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Disorders of the Penis and Scrotum
... Ectopic scrotum is extremely rare, with 27 cases reported in the literature up to 2017. [2] Two theories have been proposed to account for this condition: abnormalities in the development of the gubernaculum with its secondary attachment to the skin covering the genital tubercle and failure of fusion of the outer genital folds due to heel compression during intrauterine life. [3] The location of ectopic scrotum can be suprainguinal, infrainguinal, or perineal, and suprainguinal type is the most common. ...
... [1] Ectopic scrotum is associated with inguinal hernias, penile torsion, hypospadias, patent urachus, imperforate anus, bladder exstrophy, cleft lip or palate, and leg deformities. [1,2] In one review, 70% of boys with a suprainguinal ectopic scrotum had ipsilateral upper urinary tract anomalies, including renal agenesis, renal dysplasia, and ectopic ureter. [4] Our patient with infrainguinal ectopic scrotum had renal hypoplasia, omphalocele, penile torsion, inguinal hernia, and leg deformity. ...
... The management of ectopic scrotum includes one-stage repair (simultaneous scrotoplasty and orchiopexy), two-stage repair (orchiopexy with subsequent scrotoplasty or scrotoplasty with subsequent orchiopexy), and excision of ectopic scrotal tissue. [2] We performed one-stage repair for infrainguinal ectopic scrotum with penoplasty for penile torsion without any postoperative complication. ...
Ectopic scrotum is a rare condition, which is described as an anomalous position of one hemiscrotum along the inguinal canal. This anomaly is associated with other genitourinary anomalies. We report a 5-year-old boy with ectopic scrotum and penile torsion, who was successfully treated by simultaneous surgery.
... Penile agenesis (or aphallia) refers to complete absence of the penis as part of a developmental pelvic field defect (Cendron, 2001). The incidence of penile agenesis in not known. ...
... There may be associated anomalies such as failure of one or both testes to descend, renal abnormalities, and pulmonary problems. In the most pure form, there is absolutely no penile tissue in the normal position, two testes in a fully formed scrotum and the urethral opening on or in the anus (Cendron, 2001). To our knowledge, there are no psychosexual or neurocognitive studies of a group of these individuals due to the rarity of the condition. ...
... Different forms of ARM are commonly had an ectopic scrotum in both male and female [14,17]. Patent urachus, bladder exstrophy, cleft lip or palate, spina bifida and leg deformities are a reported associating anomalies [18]. ...
There is a confusion in literature and among some clinicians between accessory, ectopic scrotum and scrotal transposition. Ectopic scrotum is a rare congenital anomaly defined as the presence of the whole scrotum or scrotal tissue in a location away from its normal position between the penis and the perineum, with a deficient normal scrotum. The importance of this rare anomalies arises from its association with renal agenesis and its relation to the maldescended testicle. Pathogenesis of this anomaly could explain the deviated embryogenesis in both pathologies, which mainly related to abnormal insertion and direction of the gubernaculum.
... Hypospadias and bifid scrotum: It is reported that approximately 5% of patients with posterior hypospadias have a bifid scrotum [18]. A partially or completely bifid scrotum is occasionally present in proximal forms of hypospadias [19]. ...
Bifid scrotum is a rare congenital anomaly affecting the midline of the scrotum in a different spectra, in severe form the two scrotal sacs are widely separated with a laid opened urethra in the form of proximal hypospadias and the scrotal raphe is not detectable. Minor forms had a splitted or wide scrotal raphe and partial bifid scrotum may be seen at the proximal scrotal end or distally at the base of the scrotum, the later cases will give the look of scrotal dimple, which is a normal findings in some animals. Bifid scrota are usually associated with penoscrotal hypospadias, hypogonadism and androgen insensitivity syndrome, but it could be an isolated genital anomaly in association with rare somatic syndromes and maldevelopment. Bifid scrotum should be discussed along other related anomalies of the median raphae, perineal groove, accessory scrotum, scrotal transposition and diphallia. Embryologically the bifid scrotum is due to the lack of ventral growth of the caudal mesenchyme which causes failure of the urogenital folds to close over the cloacal membrane in the ventral midline. Selection of surgery to reconstruct scrotum is based on the severity of scrotal cleft and commonly done along hypospadias repair. Bifid scrotum reported recently as an indication for the severity of the associated hypospadias, and could determine the suitable type for its repair.
... Table 1 shows their differential characteristics. Although most case reports have ended in orchiectomy to date, but salvaging the gonad is occasionally possible in both scenarios [1,7,8]. In our 17-year-old case, salvaging the testis was not at all an option as explained above. ...
Polyorchidism is a rare anomaly where early segmentation in the gonadal ridge can lead to the development of three or less commonly four testes in one individual. Just over 150 reports of this phenomenon exist in English medical literature. However, once confronted by the clinical finding of supernumerary gonads, one must remain mindful of other likely diagnoses involving nontesticular origin. We report on a male patient with bilaterally impalpable testes in whom splenogonadal fusion mimicked polyorchidism. By keeping such differential diagnoses in mind, surgeons are more liable to take the appropriate intraoperative course of action.
Introduction:
The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was created to help physicians in the clinical evaluation of acute scrotum in which testicular torsion (TT) is suspected. There have been only a few reports on validation of the TWIST score since the original study was published.
Objectives:
To validate the TWIST score as a scoring system.
Patients and methods:
We reviewed the records of 106 patients with acute scrotum in our prospectively maintained database. The patients were divided into two groups by the final diagnosis: testicular torsion (group TT) or non-testicular torsion (group NTT). We retrospectively calculated the TWIST score of the patients. Patients were divided into low (0-2), intermediate (3-4), or high (5-7) risk groups according to the total score.
Results:
Fifteen patients (14%) had TT. The median age at presentation was 13.3 years (range 1.6-16.2) in group TT and 10.4 years (range 0.25-18.9) in group NTT, respectively. The sensitivity of clinical and Color Doppler ultrasonography (CDUS) findings to diagnose TT was 100%, whereas the specificity was 93.4%. Positive predictive value (PPV) and negative predictive value (NPV) were 71.4% and 100%, respectively. According to the calculated TWIST score, 65, 23, and 18 patients belonged to low, intermediate, and high risk groups, respectively. TT was found in 1(1.3%), 3(13%), and 11 (61%) patients of low, intermediate, and high risk groups, respectively. The NPV of the TWIST score for the low risk group was 98.5%, whereas the PPV of the TWIST score for the high risk group was 61.1%. Among the four patients with TT in low risk and intermediate risk groups, three patients presented to our institutions within 6 h after the onset. The torsion was 180° in two of the three patients.
Conclusion:
The TWIST score can be useful for clinical diagnosis of testicular torsion, but is inferior to clinical findings along with CDUS. We should consider the possibility that a TWIST score could be underestimated when patients present with acute scrotum immediately after onset or the affected testis is mildly twisted.
Neonatal circumcision is elective. Thus, only good anatomical candidates should be considered. It is the responsibility of the practitioner to recognize anatomic contraindications and defer circumcision where there is clear genital abnormality and, in many cases, even with more subtle anomalies. Intuition plus a good familiarity of newborn genital anatomy should be your guide. For example, upon first sight, do the penis and scrotum have a “typical” appearance in size, shape, and presentation? If not, a more thorough and focused pre-circumcision exam is in order. Remember, there is no shame in deferring a circumcision for a pediatric urology consult. The same cannot be said for the practitioner who unintentionally denudes a penis or circumcises what is in fact a girl. If you have not done so, you should first review Chaps. 3 and 4 on embryology and anatomy.
Zusammenfassung Dargestellt wird eine Übersicht klinisch-pathologischer Befunde des Skrotums und des Hodens im Kindesalter. Beginnend mit
den häufigsten anzutreffenden klinischen Bildern werden diese nach ihrem äußeren Erscheinen subsummiert als: das rote, das
blaue, das schmerzlos geschwollene, das leere Skrotum und endet mit echten kinderurologischen Raritäten wie dem fehlentwickelten
Skrotum. Für die Differentialdiagnose stehen die Anamnese und der klinische Befund im Vordergrund, während die Dopplersonographie
wichtige zusätzliche Hinweise zur Entscheidungsfindung gibt und für die Verlaufsbeobachtung Hilfestellung leisten kann. Nach
Abklärung assoziierter Fehlbildungen sollen den Eltern mögliche Auswirkungen und das erforderliche Prozedere erklärt werden.
This review addresses the long-term gender outcome of gender assignment of persons with intersexuality and related conditions. The gender assignment to female of 46,XY newborns with severe genital abnormalities despite a presumably normal-male prenatal sex-hormone milieu is highly controversial because of variations in assumptions about the role of biological factors in gender identity formation. This article presents a literature review of gender outcome in three pertinent conditions (penile agenesis, cloacal exstrophy of the bladder, and penile ablation) in infancy or early childhood. The findings clearly indicate an increased risk of later patient-initiated gender re-assignment to male after female assignment in infancy or early childhood, but are nevertheless incompatible with the notion of a full determination of core gender identity by prenatal androgens.
Testicular torsion must be considered in any patient who complains of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. Conditions that may mimic testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele and Schonlein-Henoch purpura, generally do not require immediate surgical intervention. The cause of an acute scrotum can usually be established based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character and severity of symptoms must be determined. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum and inguinal region. Urinalysis should always be performed, but scrotal imaging is necessary only when the diagnosis remains unclear Once the correct diagnosis is established, treatment is usually straightforward.
Adult stretched penile length (SPL) was determined among 22 males who were diagnosed with micropenis. These adult SPL values were compared with SPL at the time of diagnosis, age of diagnosis and etiologic category in 20 men who were diagnosed before puberty. A portion of this group completed a structured questionnaire interview, the Social Adjustment Self Report Questionnaire and the Hopkins Symptom Checklist to assess social and psychosexual milestones and the presence of psychiatric morbidity. Results show that the majority of men who had been diagnosed with micropenis had an adult SPL within 2 standard deviations of the normal adult mean, with only a minority showing values below this. It appeared that men with micropenis might have greater than average interval SPL growth between diagnosis and adulthood; it remains unclear whether this supranormal growth represents a catch-up phenomenon or results from augmentation by intermittent androgen therapy. There was no clear relationship between SPL at diagnosis and SPL in adulthood. The responses to the questionnaires indicated that men who had been diagnosed with micropenis were comparable to control men in regard to gender issues, body image, social fitness, sexuality, work, family adjustment and the presence of psychopathology.
Acute scrotal swelling may accompany Henoch-Schonlein syndrome and may be the presenting manifestation mimicking testicular torsion. Two patients with scrotal involvement were recently evaluated with nuclear imaging to assess testicular perfusion. One patient had normal perfusion, and the other had increased perfusion. Scan results allowed expectant management and avoided the need for exploratory surgery to rule out testicular torsion.
One hundred forty-eight consecutive cases of scrotal pain and swelling in boys under the age of 16 have been reviewed. Eighty-nine of these suffered from torsion, either of the testis or appendix testis. Similarity in clinical history and physical findings makes differentiation of torsion from epididymo-orchitis difficult. Operation in all appears to be the only safe treatment. Delay in operation is disastrous with no testicular salvage after 24 hours. On the other hand, 17 of 19 operated upon on the day of onset of symptoms had viable testes.
Diffusion dialysis with anionic ion exchange membranes was employed to recover sulfuric acid from the waste acid solution of aluminum surface processing plant. Experiments were conducted to examine the dialyzer performances under various operating conditions, including feed flow rates, sulfuric acid concentration in the feed solution, temperature and number of pieces of ion exchange membrane. Diffusion dialysis was found very efficient for this purpose. Based on the test results, optimum operating conditions of these variables were identified. Preliminary economic evaluation of the process indicated that diffusion dialysis is highly viable for sulfuric acid recovery due to its short payback period.
Summary— One hundred and forty consecutive cases of torsion of scrota1 contents were reviewed retrospectively. There were 95 cases of torsion of the testicular appendage and 45 cases of testicular torsion. Testicular torsion was more common on the left and patients tended to present earlier with more systemic upset in the form of vomiting, abdominal and groin pain than patients with torsion of a testicular appendage. Pathognomic features of examination were an elevated or ectopic testis in 50% of cases of testicular torsion and a palpable tender blue nodule in 21% of cases of torsion of a testicular appendage.
We believe that it is often possible to distinguish between these two conditions and, where this is possible, a trial of conservative management is justified for torsion of a testicular appendage.
Background. - Diphallia and penoscrotal transposition are rare, generally sporadic, abnormalities.Case reports. - Case 1: A 2-1/2-month old boy was admitted in hospital because he suffered from complete penoscrotal transposition, with moderate hypospadias for which he was operated on. Examination at the age of 6 years showed hypoplastic and dislocated patellae. Case 2: A 2-month-old boy, brother of case 1, also suffered from incomplete penoscrotal transposition, associated with diphallia but without double bladder, that was operated on. Ultrasonography at the age of 17 months showed absence of patellae. The sister of these two patients was normal but her mother displayed ambiguous genitalia with phallic structure located beneath partially fused labial folds. Her patellae were also absent.Conclusion. - This is the first familial case of true diphallia associated to penoscrotal transposition. This abnormality is also associated to absence of patellae and seems to be dominantly inherited.
The development of color-flow imaging has made ultrasound the primary imaging modality for the evaluation of testicular pathology. The ability to distinguish between epididymo-orchitis and torsion is of great clinical significance in those patients with acute onset of pain. Not only does the appropriate treatment depend on the correct diagnosis, but the outcome following that treatment is also dependent on establishment of the diagnosis. Although it is of less importance in the evaluation of testicular neoplasms, color-flow imaging does provide adjunctive information that can aid in establishment of the proper diagnosis in confusing clinical situations. The diagnosis of varicocele depends on color-flow imaging, and the prediction of testicular viability following trauma is essential for proper treatment. More studies concerning the use of power Doppler for imaging of scrotal disorders are necessary to determine what its role will be.
Controversy persists with regard to the diagnosis and treatment of the acute scrotum in children. The differential diagnosis includes torsion of the testis, torsion of one of the appendices testis and epididymo-orchitis. Clinical differentiation is notoriously difficult and our policy has been to explore the scrotum of all who present with signs of an acute scrotum. The medical records of 199 boys aged less than 13 years who presented with an acute scrotum at Red Cross War Memorial Children's Hospital in Cape Town during the period 1970-1996 were retrospectively reviewed. Diagnosis was made clinically in all cases. Sixty-two boys (31%) were found on exploration to have torsion of the testis (mean age 6.3 years), the left side being affecting 2.5 times more frequently than the right (1 neonate had bilateral torsion), 62 (31%) had torsion of testicular appendages and 56 (28%) had epididymo-orchitis. Nineteen were grouped separately and 13 (6.5%) of these were treated conservatively. Boys needing an orchidectomy (N = 38) for testicular torsion presented three times later than those who did not (48 v. 16.5 hours). Successful conservation of the testis was directly related to the time interval of symptom development and surgical derotation. Boys with torsion of a testicular appendage presented later (mean 51 hours) and were older (mean 10 years) than boys in the other two groups. Those with epididymo-orchitis were younger (mean 3.3 years) and 40% were younger than 1 year. Only in one-third was there any clinical supportive evidence of the diagnosis. Surgical complications were infrequent. We advocate expedient surgical exploration and derotation with contralateral orchidopexy, since clinical differentiation between torsion of the testis, testicular appendages and epididymo-orchitis is inexact, even with highly specialised investigation such as Doppler ultrasound and radionuclide scanning, which may not be widely available, may delay definitive treatment and suggest a lack of urgency where time is of the essence.
Of fourteen boys with microphallus who were studied consecutively, nine had hypopituitarism that might otherwise have not been recognised. All fourteen were treated with low-dose, intramuscular testosterone enanthate administered in one or two 3-month courses. In each case, penile size was increased into the normal range without evoking either a significant increase in height velocity or an advancement of skeletal maturation. Before considering surgical sex reversal in infants and young children with microphallus, it is essential to assess whether treatment with intramuscular testosterone will induce clinically significant growth of the microphallus.
A case report illustrating the value of spleen scanning in the diagnosis of a rare anomaly characterized by fusion of the spleen and left testis is described. This malformation results from faulty organogenesis during the fifth to the eighth week of fetal development. Only 65 cases have been reported in the world literature. In most instances, the anomaly is recognized as an incidental finding at autopsy or at surgical exploration of the abdomen. In 20% of cases the anomaly is associated with osseous malformations such as peromelia, ectromelia, micrognathia, and talipes.
IN medieval days a man with three testicles was reputed to have obtained special dispensation to marry two wives, but the majority of modern males are not so blessed. Torsion of the spermatic cord, which can produce permanent testicular damage within four hours,1 , 2 must therefore be regarded as a surgical emergency requiring prompt operative correction to preserve testicular viability. Impaired function of the opposite testis, resulting perhaps from developmental abnormalities, or subsequent contralateral torsion may otherwise result in infertility or arrested sexual development. Once considered a rarity,3 torsion actually has an annual incidence of one case per 4000 males below . . .
Two cases of ectopic scrotum are presented, and 12 previously reported cases are reviewed. This anomaly presumably develops secondary to faulty division or abnormal migration of the embryonic labioscrotal swellings.
Two patients, 1 adult and 1 infant, with complete duplication of the penis are described. The adult had a single bladder, a bifid scrotum, a low abdominal wall hernia, separation of the symphysis pubis, bilateral inguinal hernias, rectal prolapse, bilateral vesicoureteral reflux and bilateral staghorn calculi. The infant had duplication of the bladder, hypoplasia of the left kidney, lumbosacral anomalies, a hypoplastic left lower extremity, an imperforate anus, a infraumbilical wall hernia and separation of the symphysis pubis. A survey of the anomalies accompanying the 2 main types of diphallus (shaft and glans, and glans alone)showed that there was a preponderance of anomalies of posterior structures such as colon, bladder and spine in the shaft and glans diphallus, and a higher incidence of isolated exstrophy of the bladder in diphallus of the glans alone. The embryogenic implications of these findings are discussed.
About 41 cases of hemangioma of the scrotum have been previously reported. A case of scrotal hemangioma is reported and the pertinent literature reviewed. Wide local excision of the tumor with the overlying skin is the treatment of choice.
Hemihypertrophy of the right corpus cavernosum and its accompanying thickened tunica albuginea are responsible for the left lateral deviation in congenital curvature of the penis. Surgical correction is more predictable when the lengths of the dorsal and ventral curvatures of the corpora cavernosa are known.
Between January 1970 and December 1989, 171 patients underwent scrotal exploration for acute scrotum (an acute painful swelling of the scrotum or its content), at our hospital. Of 70 children scrotal explorations, torsion of appendages was found in 33 cases (47%). Torsion of testis was found in 24 patients (34%). Of the 84 adolescent scrotal explorations performed, 72 (86%) had torsion of testis, and 8 (9%) had torsion of appendages. Of 17 adults, torsion of testis was found in 15 cases (88%). These results clarify that unnecessary explorations are much more common in children (66%) than in adolescents and adults (14%). We therefore suggest using radionuclear scans and/or Doppler ultrasound to facilitate clinical diagnosis in the children group.
Congenital penile curvature secondary to asymmetry of corpora cavernosal length is an uncommon cause of penile deformity. Although the deformity generally is not severe enough to preclude sexual intercourse it can be a source of great concern to the patient and may cause him to avoid all sexual contact. The Nesbit procedure is a simple, effective surgical technique to correct lateral or ventral curvature. Rarely penile deviation is accompanied by penile torsion. This unique problem requires a novel surgical approach to create a straight, nontwisted erection. We report 2 cases of congenital lateral penile curvature with accompanying penile torsion and describe a simple modification of the Nesbit procedure for surgical correction.
This article reviews various aspects of differentiation and growth of phallic mesodermal tissues with special reference to the os penis. In many species of certain mammalian orders the penile interior contains an os penis or baculum with bona fide bone. Mechanisms of phenotypic sex differentiation and the androgenic regulation of morphogenesis of genitourinary tracts of both sexes are first overviewed. Thereafter the various mesodermal tissues in fully developed penes and clitorides are discussed. The developmental fate of mesenchymal cells in the fetal genital tubercles is then considered in detail, including considerations of epithelial-mesenchymal interactions. The review concludes with a discussion of the possible roles of certain polypeptide growth factors acting in concert with androgenic steroids. Special emphasis is placed on the potential role of bone morphogenetic proteins in formation of the os penis in a restricted number of eutherian mammalian taxa.
To further our understanding of the development of the anterior urethra a series of 38 normal human fetuses ranging from the end of the embryonic period proper to the third trimester of gestation were studied. Tissues prepared as serial histological sections were examined and appropriate specimens were reconstructed. The formation of the bulbar and spongy urethra occurred by proliferation of mesenchyme underlying the epithelium of the urethral folds, causing the creation of a tubular urethra by epithelial fusion in the ventral midline. The tubular urethra becomes invested by mesenchyme, the future corpus spongiosum. This process of fusion of the urethral folds extends to the glans penis. At this period of development the glans contains the urethral plate, a lamina of epithelium lacking a lumen. The mechanism of the subsequent connection of the spongy urethra to the canalized urethral plate has been the point of controversy. Our observations support the idea that 3 processes must act in synchrony to produce successful completion of the anterior urethra: 1) the prepuce forms by overgrowing the glans due to proliferation of the penile skin and subcutaneous tissues, and in so doing it continues the progression of closure of the urethral folds into the glans and forms the frenulum by its fusion on the ventral aspect, 2) the mesenchyme surrounding the prolongation of the urethra fuses with the mesenchyme of the glans, which before this time had existed as a mesenchymal structure distinct from the corpus spongiosum or corpus cavernosum and 3) the epithelium of the urethral plate within the glans, which underlies the epithelial tag, becomes canalized and develops continuity with the lumen of the spongy urethra.
A study of 45 patients with 51 cases of hemiscrotal inflammatory disease was done to determine the color Doppler ultrasonographic appearance of scrotal inflammatory disorders. The diagnosis was ultimately established by means of appropriate response to antibiotic treatment (47 cases) or surgery (four cases). In all cases, there was evidence of hyperemia: an increased number and concentration of detectable vessels in the affected portion of the scrotum. In 17 cases, the gray scale images were normal, and the only evidence of inflammation was the presence of hypervascularity. Abnormally decreased epididymal vascular resistance was detected in 14 cases of epididymitis; abnormally decreased testicular vascular resistance was detected in six cases of orchitis. Spontaneous venous flow was present in 18 patients. The authors conclude that color Doppler can demonstrate the hyperemic response to scrotal inflammatory disease and that, in the proper clinical setting, it can supplement the gray scale findings and increase diagnostic confidence.
hrs reported in the literature by Bostroem in~ i883 but it was Pommer, who in 1889 described in detail a ease which was associated with limb defects and other congenital abnormalities, no- tably mierognathia and anal atresia. It has been suggested that this teratologie syndrome of splenogonadal fusion, limb defects, and other Congenital abnormalities, which constitutes a subgroup of patients with splenogonadal fu- sion, be called the Pommer syndrome. Putschar and Manion in 1956 published the first detailed literature review of splenogonadal fusion in which details of 30 clinical eases and a classifi- cation system were discussed. Since their review was published the urologic and pediatric surgi- cal literature have contributed almost another 100 cases which have been mainly in the form of single ease reports with exceptionally, 2 and 3 cases described. Nevertheless, many of the re- ports conclude with the performance of an or- chieetomy, in the mistaken belief that this entity represents a malignant process. Thus it is vital that urologists, pediatric and general surgeons are aware of this condition and appreciate its benign nature.
Blunt scrotal trauma may result in a variety of injuries, including testicular rupture, torsion, dislocation, hematoma, or contusion, as well as epididymal, scrotal, and urethral injuries. Testicular rupture occurs in 50% of patients with traumatic hematocele, and is probably frequently misdiagnosed. If not aggressively diagnosed and surgically repaired, testicular rupture may lead to testicular atrophy and loss. Traumatic testicular torsion must also be diagnosed early to preclude testicular loss. Testicular scan, when rapidly available, is indicated in any case of suspected traumatic torsion. If testicular scanning is unavailable or equivocal, surgical exploration is indicated. Once torsion is ruled out, ultrasound is a useful diagnostic technique in acute scrotal trauma to differentiate those scrotal and testicular injuries requiring surgical intervention.
A case of true complete diphallia associated with multiple malformations is presented. Complete radiological evaluation should include sonography of both penes preoperatively to classify the penile duplication correctly.
We interviewed and examined 20 patients with the primary diagnosis of micropenis in infancy. The patients were divided into 2 groups: 8 prepubertal (10 to 13 years old) and 12 postpubertal (17 to 43 years old). All but 1 had been given human chorionic gonadotropin, testosterone or cortisone during childhood. Only 1 child in the prepubertal group had a stretched penile length above the 10th percentile. All postpubertal patients were below the 10th percentile. Puberty was delayed in only 2 patients in the older group. All patients were heterosexual and they had erections and orgasms. Eleven patients had ejaculations, 9 were sexually active and reported vaginal penetration, 7 were married or cohabiting and 1 had fathered a child.
The concealed penis is a long-standing problem that only recently has begun to receive the attention it deserves. We offer a classification for this general disorder, which facilitates the selection of appropriate surgical procedures for these patients. To correct the most common problem, the buried penis, involves removal of localized deposits of fat from the hypogastrium with open surgical or closed suction techniques followed by anchoring of the skin of the base of the penis to the periosteum of the pubis. During the last year we have used this approach successfully in 7 boys with various forms of penile concealment with good results.
Forty-eight boys were assessed for an acutely painful scrotum. Thirty-six (75%) of them underwent radionuclide scanning of the scrotum; the average age of this group was 11 years. The scan revealed epididymitis in 19 cases, spermatic cord torsion in 9, appendix testis torsion in 7 and acute hernia-hydrocele in 1. The diagnosis was confirmed at operation in all nine cases of spermatic cord torsion. Boys who had epididymitis received antibiotics only; all were available for short-term follow-up, and 16 were also assessed at a mean of 6 months after infection. Only one boy had testicular atrophy; he had undergone repair of an inguinal hernia, which could not be ruled out as a cause. Bacteriuric epididymitis occurred in three boys; two had known predisposing genitourinary anomalies, the third had no abnormalities. Boys who had nonbacteriuric epididymitis were investigated by renal and pelvic ultrasonography or voiding cystourethrography; no important abnormalities were detected. This prospective study indicates that radionuclide scanning can reliably differentiate spermatic cord torsion from other acute scrotal disease.
The radionuclide scrotal scan is highly accurate in the differential diagnosis of acute torsion vs epididymo-orchitis. While the scan findings of increased flow through the spermatic cord and increased static scan activity suggest inflammation, its appearance is not always diagnostic of inflammatory disorder. That this may also occur after reduction of torsion has not been emphasized in the literature. A case report of spontaneous reduction of testicular torsion is presented which demonstrates both increased flow and increased static image activity mimicking epididymitis.
Aphallia is an extremely rare disorder with profound urological and psychological consequences. Approximately 60 patients have been reported on in the literature; we report our experience with 3 additional patients. Fifty patients had sufficient information to classify the condition according to the site of the urethral meatus. With the relative relationship of the urethral meatus to the anal sphincter several observations were noted. The more proximal the meatus the higher the incidence of other anomalies and the greater the number of neonatal deaths. Of the patients 30 (60 per cent) had a post-sphincteric meatus located on a peculiar appendage at the anal verge. These patients had the lowest incidence of other anomalies (1.2 per patient) and the highest survival rate (87 per cent). A total of 14 patients (28 per cent) had pre-sphincteric urethral communications (prostato-rectal fistula), of whom 36 per cent died in the neonatal period. Six patients (12 per cent) had urethral atresia. This group had no survivors and the highest incidence of other anomalies (4 per patient). Of our patients 2 had a post-sphincteric meatus and 1 had a pre-sphincteric meatus. In addition to correction of life-threatening anomalies the management of aphallia centers on establishing gender assignment. Bilateral orchiectomy, labial construction and urethral transposition should be done in the newborn period, if possible.
Three adult patients with micropenis are described: two genetic females, reared as boys, with congenital adrenocortical hyperplasia (CAH), and one male with anorchia. The patients had a male gender identity/role. All three had established a satisfying heterosexual relationship. For only one of the patients intravaginal intercourse was possible. In one patient (with CAH), penile reconstructive surgery was attempted but failed. Nevertheless, he developed a satisfactory sexual relationship with a woman friend. This report illustrates that for patients with micropenis, penile reconstructive surgery is not obligatory for the establishment of a satisfying sexual relationship.
Approximately one third of infertile men present with varicocele, while the incidence among males in the general public is approximately 15 per cent. The etiology may be a longer left spermatic vein with its right-angle insertion into the left renal vein and/or absence of valves, which causes a higher hydrostatic pressure in the left spermatic vein causing dilatation. The nutcracker phenomenon is also a possible etiology. Much of the pathophysiology is still unknown, but increased blood flow causing an elevated intratesticular temperature may be of significance. Though there are many recent reports on the importance of a subclinical varicocele, we are not convinced of its significance. The best method for diagnosis remains a good clinical examination. The incidence of adolescents with varicocele is about the same as men with varicocele (approximately 15 per cent). Adolescents with varicocele should be treated if the testicular mass is decreased or if they are symptomatic. Surgical ligation is still the preferred method of treatment. Percutaneous treatment of varicoceles has an approximately 11 per cent incidence of minor complications and an occlusion rate of 73 per cent with a recurrence rate of 5 per cent. We reserve percutaneous treatment for recurrent varicoceles after surgical ligation, but primary percutaneous therapy is a reasonable approach.
One hundred and forty consecutive cases of torsion of scrotal contents were reviewed retrospectively. There were 95 cases of torsion of the testicular appendage and 45 cases of testicular torsion. Testicular torsion was more common on the left and patients tended to present earlier with more systemic upset in the form of vomiting, abdominal and groin pain than patients with torsion of a testicular appendage. Pathognomic features of examination were an elevated or ectopic testis in 50% of cases of testicular torsion and a palpable tender blue nodule in 21% of cases of torsion of a testicular appendage. We believe that it is often possible to distinguish between these two conditions and, where this is possible, a trial of conservative management is justified for torsion of a testicular appendage.
The use of ultrasound for evaluation of blunt testicular injury with hematocele allows contusion to be differentiated from rupture, and some authors advocate reserving surgical management for rupture. Our experience with the conservative management of 20 men with testicular contusion and hematocele was not encouraging. Of the patients 8 (40 per cent) required delayed exploration that involved orchiectomy in 3 (15 per cent) because of unresorbed hematoma or infection despite antibiotic use. In contrast, early surgical exploration in 19 patients reduced the morbidity and duration of disability, and resulted in an orchiectomy rate of 0.
A review of 100 boys less than 15 years old who were hospitalized for an acute scrotum revealed that the most common causes of the disorder were testicular torsion, including torsion of the spermatic cord (42 per cent) and torsion of the appendages (32 per cent). The remaining 26 per cent of the cases were owing to idiopathic scrotal edema (8 per cent), epididymitis and orchitis (6 per cent each), and incarcerated hernia and acute hematocele (3 per cent each). The age distribution of these children was biphasic, with the highest frequency in newborns (with exclusively extravaginal torsion) and in boys 13 years old, whereas in boys with appendiceal torsion the single peak frequency was at age 10 years. While idiopathic scrotal edema occurred in children less than 7 years old and orchitis in patients more than 12 years old, epididymitis was observed in young boys and those of pubertal age.
Penile agenesis is a rare condition requiring gender reassignment and staged perineal reconstruction. This report describes two children reconstructed by taking advantage of the posterior sagittal approach. This approach allows a precise anatomic dissection, construction of a neovagina and accurate positioning of all perineal orifices. We think that this is the preferred approach for this rare condition.
A patient with untreated rupture of the tunica albuginea underwent surgical exploration 6 weeks after acute scrotal trauma. A layer of epithelium had grown across the bulging seminiferous tubules, and no further surgical repair was necessary. This spontaneous repair phenomenon has not previously been reported pictorially in the human testis. The recommended treatment of testicular rupture is surgical exploration and repair.
Twenty-four children with a total of 31 episodes of acute idiopathic scrotal oedema (AISO) were assessed during a 5 year period. AISO accounted for 30 per cent of all admissions with acute scrotal pathology in this period and was the final diagnosis in 69 per cent of cases in those presenting under the age of 10 years. Although presentation was with unilateral (48 per cent) or bilateral (52 per cent) AISO, considerable overlap between these two groups occurred. Five patients (21 per cent) had recurrent attacks. Fourteen boys (60 per cent) had a history of allergy or had allergic manifestations at presentation compared with an incidence of allergy of 28 per cent in 42 controls (P less than 0.05). AISO is the commonest cause of the 'acute scrotum' in boys under the age of 10 years and is probably allergic in origin.
A total of 20 male patients 11 to 19 years old had a grade 2 or 3 varicocele and volume loss of the testis ipsilateral to the varicocele. None of these patients presented because of subfertility. Following varicocele ligation a significant increase in volume of the testis ipsilateral to the varicocele was observed in 16 of 20 patients. All 20 patients have been followed for 1 to 6 years. Our results suggest that a moderate to large varicocele can be responsible for testicular growth retardation and that early ligation of the varicocele may reverse this process.
We performed a retrospective survey to determine the frequency of problems of the foreskin among uncircumcised children. Among 545 boys aged 4 months to 12 years, there were 272 uncircumcised boys and 273 control patients who were circumcised at birth. The total frequency of complications was significantly higher in the uncircumcised group (14% vs 6%). Both balanitis (6% vs 3%) and irritation (4% vs 1%) were more frequent among the uncircumcised children, but the difference was not statistically significant. Problems with adhesions were uncommon (1.5%) and equal in both groups. Symptomatic phimosis was seen in eight patients. The frequency of medical visits for penile problems was significantly higher in the uncircumcised group (10% vs 5%). Although the overall frequency of complications was higher among the uncircumcised children, most of the problems were minor.
Eighteen patients were reviewed 7 to 23 years after prolonged unilateral testicular torsion. They had all undergone surgical untwisting with replacement of the nonviable testis in the scrotum during prepubertal period. Five patients were now married and had fathered one or more children. Thirteen patients were unmarried. There was absence of testis on the affected side in 14 of 18 patients. Four patients had severe testicular atrophy on the affected side (testicular volume less than 1 mL). The contralateral side showed either a normal testicular volume or a compensatory hypertrophy (testicular volume greater than 25 mL). Seminal analysis was done in 13 unmarried men and it was completely normal in 10 patients. Two patients had low sperm density but normal semen volume and motility. One patient had pathologic semen analysis. IgG and IgA specific mixed agglutination reaction (MAR) test did not show evidence of sperm autoantibodies in any patient. Our clinical experience shows that, after prepubertal torsion, the contralateral testis undergoes normal development. Furthermore, torsion in the prepubertal male does not cause autosensitization and diminished fertility in adult life.
From 9545 observations of the state of the prepuce in 1968 schoolboys aged 6-17 years, examined annually for up to eight years, the following was concluded. Physiological phimosis is a rare condition in schoolboys, and it has a tendency to regress spontaneously; operation is rarely indicated. Clumsy attempts at retraction probably cause secondary phimosis, which then requires operation. Preputial non-separation ('adhesion') occurs frequently, but separation of the epithelium takes place gradually and spontaneously as a normal biological process in the course of school life and is concluded about the age of 17. Production of smegma increases from the age of about 12-13 years. Neither this nor the hygiene of the prepuce present any problems if the boys are regularly instructed.
One hundred forty-eight consecutive cases of scrotal pain and swelling in boys under the age of 16 have been reviewed. Eighty-nine of these suffered from torsion, either of the testis or appendix testis. Similarity in clinical history and physical findings makes differentiation of torsion from epididymo-orchitis difficult. Operation in all appears to be the only safe treatment. Delay in operation is disastrous with no testicular salvage after 24 hours. On the other hand, 17 of 19 operated upon on the day of onset of symptoms had viable testes.
We have found that the blanket philosophy of emergency scrotal exploration in all cases of acute scrotal swelling in boys results in an unacceptably large number of unnecessary explorations. The use of specific aspects of the clinical examination, in conjunction with the radioisotope testicular scan in selected instances, has guided our management of 150 consecutive boys presenting with acute scrotal symptoms.
In one year's time, eight of 11 cases of torsion of the testicle were successfully untwisted in the emergency room. The doppler ultrasound was used to document return of blood flow after detorsion. Subsequent fixation of both testes may be done on a less urgent basis.