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Prostatic Cysts: Causes, Diagnosis, and Treatment

Definition

Prostatic cysts are fluid-filled cavities in the prostate, usually lined by epithelium (true cysts).

Transrectal ultrasonography (sagittal section): prostatic cyst causing bladder outlet obstruction. See also the figure of endoscopic treatment in the same patient.

Epidemiology

5–8% of men have small prostatic cysts (Ishikawa et al., 2003).

Etiology and Pathology of Prostate Cysts

According to their location, prostatic cysts are classified as median midline, paramedian, or lateral cysts.

Utricle cyst

A utricle cyst is a cystic midline structure of the prostate arising from the prostatic utricle. It extends posteriorly between the seminal vesicles into the space between the bladder and rectum. Histologically, high PSA expression is typical; squamous epithelium is absent.

Persistent Müllerian duct syndrome

Persistent Müllerian duct syndrome may cause large solid and cystic pelvic masses near the midline. Histopathologic examination shows squamous epithelium resembling vaginal epithelium; uterine tissue may also be present.

Other causes

Other cysts may arise from the seminal vesicles, seminal tract, or prostatic glands, particularly in association with infection, BPH, atrophy, or tumors (Galosi et al., 2009).

Signs and Symptoms of Prostatic Cysts

Small cystic lesions are usually asymptomatic and clinically insignificant. Larger cysts may cause bladder outlet obstruction, urinary tract infection, hydronephrosis, hematospermia, pain, or infertility.

Diagnostic Workup

• Abdominal and transrectal ultrasonography [fig. prostatic cyst in TRUS]
• Measurement of residual urine and uroflowmetry
• Cystoscopy
• CT or MRI for larger, complex, or diagnostically unclear cysts (Curran et al., 2007)

Transrectal ultrasonography (sagittal section): asymptomatic prostatic cyst between the bladder (HB) and rectum; extension toward the verumontanum suggests a utricle cyst.

Abdominal ultrasound imaging using the bladder as an acoustic window (sagittal section).

MRI of the prostate (left: axial plane; right: coronal plane; T2-weighted): typical finding of a utricle cyst, a tapered prostatic cyst extending toward the verumontanum. With kind permission, Dr. H.-P. Engels, Radiologie im Zentrum, Augsburg.

Differential Diagnosis of Prostatic Cysts

Post-TURP defect, bladder diverticulum, enlarged seminal vesicles, ureterocele, ectopic ureter, prostatic abscess, ejaculatory duct cyst, and rare malignant cystic tumors of the prostate.

Treatment of Prostatic Cysts

Small asymptomatic cysts are observed. Symptomatic small or medium-sized cysts can be treated by transurethral incision, marsupialization, or unroofing [fig. endoscopic treatment of a prostatic cyst]. Large pelvic masses of the Müllerian duct system (vagina masculina) may require open, laparoscopic, or robot-assisted surgery. Typical open approaches are a lower abdominal incision with a transvesical-trans-trigonal approach or a perineal approach. Laparoscopically, the cyst can be accessed transperitoneally after incision of the peritoneum in the rectovesical pouch.

References

S. Curran, O. Akin, A. M. Agildere, J. Zhang, H. Hricak, and J. Rademaker, “Endorectal MRI of prostatic and periprostatic cystic lesions and their mimics.,” AJR. American journal of roentgenology, vol. 188, no. 5, pp. 1373–1379, 2007.

Galosi, A. B.; Montironi, R.; Fabiani, A.; Lacetera, V.; Gallé, G. & Muzzonigro, G. Cystic lesions of the prostate gland: an ultrasound classification with pathological correlation.
J Urol, 2009, 181, 647-657

M. Ishikawa et al., “Midline Prostatic Cysts in Healthy Men: Incidence and Transabdominal Sonographic Findings,” American Journal of Roentgenology, vol. 181, no. 6, pp. 1669–1672, 2003.

M. Ishikawa et al., “Midline prostatic cysts in healthy men: incidence and transabdominal sonographic findings.,” AJR. American journal of roentgenology, vol. 181, no. 6, pp. 1669–1672, 2003.

  Deutsche Version: Ursachen und Therapie von Prostatazysten

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