Urethra and Penis

The male urethra

Congenital abnormalities
The most common congenital abnormalities of
the male urethra are:
1) Meatal stenosis
2) Congenital urethral stricture
3) Congenital valves
4) Hypospadias
5) Epispadias

Meatal stenosis

A congenital stenosis of the external urinary meatus, normally the narrowest part Of the male urethra, is a associated with Phimosis.
When the meatal opening is reduced to a pinhole there may be chronic retention of urine with backpressure effects and eventually chronic renal failure.
Lesser degrees of stenosis lead to loss of the normal urinary stream with spraying or dribbling
treatment :
Meatal dilatation ,meatotomy or meatoplasty

Congenital Posterior urethral valves

These are symmetrical folds of urothelium which can
cause obstruction to the urethra of boys
They are usually found just distal to the
verumontanum.
they behave as flap valves so, although urine does
not flow normally , a urethral catheter can be passed
without difficulty.
The valves are difficult to see on urethroscopy because the flow of irrigant sweeps them into the open position.
If the bladder is filled with contrast medium, the dilatation of the urethra above the valves can be demonstrated on a voiding cystogram


Treatment :-
1) Suprapubic catheter
2) Transurethral resection of the valves using a
paediatric resectoscope
HYPOSPDIAS
- Is a congenital defect of the penis resulting in a proximal (ventral) urethral meatus, ventral curvature (chordee) and ventral deficiency of the foreskin (hooded prepuce)
- Hypospadias is classified according to position of the meatus.
glandular hypospadias
Coronal =
Penile =
Penoscrotal =
Perineal =

Treatment

glandular hypospadias does not need treatment unless the meatus is stenosed, in which case a meatotomy is performed
surgery is indicated for other forms of hypospadias to improve the sexual function and for cosmetic reasons.
involves the surgical repair of the chordee when present and urethral reconstruction
patients with hypospadias should not be circumcised because the foreskin often is required for surgical reconstruction

injuries to the male urethra

Urethral injuries in male patients are usually divided into those involving the:
1) anterior urethra (penile and bulbous urethra)
2) posterior urethra (membranous and prostatic
urethra)
Mechanism :-
1) Anterior urethral ( bulbar ) injuries :-
- There is a history of a blow to the perineum, usually due to a fall astride a projecting object.
this is seen in cycling accidents & a loose manhole cover


( 2 Posterior urethral injuries:
these are usually seen as a result of fall on ground & usually associated with pelvic fractures
the urethra is transected at the genitourinary diaphragm, resulting in superior displacement of the prostate.
Diagnosis
1) Anterior urethral iniuries
the triad of signs of a ruptured bulbous urethra is:
urethral hemorrhage, a perineal haematoma & a retention of urine

2) Posterior urethral injuries

There is a blood at the external urinary meatus, haematoma or tenderness in the supra pubic region & anuria
NO CATHETERIZATION : because urethral injury may be partial injury & manipulation by catheterization may change it from partial to total cut.
We can know that the rupture is partial or total by IVU & retrograde urethrography
will get 2 results by urethrogram
1) partial urethral injury :- some of the contrast will reach the bladder & another part will be extravasated & by IVU the bladder will be in its normal position.
2) Total rupture (transection) & of the urethra : - all the contrast will be extravasated & by IVU the bladder will floated (ballooned) in the pelvis. i.e. the bladder position is higher radiologically than normal.

Treatment

1) Anterior urethral injuries
- Suprapubic cystostomy
- Exploration of the area, probably resection of
the damaged part, end to end anastomosis.
2) Posterior urethral injuries
• partial rupture :-
- it needs only urine diversion by suprapubic cystostorny.
- Partial tear heal spontaneously in about 3 weeks


Total rupture (transection):-
Primary realignment (Rail road) technique :
we approximate the two ends of the urethra into their position without suturing
Suprapubic cystostomy, then after 6 w – 6 m we approximate the two ends & we can suture.

complication :-
Urethral stricture → perineal abscess → urethrocutaneous fistula

urethral stricture

is a narrowing of the urethra caused by injury or disease such as urinary tract infections or other forms of urethritis.
What causes a urethral stricture
Injury or damage to the urethra can heal with scar tissue that may cause a stricture.
Infection
Congenital - some babies are born with a urethral stricture
Cancer which spreads from a prostate cancer or a bladder cancer is a rare cause.

What are the symptoms of a urethral stricture?

Reduced urine flow is the usual first symptom. Straining to pass urine is common but a complete blockage of urine flow is rare.
Spraying of urine or a ‘double stream’ may occur.
Dribbling of urine for a while after going to the toilet to pass urine.
Frequency sometimes occurs (needing to pass urine more often than normal).
Mild pain on passing urine sometimes occurs.


Complications
Urinary retention
Urethral diverticulum
Periurethral abscess
Urethral fistula
Bilateral hydronephrosis
Urinary infections
Urinary calculus
Hernia, hemorrhoids or Rectal prolapse from straining

Diagnosis

Urethroscopy
Urethrography
Treatment
Instrumental Treatment
- Intermittent dilatation (at suitable intervals twice a week 1st, once a week for month, once a month for a year, then once every year)
Operative Treatment
- Internal urethrotomy
- Urethroplasty