Urological problems – part two Phimosis It is a condition in which the foreskin of the penis cannot be pulled back past the glans. A balloon-like swelling under the foreskin may occur with urination. In teenagers and adults, it may result in pain during an erection, but is otherwise not painful. Those affected are at greater risk of inflammation of the glans. In young children, it is normal to not be able to pull back the foreskin. Typically, it resolves without treatment by the age of three. For those in whom the condition does not improve further time can be given or a steroid cream may be used to attempt to loosen the tight skin. If this method, combined with stretching exercises, is not effective then other treatments such as circumcision may be recommended. Treatment Paraphimosis A potential complication of phimosis is paraphimosis, where the tight foreskin becomes trapped behind the glans. Paraphimosis • Paraphimosis can often be effectively treated by manual manipulation of the swollen foreskin tissue. This involves compressing the glans and moving the foreskin back to its normal position, perhaps with the aid of a lubricant, cold compression, and local anesthesia as necessary. If this fails, the tight edematous band of tissue can be relieved surgically with a dorsal slit or circumcision. Cryptorchidism • Cryptorchidism is the absence of one or both testes from the scrotum. It is the most common birth defect of the male genitals. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. Cryptorchidism Cryptorchidism A testis absent from the normal scrotal position may be: • anywhere along the "path of descent" from high in the posterior (retroperitoneal) abdomen, just below the kidney, to the inguinal ring; • in the inguinal canal; • ectopic, having "wandered" from the path of descent, usually outside the inguinal canal and sometimes even under the skin of the thigh, the perineum, the opposite scrotum, or the femoral canal • undeveloped (hypoplastic) or severely abnormal (dysgenetic); • missing About two-thirds of cases without other abnormalities are unilateral; most of the other third involve both testes. In 90% of cases an undescended testis can be felt in the inguinal canal. In a small minority of cases missing testes may be found in the abdomen or appear to be nonexistent (truly "hidden"). Undescended testes are associated with reduced fertility, increased risk of testicular germ cell tumors and psychological problems when the boy is grown. Undescended testes are also more susceptible to testicular torsion (and subsequent infarction) and inguinal hernias. • In cases where the testes are identified preoperatively in the inguinal canal, orchiopexy is often performed and has a very low complication rate. An incision is made over the inguinal canal. The testis with accompanying cord structure and blood supply is exposed, partially separated from the surrounding tissues ("mobilized"), and brought into the scrotum. It is sutured to the scrotal tissue. The associated passage back into the inguinal canal, an inguinal hernia, is closed to prevent re-ascent. In patients with intraabdominal maldescended testis, laparoscopy is useful to see for oneself the pelvic structures, position of the testis and decide upon surgery. Testicular torsion Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply, a condition called ischemia. The principal symptom is rapid onset of testicular pain. Testicular torsion usually presents with sudden, severe, testicular pain (in groin and lower abdomen) and tenderness. • The testis may be higher than its normal position, swollen and painful. Mild pyrexia and redness of overlying area may be found. Testicular torsion • Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood. If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of saving the testicle. At 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the ability to save the testicle approaches 0. About 40% of cases result in loss of the testicle. Common treatment for children is surgically sewing the testicle to the scrotum to prevent future recurrence (orchiopexy). Hydrocele testis A hydrocele testis is an accumulation of clear fluid in the tunica vaginalis, the most internal of membranes containing a testicle. A primary hydrocele causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis (investing membrane). A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis. A hydrocele usually occurs on one side, but can also affect both sides. The accumulation can be a marker of physical trauma, infection, tumor or varicocele surgery, but the cause is generally unknown. Indirect inguinal hernia indicates increased risk of hydrocele. Hydrocele testis A hydrocele feels like a small fluid-filled balloon inside the scrotum. It is smooth, and is mainly in front of the testis. Hydroceles will vary greatly in size and are normally painless and harmless. However, as the fluid continues to accumulate and the scrotum further enlarges, more discomfort can be expected. As the fluid of a hydrocele is transparent, light shone through the hydrocelic region will be visible from the other side. This phenomenon is called transillumination. Treatment Treatment is a surgical procedure, called a hydrocelectomy. Incision of the hydrocele sac after complete mobilization of the hydrocele. Partial resection of the hydrocele sac. If the hydrocele is not surgically removed, it may continue to grow. Hypospadias • It is a birth abnormality of the urethra where the urinary opening is not at the usual location on the head of the penis. It is the second most common birth abnormality of the male reproductive system, affecting approximately 1 of every 250 males at birth. In approximately 90% of cases, the opening (meatus) is on or near the head of the penis, referred to as distal hypospadias, while the remainder have proximal hypospadias with a meatus near or within the scrotum. Hypospadias In most cases the foreskin is also underdeveloped and does not wrap completely around the penis, leaving the underside of the glans penis uncovered. There may also be downward bending of the penis, commonly referred to as chordee. Hypospadias is thought to result from failure of the urinary channel to completely tubularize to the end of the penis. The cause of hypospadias is not known. Most often, it is the only abnormal finding, although in about 10% of cases hypospadias may be part of a syndrome with multiple abnormalities. The most common associated defect is an undescended testicle. The combination of hypospadias and an undescended testicle sometimes indicates a disorder of sexual differentiation, and so additional testing may be recommended. Chordee Surgery is usually recommended for hypospadias, with the goal to restore normal appearance and function to the penis. Hypospadias repair can be done in full-term, healthy infants at any time from 3 months of age. Premature babies generally have surgery done at 6 months or older. There are many techniques which have been used during the past 100 years to extend the urinary channel to the correct location. Most distal and many proximal hypospadias are corrected in a single operation. However, those with the most severe condition having a urinary opening in the scrotum and downward bending of the penis are often corrected in a 2-stage operation. During the first operation the curvature is straightened. At the second, the urinary channel is completed. Treatment Problems that can arise include a small hole in the urinary channel below the meatus, called a fistula. The head of the penis, which is open at birth in children with hypospadias and is closed around the urinary channel at surgery, sometimes reopens, known as glans dehiscence. The new urinary opening can scar, resulting in meatal stenosis, or internal scarring can create a stricture, either of which cause partial blockage to urinating. This case may need many procedures of dilatation to the new urethra. Complications like fistulas are usually successfully corrected with another operation, most often delayed for at least six months after the last surgery to allow the tissues to heal sufficiently before attempting another repair. Epispadias • It is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect (the dorsum) of the penis. It can also develop in females when the urethra develops too far anteriorly. It occurs in around 1 in 120,000 male and 1 in 500,000 female births (short vagina, split of clitoris, immaturity of labia lips). Exstrophy – epispadias complex Epispadias is an uncommon and partial form of a spectrum of failures of abdominal and pelvic fusion in the first months of embryogenesis known as the exstrophy - epispadias complex. While epispadias is inherent in all cases of exstrophy it can also, much less frequently, appear in isolation as the least severe form of the complex spectrum Most cases involve a small and bifid penis, which requires surgical closure soon after birth, often including a reconstruction of the urethra. Where it is part of a larger exstrophy, not only the urethra but also the bladder (bladder exstrophy) requiring closing. Sex differentiation disorders - intersex • An intersex human or other animal is one possessing any of several variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit the typical definitions for male or female bodies". Such variations may involve genital ambiguity, and combinations of chromosomal genotype and sexual phenotype other than XY-male and XX-female.