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The boy who has significant concealment preventing newborn circumcision will generally be scheduled for surgical reconstruction, which includes the circumcision and correction of his concealment between 6 and 12 months of age.
There are a number of techniques in the literature for correction of the concealed penis.5 One of the more popular approaches in the absence of significant webbing is to use internal suture fixation at various points at the base of the penis and affix them to the corresponding dermis of the abdominal wall-shaft skin juncture. In the presence of a penoscotal web where the ventral penile shaft is deficient, a scrotoplasty is performed and the lateral skin edges are transferred ventrally to create a cosmetically normal ventral shaft. Sometimes there is an obese prepubescent or adolescent male who might benefit liposuction to remove the large suprapubic fat pad. Often in those situations, the liposuction by itself allows improved exposure of the previously hidden penis. However, these children need to be placed on a diet regimen and exercise program to prevent recurrent problems.
7.3.3 Complications
Penile adhesions may be treated by the use of topical steroid creams.
Penile skin bridges may require surgical division, many of which can be done in the surgeon’s office.
Recurrent penile concealment may improve spontaneously on its own with tincture of time but, in cases where a cicatrix scar forms and prevents penile exposure, first try topical steroid treatment. If that were to fail to loosen up the adhesions and expose the penis, then repeat surgery is necessary.
7.3.4 Benign Urethral Lesions in Boys
Urethral polyps are congenital benign growths of fibrous stalks of tissue and may present with gross hematuria, symptoms of a urinary tract infection or problems voiding.
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FIGURE 7.13. Meatal stenosis in a circumcised boy.
Diagnosis is made by voiding cystourethrography (VCUG) and cystoscopy.
Meatal stenosis (Fig. 7.13) occurs in only males and represents a tiny urethral opening in the orthotopic position. This is most commonly diagnosed during puberty when the parents note a thin and/or misdirected urinary stream. Dysuria is also a common symptom and bloody spotting may occur.This is seen predominantly in circumcised males.
Congenital urethral fistula is rare but the findings are similar to fistula seen after hypospadias repairs. Observation and physical exam make the diagnosis.
Anterior urethral diverticuli are pouch like enlargements of the urethra. They may present either as a saccular form where the diverticulum arises from the floor of the urethra or the megalourethra, which involves the entire anterior urethra. Both entities are discovered by observation during voiding whereby a weak urinary stream is observed in conjunction with visible expansion and bulging of the urethra. Boys with
Prune Belly Syndrome are at risk for having megalourethras. Cowper’s Duct cysts result when the bulbourethral glands, which are located beneath the prostate gland, expand into cystic like structures due to abnormal narrowing of the glands’ exit passageway. They can cause discomfort during voiding, bloody spotting and a weakened urinary stream with associated
post void dribblig. The diagnostic test of choice is a VCUG.
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FIGURE 7.14. Urethral duplication. Note the dorsal located “extra” meatus.
Urethral duplication (Fig. 7.14) is rare and is represented by a spectrum from simply having a dorsal blind ending sinus tract below the normally located meatus to where there is not only a complete duplicated urethra but a duplication of the bladder as well. They may present as a serendipitous physical finding or by noting two distinct separate urinary streams. They may also present with infection and/or obstructing symptoms in the other urethra.
7.3.5 Treatment
When urinary symptoms as noted above occur, referral to pediatric urology is indicated to complete the workup. Once a diagnosis is made surgical correction is individual tailored to the condition.
Urethral polyps are excised and the base fulgurated by using minimally invasive cystoscopy.
Meatal stenosis can be corrected either as a meatotomy in the office setting with local topical anesthetic in a cooperative child or, as a short outpatient procedure by performing a
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urethromeatoplasty to enlarge the urethral opening. It is important to provide instructions for the patient to apply ointment at least twice a day and to spread the raw edges apart until healing occurs in about 2 weeks.
Congenital urethral fistula is repaired using the same techniques for fistula resulting after hypospadias surgery as outpatient procedures.
Congenital urethral diverticulum is corrected much the same way as that done for diverticulum occurring after hypospadias repair. In addition a complete urological evaluation is necessary since there is a high association of other urologic problems.
Cowper’s duct cysts are treated by endoscopic resection to relieve symptoms. If this is impossible, then open surgery is done.
Urethral duplication does not require treatment for a blind ending sinus or incomplete duplication that is not causing any adverse symptoms. A simple technique when there are two streams and the urethral openings are close to one another would be to connect the openings together to create one single urinary stream. Some urethral duplications are associated with penile curvature, which then needs correction and the extra urethra excised.
7.3.6 Follow-Up After Treatment
Urethral polyps once successfully resected should result in resolution of preoperative symptoms.
After surgery for meatal stenosis, the child may experience dysuria for a few days that may be easily treated with a urinary analgesic in the older children. In the young boy who cannot swallow pills, placement in a warm tub of water will allow him to void with less discomfort. Also by spreading the meatus and placing ointment over the raw edges a few times per day will also improve any discomfort.The key to preventing a recurrence is the frequent and active spreading of the raw edges after surgery for up to 2 weeks until there is no more crusting over the wound and the meatus is well healed.