11,12
Assessment of urachal pathology: the
role of imaging
Accurate diagnosis of benign from malignant urachal pathology
on imaging is imprecise. Meeks et al found that pre-­operative
imaging with CT had a low specificity and negative predictive
value of 21 and 43% respectively.13 In addition, although the
majority of malignant urachal tumours are solid, up to 27% can
demonstrate a cystic component.2 Similarly, although intrinsic
calcification is considered 'pathognomic' of urachal cancer
seen in up to 70% of cases on CT, 'egg-­shell' calcification can
Figure 12. 39-­year-­old female with abdominal bloating. Sag-
gital (a) and coronal (b) T2 weighted magnetic resonance
images show a paramidline cystic mass arising from the dome
of the bladder (*). Histopathology confirmed mucinous ura-
chal adenocarcinoma.
5 of 6 birpublications.org/bjr
BJR
Figure 13. 45-­year-­
old female with haemturia and abdom-
inal bloating. Axial (a) and sagittal (b) T2 weighted images
demonstrate a complex, multilobulated mass involving the
dome of the urinary bladder (*) with intravesical extension
(arrowhead). Histopathology confirmed mucinous urachal
adenocarcinoma.
Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024
also be seen in ~20% of urachal cysts.2,3 Fludeoxyglucose posi-
tron emission tomography (PET) CT (Figure 14, 14,15) has been
demonstrated as useful in the assessment of urachal cancer14
However, due to lack of avid fludeoxyglucose uptake in over
half of mucinous tumours, diagnostic performance of PET/CT
may be unreliable in excluding urachal malignancy, given that
up to three quarters urachal tumours produce mucin. Imaging
may identify a urachal remnant complication but ultimately
cystoscopy and biopsy may be required to confirm the diag-
nosis of a benign or malignant lesion.2,7,8,15
Treatment of urachal pathology
Controversy regarding optimal treatment of urachal remnants
has become more apparent in recent years. Management strat-
egies also differ between adult and paediatric patients. While
surgery is required for most symptomatic patients, sponta-
neous regression of urachal anomalies has also been reported.
Current series demonstrate a 10-­year survival rate of only 49%
with surgery for urachal cancer while salvage chemotherapy
is effective in less than 10% of patients with metastases,
suggesting that the risk of delaying the urachal remnant resec-
tion in older adults may exceed the risk of surgery.2,7,8
Figure 14. 47-­year-­old female with haematuria. Axial (a) and
sagittal (b) 18-­
fluorine FDG PET CT showing an FDG-­ avid
supravesical mass (arrows) containg punctate calcifications
demonstrating a maximum SUV of 6.8. Biopsy and subse-
quent resection confirmed the diagnosis of urachal adeno-
carconoma. FDG, fludeoxyglucose; PET, positron emission
tomography; SUV, standardized uptake value.
Br J Radiol;93:20190118
 BJR Das et al

Whereas earlier recommendations favoured surgical interven-
tion for in the majority of paediatric patients with a urachal
remnant (due to the risk of recurrent infection and urachal
cancer in later life), more recent reports have suggested that
between 50 and 80% resolve non-­ operatively. In addition,
almost 15% of paediatric patients develop post-­ operative
complications including iatrogenic bladder injury requiring
reoperation.2,13,16
disease can potentially result in delayed diagnosis and treatment.
Multimodal imaging with ultrasound, CT, PET/CT and MRI can
identify and characterise potential complications related to the
urachal remnant, however differentiating benign from malignant
urachal complications is imprecise with imaging alone and histo-
pathological analysis is usually required to confidently diagnose
urachal cancer from an infectious/inflammatory process.

Conclusion Funding
Urachal pathology, although rare, can cause significant morbidity This research was funded in part through the NIH/NCI Cancer
and mortality. Non-­specific pelvic symptomatology of urachal Center Support Grant P30 CA008748

Downloaded from https://academic.oup.com/bjr/article/93/1110/20190118/7449193 by guest on 06 March 2024

REFERENCES
1. Parada Villavicencio C, Adam SZ, Nikolaidis
P, Yaghmai V, Miller FH. Imaging of the
urachus: anomalies, complications, and
mimics. Radiographics 2016; 36: 2049–63.
doi: https://​doi.​org/​10.​1148/​rg.​2016160062
2. Ashley RA, Inman BA, Routh JC, Rohlinger
AL, Husmann DA, Kramer SA. Urachal
anomalies: a longitudinal study of urachal
remnants in children and adults. Journal of
Urology 2007; 178(4S): 1615–8. doi: https://​
doi.​org/​10.​1016/​j.​juro.​2007.​03.​194
3. JS Y, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim
MJ. Urachal remnant diseases: spectrum of
CT and US findings. RadioGraphics 2001; 2:
451–61.
4. Goldman IL, Caldamone AA, Gauderer
M, Hampel N, Wesselhoeft CW, Elder JS.
Infected urachal cysts: a review of 10 cases.
Journal of Urology 1988; 140: 375–8. doi:
https://​doi.​org/​10.​1016/​S0022-​5347(​17)​
41612-0
5. Ilica AT, Mentes O, Gur S, Kocaoglu M,
Bilici A, Coban H. Abscess formation as
a complication of a ruptured urachal cyst.
Emerg Radiol 2007; 13: 333–5. doi: https://​
doi.​org/​10.​1007/​s10140-​006-​0560-2
6. Schiffman JS. Urachal remnants in patients
presenting to the emergency department
with abdominal pain. J Emerg Med 2018;
55: 333–8. doi: https://​doi.​org/​10.​1016/​j.​
jemermed.​2018.​05.​023
7. Pinthus JH, Haddad R, Trachtenberg J,
Holowaty E, Bowler J, Herzenberg AM,
et al. Population based survival data on
urachal tumors. Journal of Urology 2006; 175:
2042–7. doi: https://​doi.​org/​10.​1016/​S0022-​
5347(​06)​00263-1
8. Ashley RA, Inman BA, Sebo TJ, Leibovich
BC, Blute ML, Kwon ED, et al. Urachal
carcinoma: clinicopathologic features
and long-­term outcomes of an aggressive
malignancy. Cancer 2006; 107: 712–20. doi:
https://​doi.​org/​10.​1002/​cncr.​22060
9. Niedworok C, Panitz M, Szarvas T, Reis
H, Reis AC, Szendröi A, et al. Urachal
carcinoma of the bladder: impact of clinical
and immunohistochemical parameters on
prognosis. Journal of Urology 2016; 195:
1690–6. doi: https://​doi.​org/​10.​1016/​j.​juro.​
2015.​11.​067
10. Thali-­Schwab CM, Woodward PJ, Wagner
BJ. Computed tomographic appearance of
urachal adenocarcinomas: review of 25 cases.
Eur Radiol 2005; 15: 79–84. doi: https://​doi.​
org/​10.​1007/​s00330-​004-​2408-z
11. Chung AD, Schieda N, Flood TA,
Cagiannos I, Kielar AZ, McInnes MDF, et al.
Suburothelial and extrinsic lesions of the
urinary bladder: radiologic and pathologic
features with emphasis on MR imaging.
Abdom Imaging 2015; 40: 2573–88. doi:
https://​doi.​org/​10.​1007/​s00261-​015-​0467-z
12. Rafal RB, Markisz JA. Urachal carcinoma:
the role of magnetic resonance imaging. Urol
Radiol 1990; 12: 184–7. doi: https://​doi.​org/​
10.​1007/​BF02924004
13. Meeks JJ, Herr HW, Bernstein M,
Al-­Ahmadie HA, Dalbagni G, et al.
Preoperative accuracy of diagnostic
evaluation of the urachal mass. Journal of
Urology 2013; 189: 1260–2. doi: https://​doi.​
org/​10.​1016/​j.​juro.​2012.​10.​043
14. Li X, Liu S, Yao S, Wang M. A rare case of
urachal mucinous adenocarcinoma detected
by 18F-­FDG PET/CT. Clin Nucl Med 2015;
40: 282–5. doi: https://​doi.​org/​10.​1097/​RLU.​
0000000000000674
15. Berger KL, Nicholson SA, Dehdashti F,
et al. Fdg PET evaluation of mucinous
neoplasms: correlation of FDG uptake
with histopathologic features. AJR Am J
Roentgenol 2000; 4: 1005–8.
16. Naiditch JA, Radhakrishnan J, Chin AC.
Current diagnosis and management of
urachal remnants. J Pediatr Surg 2013; 48:
2148–52. doi: https://​doi.​org/​10.​1016/​j.​
jpedsurg.​2013.​02.​069

6 of 6 birpublications.org/bjr Br J Radiol;93:20190118