pediatrics
Penile and Urethral Anomalies
Penile Anomalies
This anomaly is ventral, lateral, and/or rotational curvature of the penis, which is most apparent with erection and is caused by fibrous tissue along the usual course of the corpus spongiosum, or by a size difference between the two corpora cavernosa. Chordee may be associated with Hypospadias . Severe deformity may require surgical correction. The urethra opens on the dorsum of the glans or penile shaft, or at the penopubic junction. In girls, the urethra opens between the clitoris and labia or in the abdomen. Epispadias can be partial (in 15%) or complete; the most severe form occurs with Bladder exstrophy . Symptoms and signs of epispadias are Treatment of epispadias is surgical. In partial epispadias, prognosis for continence with treatment is good. In complete epispadias, surgical reconstruction of the penis alone may lead to persistent incontinence; bladder outlet reconstruction is required to achieve complete urinary control. This anomaly is caused by failure of tubularization and fusion of the urethral groove. It almost always occurs in boys, in whom the urethra opens onto the underside of the penile shaft, at the penoscrotal junction, between the scrotal folds, or in the perineum. The foreskin fails to become circumferential and appears as a dorsal hood. Hypospadias is frequently associated with Chordee . Prognosis for functional and cosmetic correction is good. Outpatient surgery at about 6 months of age involves construction of a neourethra using penile shaft skin or foreskin and repair of the chordee. Hypospadias is extremely rare in girls; the urethra opens into the vaginal introitus. In this image, the arrow is pointing to the meatus. Image courtesy of Drs. Ronald Rabinowitz and Jimena Cubillos. In this image, the arrow is pointing to the meatus. Image courtesy of Drs. Ronald Rabinowitz and Jimena Cubillos. Images courtesy of Drs. Ronald Rabinowitz and Jimena Cubillos. Phimosis the most common penile abnormality, is constriction of the foreskin with inability to retract over the glans; it may be congenital or acquired. Paraphimosis is inability of the retracted constricting foreskin to be reduced distally over the glans. Phimosis may respond to topical corticosteroids and gentle stretching; some boys require circumcision. Paraphimosis should be reduced urgently because the constricting foreskin functions as a tourniquet, causing edema and pain. Firm circumferential compression of the edematous foreskin with the fingers may reduce edema sufficiently to allow the foreskin to be restored to its normal position by pushing the glans back through the tight foreskin using both thumbs. If this technique is ineffective, a dorsal slit done using a local anesthetic relieves the condition temporarily. When edema has resolved, the phimosis may be treated with circumcision or topical corticosteroids. A very tight frenulum may prevent complete retraction of the foreskin or cause pain or bleeding with foreskin retraction or erection. Frenulectomy may be sufficient to resolve symptoms if patients do not want circumcision. Less common anomalies include penile agenesis, duplication, and lymphedema. Many anomalies also involve urethral abnormality, or other anomalies, such as Bladder exstrophy . Treatment of most anomalies is surgical. Microphallus results from androgen deficiency or insensitivity; in boys with deficiency, treatment istestosteronesupplementation. 