1. SURGERY OF THE PENIS
AND URETHRA

3. Agenesis Penis Congenital Anomaly : Micropenis/Microphallus
Buried Penis
(Concealed/Hidden/Trapped)
Phimosis
Paraphimosis
Hypospadias
Epispadias

4. Infection of the penis : balanopostitis
Penile Cancer
Urethritis
Urethral Stone
Urethral Strictures

5. 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

6. 10 % of boys have non retractile foreskin 1 % at puberty
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

7. Pathologic phimosis
cicatricial preputial ring (from irritation result in inflammation and scarring) : poor local hygiene, chronic balanitis
(Diabetes Mellitus), early forceful retraction of foreskin
balloon during voiding

8. Pathologic phymosis Risk factors / causes poor hygiene, chronic
balanopostitis, diabetes mellitus
Complications
infection, increased risk of penile
cancer  

9. Defferential Diagnosis
physiologic phimosis
pathologic phimosis
post circumcision phimosis

10. 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 ?

11. 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

14. frenular lacerations
preputial fissure
cicatricial band
inflammation or active infection
“foreskins pearl” / smegma collection
evidens of malignancy

15. Laboratory testing
serum glucose to evaluate for diabetes
culture and sensitivity of the subpreputial space
Imaging : none
Special studies : none

16. 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

17. Pathologic phimosis
good hygiene
steroid ointment
infection antibiotics systemic or topical

18. Phisiologic phimosis 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

19. Pathologic phimosis
circumcision standard of care
preputial dilatation
dorsal / ventral slit
surgical correction with preservation of foreskin

20. 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

21. Complication of circumcision
is low ( 0,2 % - 0,6 % )
hemorrhage
infection
avascular necrosis
meatal stenosis
fibrous bridge

22. urethrocutaneus fistula
concealed penis
penile denudation
lymphedema penile
Prevention : none
Associated condition : diabetes
mellitus

23. Paraphimosis Discription
Discription
Painful swelling of the foreskin distal to a phimotic ring after retraction of the foreskin for a prolonged period.

24. The foreskin is retracted behind the glans
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

25. 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

26. the foreskin is retracted behind the glans
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

27. 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

28. Differential diagnosis
Balanitis
Balanoposthitis
Angioneurotic edema
Anasarca edema

29. 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 ?

30. 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.

31. 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

32. 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 )

33. gauge needle is used to make multiple
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

34. Surgical
Dorsal or ventral slit using 1 %
lidocaine penile block
Convert to normal circumcision

35. 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

36. When inserting or changing Foley catheters or performing clean
Prevention
When inserting or changing Foley
catheters or performing clean
intermittent catheterization, reduce the
foreskin after the procedure is
completed

37. 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.

38. Commonly associated with chorde
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.

39. 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

40. Staging
Classification
Based on location of meatus :
glans, subcoronal, penile,
penoscrotal, scrotal, perineal
Distal hypospadias (subcoronal
or penile) comprises 60 % of
cases

41. 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 % )

42. Pathophysiology
Unknown, but several factors
involves
Alterations of urethral fold closure
result in hypospadias
Testosterone biosynthetic defects
occur in half proximal hypospadias

43. 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

44. Cause/Risk Factors
Unknown, some suggestion of
familial risk
Complications
Infertility
Psychological trauma ( Cosmetic )

45. Differential Diagnosis
Glandular
Subcoronal
Penile
Penoscrotal
Scrotal
Perineal

47. 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

48. 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

49. Treatment
General measures
With any suspicion hypospadias,
neonatal circumcision should not be
perfomed
Many consider severe hypospadias
to be a type of intersex disorder

50. 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

51. Epispadias Description
Description
Development abnormality wherein the urethra opens on the dorsum of the penis.

52. Epidemiology
1 in newborn boys
1 in newborn girls
Male – to – Female ratio : 5 : 1

53. Signs and symptoms
Male
Urethra opens anywhere from under
pubic to the tip of penis
The complete or penopubic
epispadias is most common

54. Female
Urethra opens from bladder neck to
tip of urethra
Most severe and common type
Labia may obscure the epispadias in
female

55. Pathophysiology Absence of urinary sphincters in
complete type(penopubc) in males
and type III in female
Short, widened penis with dorsal
chordee

56. 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

57. Cause/Risk Factor
Unknown
Complication
Urinary incontinence
Upper tract damage
Infertility

58. Differential diagnosis
Classic bladder exstrophy
Lesser degrees of epispadias
History
Family history of epispadias

59. Physical examination Pubic diastasis Position of testes
Present of any degree of bladder
prolapse or exstrophy

60. 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

61. 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

62. Female
Repair of urethra and genital
reconstruction at around 12
months of age
Bladder neck repair

63. 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

64. 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

65. 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

66. 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

67. Urethral Stricture Description narrowing of the urethral lumen /
Description
narrowing of the urethral lumen /
a scar within the urethra
60 – 70 %, in the bulbar urethra

69. Etiology
Congenital : rare, soft, often without
spongiofibrosis
2. Infection / inflammation :
Urethritis ( GO, TBC and
Clamydial )
may involve long segment,
include bulbar urethra.

70. 3. Traumatic
the most common type
blunt perineal “ straddel
injury “ where urethra is
trapped against the symphysis
pubis
usually partial tear

71. 4. Iatrogenic : instrumentation
( urethrocystoscopy,
transurethral resection
prostatectomy,
catheterization ), usually
found at meatus or
penoscrotal junction.

72. 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.

73. penetrating : gunshot wounds
degree of tissue injury
according to projectile and
velocity

74. Symptoms and Signs
decrease urinary stream ----more common
spraying, double stream
postvoiding dribbling
mild dysuria
hematuria
urinary tract infection
urethral bleeding

75. urethrocutaneus fistula induration in the area of the stricture
epididymitis
chronic prostatitis
cystitis
urethrocutaneus fistula
induration in the area of the stricture
periurethral absces
palpable bladder ( urinary retention )

76. Physical examination
usually no specific findings
evidence of epididymitis
palpable bladder
small meatal

77. Imaging
retrograde urethrography
urethrogaphy bipolar/voiding
urethrocystography
IVU ( upper urinary tract
evaluation and pelvic bone)

78. Special studies
Endoscopy : urethroscopy allows
direct visualization
of the stricture
Uroflowmetry : may indicate
obstructive
pattern

79. Laboratory testing nothing special, except as
indicated ( urine culture /
infection )
blood analysis for preoperative
care

80. false passages ) Treatment Conservative : urethral dilatation ( cause
Surgical
Endoscopy :Internal urethotomy (Sachse)
or blind Otis
Conventional (open surgical) :
meatal stricture : meatotomy,
meatoplasty
long urethral strictures : two and
multiple stage repairs