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Urethral fistula follow-up is similar to hypospadias.Patients are generally seen at 2 weeks, 3 months, 1 year, and puberty.
Urethral diverticulum secondary to the megalourethral fusiform variant are not going to have a functional penis except for the passage of urine due to the congenital absence of corporal tissue. The milder varieties should have acceptable penile function after successful repair.
Cowper’s duct cysts after resection are essentially symptom free.
Connecting the urethral meati should relieve the symptoms in urethral duplications when surgery is needed.
References
1.Zaontz MR. Nuances of hypospadias. In: Kramer SA, Paulson DF, eds. Problems in Urology, vol. 4. Philadelphia: JB Lippincott Co; 1990:705-717.
2.Zaontz MR, Packer MP. Abnormalities of the external genitalia. Pediatr Clin North Am. 1997;44(5):1276-1297.
3.Maizels M, Zaontz MR, Donovan J, et al. Surgical Correction of the buried penis: Description of a classification system and a technique to correct the disorder. J Urol. 1990;136:268-271.
4.Hatch DA, Maizels M, Zaontz MR, Firlit CF. Hypospadias hidden by a complete prepuce. Surg Gyn Obst. 1989;169(3):233.
5.Zaontz MR. The concealed penis. Dialog Pediatr Urol. 2006;28:1-9.
6.Zaontz MR, Kaplan WE, Maizels M. Surgical repair of anterior urethral diverticula after hypospadias repair in children. Urology. 1989;33:39-42.
7.Zaontz MR. Congenital microphallus. In: Seidmon EJ, Hanno PM, eds. Current Urologic Therapy. 3rd ed. Philadelphia: WB Suanders Co; 1994:436-437.
8.Zaontz MR, Steckler RE, Shortliffe, LMD et al. Multicenter experience with the Mitchell technique for epispadias. J Urol. 1998;160(1): 172-176.
Chapter 8
Disorders of Male External
Genitalia: Undescended Testis
Michael C. Large and Mohan S. Gundeti
Key Points
››Cryptorchidism, or undescended testis, occurs in 3% of full term males.
››Spontaneous descent rarely occurs after age 6 months.
››Surgical therapy minimizes the risk of infertility in men with an undescended testicle.
››Orchidopexy improves the patient’s ability to perform testicular self-examination, and when done at an early age, may marginally decrease the relative risk of testicular cancer in an undescended testicle.
8.1 Introduction
Three percent of term male infants have cryptorchidism, or undescended testis, while approximately 17% of premature males are affected.1 The rate of spontaneous descent is debatable, with incidence ranges of 10–70% reported.1,2 The testis may be abdominal, inguinal, scrotal or ectopic. The rationales for repair are many:
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84 M.C. Large and M.S. Gundeti
1.Men with an undescended testis appear to have higher infertility rates and lower sperm quality and counts when compared to males with bilateral descended testes.3
2.Spermatic indices in undescended testes reach critically low levels by 9 months age, and spontaneous descent is very rare after age 6 months.2,4 Thus, repair is frequently performed during this time.
3.Infertility rates worsen if both testes are affected.5
4.Improved physical examination of the testis allows earlier detection of malignancy.6
a.The contralateral descended testis appears to have no increased risk of malignancy.7
b.The relative risk of testicular cancer in a cryptorchid testis repaired by age 12 is 2–3, but 2–6 when repaired after age 12.As such, orchiectomy should be considered in patients between 12 and 50 years of age.7
5.A vast majority of undescended testes are associated with
apatent processus vaginalis and thus increased likelihood of hernia.8
6.Torsion may occur relatively more frequently in the undescended testis.9
8.2 Common Conditions
Three types of nonpalpable testicle exist: undescended, ectopic and retractile. Radiographic studies for the undescended testicle are not warranted as their negative predictive values are shy of the requisite 100%.10
1.Undescended testes have a normal gubernacular attachment but have failed to reach the scrotum during descent.
The examiner gently sweeps from the internal inguinal ring caudally, sometimes with the aid of lubricant, and frequently will feel the oval testis roll under the finger and then retract inguinally when released (Fig. 8.1).
2.Ectopic testes have an abnormal gubernacular attachment and may be found in the thigh, prepubic or abdominal regions. If maneuvered into the scrotum, the testis will immediately retract to its ectopic position once released.
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FIGURE 8.1. Physical examination of the testicles. (a) Appearance of empty left hemi-scrotum. (b) Application of pressure at external inguinal ring, directed toward scrotum. (c) Palpation of right testicle. (d) Application of pressure at the left external ring. (e). Attempt at palpating the left testis between index finger and thumb. (f). Milking movement of finger and thumb distally in an attempt to delineate testis (here, no left testis was palpable).
3.Retractile testes have an exaggerated cremasteric response. If manipulated into the scrotum, they will remain there until the cremasteric reflex is stimulated.
4.Risk factors include family history, prematurity, low birth weight or gestational size,multiple gestation,Eagle-Barrett syndrome, or in vivo exposure to estrogen.