Penile Anomalies Research Articles

Prepuce in boys and adolescents: What, when, and how?

The prepuce envelops the glans as a variant of a mucocutaneous tissue presenting with a lot offunctions, the most important of them being to protect the infant's glans from feces and ammonia in diapers, to protect the glans from abrasions and trauma throughout life, and to provide sufficient skin in erection. Circumcision was recognized as a method of solving foreskin problems a long time before Christ. Practicing male circumcision in history was customary several thousand years ago and has spread worldwide. Today it depends on races, and it is often an initiation ceremony near the age of puberty. In everyday practice in pediatric urology outpatient department the foreskin problems have been noticed as a phimosis in 9.91% cases and prepuce adhesions in 3.98%. Congenital anomalies are present in different numbers. Other problems, such as paraphimosis, balanoposthitis, are recorded as accidental cases. Over-all prepuce pathology can be observed in 12%-25% of patients. The article presents a review of foreskin conditions, clinical manifestation, therapy and arguments for patient's benefits. The term phimnosis describes a foreskin that is unable to retract. It is necessary to distinguish normal anatomic situation in neonate and infantile period, when prepuce has not been separated yet from true pathologic phimosis due to fibrosis and sclerosis. Up to six years of age the tip of the prepuce is elastic and might be retracted by gentle manipulations. In cases when the foreskin is trapped behind the glans penis and cannot be pulled back to normal position, paraphimosis is present and can be treated as a medical emergency by manual manipulation, or by dorsal slit (incision). Many studies have demonstrated that frequency of urinary tract infection increases in uncircumcised males and that is a reason for routine circumcision. The others are against routine circumcision. The contraindications are newborns, especially prematurely born. and congenital penile anomalies. Condition in which the frenulunm of penis is short with consequent restriction of movement of the prepuce can be easily treated by frenulotomy. Hooded prepuce is a condition of incomplete circumferential formation of foreskin with a dorsal component present and ventral component absent. In cases without any penile anomalies this is only a cosmetically unattractive appearance and could be corrected by circumcision. Infection of the foreskin due to bacterial colonization could be both prevented and treated easily However, an infection due to peno-preputial incisions in adolescent age is serious and has to be cured promptly. As a part of external genitalia, the foreskin has a lot of functions. Despite its natural role many advocates routine circumcision due to problematic condition that can develop. Routine circumcision is not generally recommended. Improved education for physicians and parents with regard to the foreskin development and management is required.

The Effects of Long‐Term Androgen Deprivation Therapy on Penile Length in Patients with Prostate Cancer: A Single‐Center, Prospective, Open‐Label, Observational Study

The adverse effects of long-term drug therapy for prostate cancer (PCa) can dramatically impact patient quality of life and are considered to be important factors when selecting treatment. To assess stretched penile length before and after long-term androgen deprivation therapy (ADT) for treatment of PCa. From January 2008 to June 2010 at a single institution, 39 consecutive patients without distant metastases who were elected to receive ADT as initial therapy for PCa were prospectively enrolled. Exclusion criteria were history of penile anomalies and/or trauma, and prior radical prostate surgery or radiation therapy. Erectile functions were evaluated at baseline according to the International Index of Erectile Function (IIEF). Vertically stretched penile length was measured every 3 months from the pubopenile junction to the meatus with a spring scale. After ADT, significant 3-month interval changes in stretched penile length were noted for up to 15 months (P < 0.001). The relationship between potency and penile shortening was not significant (P = 0.45). The mean patient age was 67.1 years. Before therapy, the mean stretched penile length was 10.76 cm. After 24 months of ADT, mean penile length had decreased to 8.05 cm. However, these changes plateaued after 15 months. Normal erectile function (EF) was reported by 41% of patients before therapy, while 10.5% reported normal EF at the 24-month follow-up. The relationship between potency and penile shortening was not significant. However, patients who preserved their potency tended to experience less penile shortening. The administration of luteinizing hormone-releasing hormone (LHRH) agonists induced significant decreases in penile length for only up to 15 months in the absence of the confounding effects of surgery and radiation.

Impact of Anatomical and Socioeconomic Factors on Timing of Urological Consultation for Boys With Cryptorchidism

Cryptorchidism is a common finding in infants and young boys. Early repair lessens the extent of testicular injury. We hypothesized that anatomical and socioeconomic factors affect the timing of consultation and treatment for boys with cryptorchidism. Under an institutional review board approved protocol we reviewed the records at a single institution of children who underwent exploration for unilateral or bilateral cryptorchidism. Demographic and anatomical factors were recorded. The median age of 677 boys at consultation and surgery was 20.3 and 28.9 months, respectively. Median age at consultation for boys with nonpalpable and palpable testicles was 12.3 and 20.9 months, respectively (p = 0.03). Boys with a concomitant penile anomaly had a younger median age at consultation than boys without a penile anomaly (8.5 vs 20.3 months, p <0.01). Demographic factors did not vary with respect to time to consultation and surgery (p >0.05). Multivariate analysis showed that abdominal site and concomitant penile anomaly were associated with earlier time to consultation (p = 0.02 and <0.01, respectively). The timing of consultation for boys with undescended testicles does not vary in regard to race, language or insurance type at this tertiary care institution. Instead, anatomical factors influenced age at consultation for boys with cryptorchidism. This suggests that in some geographic regions access to care is not restricted for minorities or noncommercially insured children.

Epidemiologic trends in penile anomalies and hypospadias in the state of California, 1985–2006

Purpose Using statewide data, we evaluated whether the changing incidence of penile anomalies and hypospadias is reflected in the diverse California population of newborn males over the past 20 years. Methods Discharge data from all California hospitals, prepared by the OSHPD (Sacramento, CA) was reviewed for the years 1985–2006 for male infant births with an ICD-9 code (752.6) for hypospadias, epispadias or other penile anomalies. Trends were examined by Generalized Estimation Equations for Poisson regression. Results From 1985 to 2006, the birth incidence of newborn penile anomalies increased in California from 47 to 57 cases per 10,000 newborn discharges, yet the trend for hypospadias alone appears stable from 1997. The rates for penile anomalies in newborns increased 1.4% annually ( p < 0.001). All racial/ethnic groups analyzed showed this increase ( p < 0.001 for each). During the study period there was a 2% increase per year in plural births ( p < 0.001). Interestingly, the rate of change in penile anomaly incidence was greater in males of plural births compared to their singleton cohorts (2% vs 1% annually) ( p < 0.001). The birth incidence of cleft palate, another congenital anomaly known to be stable over time, remained unchanged over this period. Conclusions From 1985 to 2006 in California the incidence of penile anomalies increased in a statistically significant manner, but the incidence of hypospadias appears stable for the last decade. Our data support the notion that different racial/ethnic groups have distinct incidences of penile anomaly formation and that an association with plural births appears to be present.

Penile Anomalies in Adolescence

This article considers the impact and outcomes of both treatment and underlying condition of penile anomalies in adolescent males. Major congenital anomalies (such as exstrophy/epispadias) are discussed, including the psychological outcomes, common problems (such as corporal asymmetry, chordee, and scarring) in this group, and surgical assessment for potential surgical candidates. The emergence of new surgical techniques continues to improve outcomes and potentially raises patient expectations. The importance of balanced discussion in conditions such as micropenis, including multidisciplinary support for patients, is important in order to achieve appropriate treatment decisions. Topical treatments may be of value, but in extreme cases, phalloplasty is a valuable option for patients to consider. In buried penis, the importance of careful assessment and, for the majority, a delay in surgery until puberty has completed is emphasised. In hypospadias patients, the variety of surgical procedures has complicated assessment of outcomes. It appears that true surgical success may be difficult to measure as many men who have had earlier operations are not reassessed in either puberty or adult life. There is also a brief discussion of acquired penile anomalies, including causation and treatment of lymphoedema, penile fracture/trauma, and priapism.

Actualités sur l’hypospade

Hypospadias surgery has considerably evolved during the last 15 years, thanks to a new anatomical approach of ventral penile anomalies and new techniques of repair. The description of the hypoplasia of the tissues forming the ventral aspect of the penis beyond the division of the corpus spongiosum and the concept of urethral plate are the two key-elements to select the most appropriate technique of reconstruction. These modern concepts and the various surgical techniques used in 2008 are reported here with their results.

Hypospadias and associated penile anomalies: a histopathological study and a reconstruction of the pathogenesis

Hypospadias is considered to be the result of inadequate fusion of urethral folds and, possibly, of canalization of a glandar epithelial cord during the formation of the spongy urethra. This theory had to be reconsidered because a recent study in normal human embryos has exposed such fusion and invagination as misconceptions. Autopsy specimens of five penises with hypospadias from foetuses and neonates were studied histologically. The findings complemented with data from the literature were correlated to the normal developmental process to reconstruct the pathogenesis of the disorder. Histopathological analysis revealed that the hypospadic orifice was the proximal part of a mucosal delta which revealed the structure of the roof and meatus of a flattened distal urethra. Branches of the raphe bordering the delta and terminating in prominent 'dog ears' had the characteristics of the transient urethral labia (folds). Associated curvature and torsion could be related to structural abnormalities of vascular structures, notably the distal corpus spongiosum, and fasciae predominantly proximal to the hypospadic orifice. Correlation with normal development indicated that hypospadias and associated anomalies are not caused by disturbed fusion or glandar invagination but by maldevelopment of a complex of primordial fascial and vascular tissue proximal to the urethral orifice which normally form the venter side of the penis by disproportionately strong proliferation and make the urethral orifice shift distalward. Insufficient growth may disturb that shift with the degree of deficiency determining the precise position of the urethral orifice, size of the urethral delta and defect of the prepuce. Shortage and/or poor organisation of these tissues explain curvature and, if asymmetrical, torsion, both of which can occur also with minimal urethral deformity or as congenital ventral curvature and torsion without hypospadias.

P-656: Conception method does not influence hypospadias characteristics in twin gestations

Concerns have been raised about a potential association between ARTs and hypospadias. Since same sex twins share the same in utero exposures to medications and maternal factors, they provide an opportunity to discover whether environmental or genetic factors play the dominant role in the pathogenesis of this congenital anomaly. Although the spontaneous twinning rate in the general population is 1.25%; 30% of live births following ART are twins. This becomes a public health matter since twin pregnancies have twice the congenital malformation rate of singletons. The most recent NY state report has 4% incidence of neonatal malformations among all live births and 8% in twin pregnancies. We have examined whether differences in hypospadias grade severity exist between singletons and twins, and whether ART influences the incidence of hypospadias in second male twins or the severity of hypospadias in affected twins from 07/1996 to 03/ 2006 at a university based Pediatric Urology Center. Patient data included medical and surgical histories such as congenital anomalies, gestational order, family history, parental medical, fertility and obstetric history were reviewed. Patients were first separated into singleton and twin groups. The twin group was further subdivided into opposite- or same-gender twins. The singleton and same gender twin groups were classified according to the conception method: ART or naturally conceived. Finally, these groups were categorized by hypospadias grade as mild (glandular or coronal), or severe (midshaft, penoscrotal or perineal). Comparisons between singletons and twins revealed no differences in hypospadias grade severity, whether analyzing only ART singletons and twins or naturally conceived singletons and twins. The database included 227 patients, 193 (85%) singletons and 34 (15%) twins comprising 30 twin sets. Of the 30 twin sets, 18 (60.0%) were of the same gender, and 12 (40.0%) were opposite gender twin sets. We further examined only the same gender twin sets. All of the 9 (100%) sets conceived by ART were dizygous and discordant for hypospadias; only one twin being affected, whereas among the naturally conceived twins, 4 (44.4%) were monozygous and 5 (55.6%) were dizygous. In three of the four monozygous twin sets, both twins were affected with hypospadias and in 4 (80%) of the dizygous twin sets, only one twin was affected. Although none of the considered aggressors proved to have any role in the occurrence and severity of hypospadias, a tendency toward being discordant in dizygous gestations and concordant in monozygous twins was confirmed. In assessing the severity of the hypospadias, the twins needed to be evaluated individually because even if they were concordant for the occurrence of hypospadias, they were discordant for grade. There was no difference in the severity of the anomaly between the ART and naturally conceived same gender twins. The occurrence of twins does not appear to increase the severity of hypospadias, nor does the conception method (natural or ART) correlate with the risk of hypospadias in second male twins or its type in those affected. Interestingly, the pattern the discordant presence of hypospadias in dizygotic twin pregnancies may absolve ART of any responsibility in the increased incidence of penile anomalies, while the consistent appearance of the anomaly in both monozygotic twins, appears to suggest a genetic origin.

Congenital penile anomalies on the increase

Congenital penile anomalies on the increase

THE INCREASING INCIDENCE OF CONGENITAL PENILE ANOMALIES IN THE UNITED STATES

Epidemiologic studies have suggested that the incidence of congenital penile anomalies (CPA), particularly hypospadias, is increasing. This phenomenon has significant biological and socioeconomic implications. We sought further confirmation of the reported trends using a large national database. The Nationwide Inpatient Sample is a 20% sample of United States hospitals containing data on 5 to 7 million hospital inpatient stays per year. We identified male newborns, used ICD-9 codes to identify newborns with CPA, determined nationally weighted incidence over time and performed multivariate analyses to identify factors associated with CPA. Of the 4.84 million male newborns in the Nationwide Inpatient Sample we identified 37,577 with CPA (weighted incidence rate 7.8/1000 newborns). The weighted incidence increased from 7.0/1000 newborns in 1988 to 1991 to 8.3/1000 in 1997 to 2000 (p <0.0001). The most common diagnosis was hypospadias (68.3%), followed by chordee (8.6%) and hypospadias plus chordee (5%). Unspecified genital or penile anomalies were reported for 14% of the cases. The highest incidence of CPA was in white newborns (9.2/1000), followed by black newborns (7.5/1000), Asians (5.0/1000) and Hispanics (4.7/1000) (p <0.0001). Socioeconomic status (SES) was strongly associated with CPA, with CPA odds 19% higher for the highest SES category versus the lowest (OR 1.18, 95% CI 1.16-1.20). Increasing incidence of CPA over time was observed even after adjusting for race/ethnicity, geographic region, insurance status and SES. These nationally representative, weighted analyses reveal a significant increase in the incidence of CPA, with striking variation by race, region and SES. Further research into potential causes, as well as the observed disparities in incidence, is needed.

Urogenital anomalies in human male fetuses

Background: There are few studies in the literature performed in human fetuses evaluating the incidence of genitourinary anomalies. Aims: Analyze the incidence of congenital urogenital malformations in human male fetuses. Study designs and subjects: We analyzed 166 human male fetuses well preserved. The gestational age was determined in weeks post conception (WPC) according to the foot length criterion and ranged from 10 to 35 WPC. The fetuses were dissected with the aid of a stereoscopic lens with 2.5× magnification. We performed abdominal and pelvic incisions to expose the urogenital organs. We studied the incidence of renal, ureteral, vesicle, urethral, testicular, epididymal, vas deferens, prostate and penile anomalies. Results: Of the 166 fetuses, 7 (4.2%) presented some kind of anomaly of the urogenital system. Renal anomalies were found in two fetuses (1.2%). Unilateral renal agenesis was found in a 25 WPC fetus. Horseshoe kidney was found in a 20 WPC fetus. In a 23 WPC fetus (0.6%) the two testes were absent. Epididymal disjunction anomalies were found in four fetuses (2.4%). Conclusions: The urogenital anomalies in human male fetuses are rare and have an incidence around 4%.

Penile surgery and reconstruction.

This review will highlight recent advances in the field of penile reconstructive surgery in the paediatric and adult population. It is based on the work published during the year 2001. Besides the anatomical and histological studies of the penis, major contributions have been described in congenital and acquired penile anomalies. Also, a few new techniques and modifications of old procedures are described in order to improve the final functional and aesthetic outcome. The techniques for penile enlargement present a trend in the new millennium, but are still at the stage of investigation.

Natural erection induced by prostaglandin-E 1 in the diagnosis and treatment of congenital penile anomalies : S. Perovic, M. Djordjevic, and N. Djakovic. Br J Urol 79:43–46, (January), 1997

Natural erection induced by prostaglandin-E 1 in the diagnosis and treatment of congenital penile anomalies : S. Perovic, M. Djordjevic, and N. Djakovic. Br J Urol 79:43–46, (January), 1997

Natural erection induced by prostaglandin-E1 in the diagnosis and treatment of congenital penile anomalies.

To report the use of a natural erection induced by prostaglandin EI (PGE1) in the diagnosis and therapy of congenital penile anomalies as an alternative to artificial erection. From February 1991 to December 1995 a natural erection was induced in 672 patients (mean age 5.7 years, range 12 months-47 years) to diagnose and treat congenital anomalies, e.g. simple penile curvature, chordee with and without hypospadias, epispadias, micropenis, cripple penis, etc. The dose injected intracavernosally was dependent on the patient's age, penile size and response, and ranged from 0.5 to 15 micrograms. A natural dilatation of erectile tissue was achieved in all forms of penile anomalies except in seven patients who did not respond. The mean duration of erection was 80 min, but a prolonged erection, for up to 6 h, occurred in two patients. The natural erection achieved by injecting PGE1 into the corpora cavernosa is a useful alternative to artificial erection in the diagnosis and treatment of congenital penile anomalies.

Analysis of Meatal Location in 500 Men: Wide Variation Questions Need for Meatal Advancement in All Pediatric Anterior Hypospadias Cases

The high incidence (70 percent) of anterior hypospadias, mostly without penile curvature, in our pediatric hypospadias patients led us to study the meatal location in normal men to investigate if meatal advancement in all patients with anterior hypospadias can be justified when the wide variation of meatal locations in normal men is considered. The location of the external meatus was analyzed in 500 men (mean age 57 years) with classification of the meatal position in relation to the tip of the glans and corona. Quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview. Of the 500 men only 275 (55 percent) were normal with the meatus in the distal third of the glans, while 65 (13 percent) had anterior hypospadias (glanular in 49, coronal in 15 and subcoronal in 1).In 160 men (32 percent) the urethral meatus was located in the mid third of the glans. Analyzing coronal and subcoronal hypospadias further, all but 6 patients were not aware of any penile anomaly, all but 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream. In our study of 500 “normal” men the meatal location varied widely with only 55 percent of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional aspects. We believe that these observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature.

Urethral Reconstruction Using an Autologous Bladder Mucosal Graft*

Since 1988 twelve children underwent urethral reconstruction by using an autologous bladder mucosal graft. In 10 of these previous surgery for hypospadias or other penile anomalies had failed. Bladder mucosal graft was used in 2 cases for primary urethral reconstruction. Our results in using this method, mostly in hypospadias cripples, are satisfying, so that we are encouraged to use the autologous bladder mucosal graft for primary urethral reconstruction in selected cases with severe forms of hypospadias as well.

Rare Penile Anomalies Presenting With Complication of Circumcision

Rare Penile Anomalies Presenting With Complication of Circumcision

Rare penile anomalies presenting with complication of circumcision

Two rare penile anomalies, scaphoid megalourethra and 180-degree torsion of the penis, which presented as complications of circumcision are reported. Complications of circumcision of this type may be prevented by careful inspection of the penis prior to circumcision, by delaying circumcision if a penile abnormality is noted, and by careful visualization during all aspects of the procedure.

It is not "Just Circumcision".

Objective:Circumcision is one of the most commonly performed operations during childhood. The procedure is often underestimated in areas where it is frequently executed due to social and religion-based indications. In fact it might be an opportunity to detect and to correct any existing penile anomaly. The aim of the study was to retrospectively evaluate the boys who were admitted to a hospital for circumcision and the outcome of the procedure.Methods:The boys who were brought to outpatient clinics for circumcision between 2009-2015, were retrospectively evaluated. The indications for hospital admission and the presence of associated penile anomalies were searched. All the boys were examined and operated by a single surgeon of the institution.Results:Nine hundred forty four boys were brought to pediatric surgery outpatient clinics in order to be circumcised. The operation was performed in 318 of them. The physical examination revealed penile anomalies in 29 of the 318 cases. The detected anomalies were webbed penis, penile torsion, hypospadias, chordee without hypospadias and meatal stenosis.Conclusions:The proper examination of the boys by a physician prior to circumcision provides the detection of penile anomalies which can be corrected at the same session. The arrangements for performing circumcision in hospitals by the medical staff should be favored. The misleading perception of underestimation of the procedure where it is ritually performed, should be corrected.