SURGERY OF THE PENIS

AND URETHRA
Congenital Anomaly :
Agenesis Penis
Micropenis/Microphallus
Buried Penis
(Concealed/Hidden/Trapped)
Phimosis
Paraphimosis
Hypospadias
Epispadias
Infection of the penis : balanopostitis
Penile Cancer
Urethritis
Urethral Stone
Urethral Strictures
Phimosis
Description
inability to retract the foreskin
phimosis at the first few years is physiologic
the foreskin cannot be retracted after it has
previously been retractable pathologic
phimosis
by age 3 , 5 years, most foreskins can be
retracted
Epidemiology
10 % of boys have non retractile foreskin
1 % at puberty
Signs and symptoms
discharge, soiling of undergarment
irritation, cracking, bleeding from foreskin
Pathophysiology
Physiologic phimosis
the glans penis is adherent to the prepuce in infants
glandular secretions and smegma facilitate
separation
Pathologic phimosis
cicatricial preputial ring (from irritation
result in inflammation and scarring) :
poor local hygiene, chronic balanitis
(Diabetes Mellitus), early forceful
retraction of foreskin
my balloon during voiding
Risk factors / causes
Pathologic phymosis
poor hygiene, chronic
balanopostitis, diabetes mellitus
Complications
infection, increased risk of penile
cancer
Defferential Diagnosis
physiologic phimosis
pathologic phimosis
post circumcision phimosis
History
hygiene problems ?
history of balanopostitis ?
history of diabetes mellitus ?
ballooning of foreskin when voiding ?
post void dribbling ?
has there been a prior circumcision ?
could the foreskin be previously
retracted ?
Physical Examination
Classification of retractability of the
foreskin
0 : full retraction
1 : full retraction, tight behind glans
2 : partial exposure of the glans
3 : partial retractil, meatus just visible
4 : slight retraction, unable to
visualize meatus
5 : no retraction
 Appearance of the foreskin
0 : normal
1 : crack in prepuce and skin splitting on
gentle retraction
2 : small, partially circumferensial white
scar
3 : balanitis xerotica obliterans / severe
scarring
 frenular lacerations
preputial fissure
cicatricial band
inflammation or active infection
foreskins pearl / smegma collection
evidens of malignancy
Laboratory testing
serum glucose to evaluate for diabetes
culture and sensitivity of the
subpreputial space
Imaging : none

Special studies : none

General measure
Physiologic phimosis
encourage good hygiene
gentle cleaning of smegma
instruct parents in gentle and gradual
retraction of prepuce
never circumcise in patient with
hipospadias, prepuce may needed for
reconstruction
Pathologic phimosis
good hygiene
steroid ointment
infection ------ antibiotics systemic
or topical
Treatment
Medical
local steroid application ( topical vs
injection )
nonsteroidal drug application ( cream )
Surgical
Phisiologic phimosis
circumcision ( not absolutely indicated )
surgical correction of phimosis with
preservation of the foreskin
Pathologic phimosis
circumcision ---- standard of care
preputial dilatation
dorsal / ventral slit
surgical correction with preservation
of foreskin
Alternative therapies : none
Patient education : none
Monitoring post circumcision
Post circumcision phimosis
inadequate primary procedure, post
procedure scarring
may occure with Gomco clamp,
Guillotin techniques
requires surgical revision
glandular hyperaesthesias ( take several
month after circumcision / epithelium
develops squameus keratinized layer
 Complication of circumcision
is low ( 0,2 % - 0,6 % )
hemorrhage
infection
avascular necrosis
meatal stenosis
fibrous bridge
 urethrocutaneus fistula
concealed penis
penile denudation
lymphedema penile
Prevention : none
Associated condition : diabetes
mellitus
Paraphimosis

Discription
Painful swelling of the foreskin distal
to a phimotic ring after retraction of the
foreskin for a prolonged period.
Pathophysiology
In children
A congenital narrowed preputial opening is
present
The foreskin is retracted behind the glans
penis and not promptly reduced
Entrapment in the coronal sulcus occurs
secondary to swelling of the glans
This lead to venous congestion, edema, and
enlargement of the glans,
followed by arterial occlusion and necrosis of
the glans
In adults

Typically occurs in elderly men and may

be associated with poor hygiene
and/or chronic balanoposthitis
This iflamation leads to a contraction of
the opening prepuce and forms
a fibrotic ring of tissue
 This in turn leads to constriction when
the foreskin is retracted behind the glans
Result in venous congestion with edema
Failure to promptly reduce the
paraphimosis can result in arterial
occlusion and necrosis of the glans
penis.
This constitutes a urologic emergency
Cause/risk factor

Phimosis
Chronic balanoposthitis
Chronic indwelling Foley catheterization
and catheter changes
Patients requiring clean intermittent
catheterization

Complication
Necrosis of glans and distal urethra
Differential diagnosis
Balanitis
Balanoposthitis
Angioneurotic edema
Anasarca edema
Hystory
Has the patient been circumcised ?
Recurrent bouts of chronic balanitis ?
Chronic indwelling Foley catheterization ?
Clean intermittent catheterization ?
Diabetes mellitus : may be risk factor for
phimosis
Phimosis ?
Physical examination
Edema and swelling of penile shaft
proximal to the glans and corona
Thick phimotic ring proximal to
corona
Late finding : swelling of the glans,
venous congestion, necrosis of the
glans penis.
Laboratory Testing
Not usually necessary
If surgery planned, preoperative
laboratory studies, including coagulation
factors

Imaging: Chest film, if surgery planned

General Measures
Considered urologic emergency
Delay in reducing paraphimosis can
result necrosis of the glans
Medical

Gentle steady pressure to foreskin to

decrease swelling
(May use elastic wrap or Kerlix
bandage)
Push the glans with thumbs, pulling the
foreskin forward over the glans with
the fingers ( Use the gauze pad to
facilitate traction on the foreskin )
 As an adjunct to simple reduction, a 25
gauge needle is used to make multiple
stab wounds in the edematous foreskin
to help remove edema fluid
May use 2 % lidocaine gel for local
anesthetic
Hyaluronidase 1 cc ( 150 U/cc Wydase )
injected into the one or more sites in
the edematous prepuce
Surgical

Dorsal or ventral slit using 1 %

lidocaine penile block
Convert to normal circumcision
Follow Up

Circumcision should be performed when

the edema/inflammation resolves
If there is no definitive treatment,
paraphimosis tends to recur
Debridement of necrotic tissue is rarely
indicated
Prevention
When inserting or changing Foley
catheters or performing clean
intermittent catheterization, reduce the
foreskin after the procedure is
completed
Hypospadias
Description
Common urogenital malformation in
males, characterized by incompletely
formed urethra wherein the misplaces
meatus variably opens on the ventral
aspect of the penis, scrotum, or
perineum.
Malformation varies greatly in severity,
ranging from the extreme form of perineal
hypospadias with genital ambiguity to
mild distal glans hypospadias.
Commonly associated with chorde
(abnormal curvature of the penis) in 50 %
of the cases and/or meatal stenosis 30 % of
cases.
Epidemiology
Incidence 1 in 300 live male births
More common in Whites than in Blacks,
and in Italians and Jews than in other
ethnic groups

Genetics
Familial tendency 8 % of fathers of
affected children have hypospadias,
14 % of male siblings affected
Staging

Classification
Based on location of meatus :
glans, subcoronal, penile,
penoscrotal, scrotal, perineal
Distal hypospadias (subcoronal
or penile) comprises 60 % of
cases
Sign and Symptoms

Associated anomalies
Undescended testicle: 9 %
Inguinal hernias: 9 %
Clinically significant upper tract
anomalies ; rare

Chordee
Chordee can occur without
hypospadias, but is rare ( 0,6 % )
Pathophysiology

Unknown, but several factors

involves
Alterations of urethral fold closure
result in hypospadias
Testosterone biosynthetic defects
occur in half proximal hypospadias
 Exposure to synthetic endocrine
disrupters that block the effect of
testosterone is critical from 9 to 12
weeks gestation
Related to low birth rate in
discordant monozygotic twins
Cause/Risk Factors
Unknown, some suggestion of
familial risk

Complications
Infertility
Psychological trauma ( Cosmetic )
Differential Diagnosis
Glandular
Subcoronal
Penile
Penoscrotal
Scrotal
Perineal
History : any family history ?

Physical Examination
The urethral opening may be anywhere along
the shaft of the penis or into the perineum, 62
% of the openings subcoronal or penile, 22 %
penoscrotal angle, and 16 % scrotum or
perineum
Severe proximal hypospadias may be confused
with intersex disorders
The more proximal meatus, the more the
ventral curvature (chordee) will be seen
Undescended testes and inguinal hernia
Laboratory testing
If surgery planned

Imaging
Incidens of upper urinary tract
abnormalities is rare. With more
severe ( proximal ) cases of
hypospadias, some recommended
screening the upper tract
Treatment

General measures
With any suspicion hypospadias,
neonatal circumcision should not be
perfomed
Many consider severe hypospadias
to be a type of intersex disorder
Surgery
Treatment of the hypospadias is surgical
repair and the timing of repair is best
between 6 and 18 months
Current techniques are superior than
the older techniques
Short term follow up
examinations for development of
fistulas/stricture

Alternative therapies is psychosocial support as

part of overall care
Epispadias

Description
Development abnormality wherein
the urethra opens on the dorsum of
the penis.
Epidemiology
1 in 117.000 newborn boys
1 in 484.000 newborn girls
Male to Female ratio : 5 : 1
Signs and symptoms

Male
Urethra opens anywhere from under
pubic to the tip of penis
The complete or penopubic
epispadias is most common
Female
Urethra opens from bladder neck to
tip of urethra
Most severe and common type
Labia may obscure the epispadias in
female
Pathophysiology
Absence of urinary sphincters in
complete type(penopubc) in males
and type III in female
Short, widened penis with dorsal
chordee
 Urethra most commonly as
base of penis under pubic,
opening can be on shaft or also
on glans
Bifid clitoris, separated and
rudimentary labia minora
Wide pubic diastasis; usually
not as wide as in bladder
exstrophy
Cause/Risk Factor
Unknown

Complication
Urinary incontinence
Upper tract damage
Infertility
Differential diagnosis
Classic bladder exstrophy
Lesser degrees of epispadias

History
Family history of epispadias
Physical examination
Pubic diastasis
Position of testes
Present of any degree of bladder
prolapse or exstrophy
Laboratory testing
CBC, serum electrolytes

Imaging
Plain X Ray of pelvis to determine
pubic diastasis
Renal ultrasound to assess presence of
two kidneys and presence/absence
hydronephrosis
Treatment
General measure :
Careful, overall examination of
infant
Surgical
Objectives
Preservation of upper urinary tract
Reconstruction of functional and
cosmetically acceptable external
genitalia
Achievement of urinary continence
Female
Repair of urethra and genital
reconstruction at around 12
months of age
Bladder neck repair
Male
Epispadias repair at 6 12 months
of age after testosterone stimulation
( 3 mg/kg IM 2 weeks before
surgery )
Bladder neck repair at 4 to 5 years
of age when bladder capacity is
adequate
and child is participate in
postoperative voiding program
Follow - up after epispadias repair
Urethral stent removed 10 12 days
after surgery
Renal and bladder ultrasound at 4
months after surgery
Urine cultures at three monthly interval
Yearly cytoscopies and bladder
capacity measurement under anesthesia
until bladder capacity adequate for bladder
neck repair
Follow - up for bladder neck repair
Clamp the suprapubic tube at 3 weeks
after surgery and begin voiding trial
Removal of suprapubic tube when
urine residuals are lees than 15 cc and
child is voiding well
Cytoscopy and placement of small (8
Fr) urethral catheter if child cannot
voiding well
 Renal and bladder ultrasound prior
to removal of suprapubic tube and
again a 3 and 12 month after
surgery
Antibiotic prophylaxis until follow
up shows nonreflux and child is
voiding well
Urethral Stricture

Description
narrowing of the urethral lumen /
a scar within the urethra
60 70 %, in the bulbar urethra
Etiology

1. Congenital : rare, soft, often without

spongiofibrosis

2. Infection / inflammation :
Urethritis ( GO, TBC and
Clamydial )
may involve long segment,
include bulbar urethra.
3. Traumatic
the most common type
blunt perineal straddel
injury where urethra is
trapped against the symphysis
pubis
usually partial tear
4. Iatrogenic : instrumentation
( urethrocystoscopy,
transurethral resection
prostatectomy,
catheterization ), usually
found at meatus or
penoscrotal junction.
 pelvic fracture : traffic accidents or
industrial injuries
10 %, pelvic fracture will have
urethral injury, which may vary from
simple contusion through partial tear
to complete transection with
separation of the urethral end.
 penetrating : gunshot wounds

degree of tissue injury

according to projectile and
velocity
Symptoms and Signs

decrease urinary stream ----more

common
spraying, double stream
postvoiding dribbling
mild dysuria
hematuria
urinary tract infection
urethral bleeding
 epididymitis
chronic prostatitis
cystitis
urethrocutaneus fistula
induration in the area of the stricture
periurethral absces
palpable bladder ( urinary retention )
Physical examination
usually no specific findings
evidence of epididymitis
palpable bladder
small meatal
Imaging
retrograde urethrography
urethrogaphy bipolar/voiding
urethrocystography
IVU ( upper urinary tract
evaluation and pelvic bone)
Special studies

Endoscopy : urethroscopy allows

direct visualization
of the stricture
Uroflowmetry : may indicate
obstructive
pattern
Laboratory testing
nothing special, except as
indicated ( urine culture /
infection )
blood analysis for preoperative
care
Treatment
Conservative : urethral dilatation ( cause
false passages )
Surgical
Endoscopy :Internal urethotomy (Sachse)
or blind Otis
Conventional (open surgical) :
meatal stricture : meatotomy,
meatoplasty
long urethral strictures : two and
multiple stage repairs