Tuesday 19 November 2013

Penis Problems 3: Urethras

[WARNING: this article contains photographs of penes (penises).]

I have no medical training whatsoever. I am writing this article as I personally have a urethral condition. If in any doubt - especially if you are in pain, sore or have any bleeding - please do not be embarrassed and seek qualified medical attention.

I have quoted and cited various articles. I have attempted to go from the simple to the more complex. Whilst seeking advice and information can be reassuring, it can also induce fear. This article is no substitute for qualified medical advice. The blog-post is a pointer only.

The urethra has an opening known as a urethral/urinary meatus/orifice - it is a thin slit with tiny lip-like sides (or labia) found at the end of the glans, the head of the penis. The urethral orifice may also appear slightly rounded, which is perfectly normal, especially so where the penis has been circumcised. The image below is of a healthy penis with a normal urethral slit.

[Image description: glans courtesy Wikipedia]

There are three main fairly common malformations:

If the urethra is on the underside of one’s penis the condition is known as hypospadias.

If the urethra is on the upper side of one’s penis the condition is known as epispadias.

If the urethra is misshapen it may lead to a condition known as meatal stenosis.

However, there are several other possible urethral conditions. The image below highlights a glans with split urethral orifice. The writer has this condition. In my case it can make urination a tad messy: were I to retract my foreskin two separate flows of urine would shoot out in two different directions making it impossible to control.  Growing up I was constantly in trouble for missing the w.c. Thankfully, I was not circumcised, so this means I can use my foreskin to direct urine flow. I have no idea of the anatomical reasons for my personal condition as my parents never had it checked out and I have learned to live with it. “It could be a double or duplicated urethra. It could be a fistula. It could be any number of rare conditions.”

[Image description: glans with split urethral orifice; courtesy & © The Penis.]

The following is an article (redacted by this writer) taken from Mothering.

"The urinary system is both amazing and complex. Urine is formed in the kidneys by their filtering the blood. The kidneys are located in the back, just under the ribs. A tube called a ureter extends from each kidney down to the bladder. As the urine is formed, it flows down these tubes and is stored in the bladder. Urine leaves the bladder and exits the body through a tube called the urethra.

In … boys the urethra is long, and S-curved. The final portion travels the length of the penis, and typically opens at the hole in the tip.

The formation of the male urethra in utero is complex, and not completely understood. This development can go awry in a number of ways, including part or all of the urethra in the wrong location, valves blocking urine flow, or dilatation so that flow isn't blocked when it should be. Some boys even have two urethras.

Urethral duplications occur in many varieties and seem to come from many different abnormalities of development. No widely accepted classification has yet been adopted. Most duplications occur with one urethra on top of the other. Occasionally, however, duplex urethras occur side by side. This is usually the case if a child has two complete penises, but also occurs if the penis is fused but widened. Most of these children have two bladders, plus two normal urethras, and only need surgery if it is needed for cosmetic reasons.

The more common situation of one urethra on top of another occurs in dorsal and ventral varieties.

In dorsal duplications of the urethra, a normal urethra follows the usual channel and ends in a normal hole at the tip of the penis. The other opening appears on the upper surface of the penis, anywhere between the tip and the base. This extra urethra may end in a blind pouch before reaching the bladder. If it does extend the entire length and insert into the bladder, the child will usually dribble urine out of this urethra, since there is no sphincter mechanism to restrain urine flow. Surgery is sometimes needed for incontinence or repeated infections. Since the normally positioned urethra has a normal bladder neck and normal sphincter mechanism, surgery consists of simply excising the extra urethra.

The ventral variety is more variable and less well understood. In some instances, two complete urethras come off the bladder; in others, the urethra bifurcates somewhere along the path. The opening from the second urethra is often located on the underside of the penis (and is thus less visible than in the dorsal variety), but it can appear further down, even as far away as the anterior rim of the anus. The closer the opening is to the anus, the more likely that this abnormally placed urethra is the normal one, with the functioning sphincter mechanism. The normally located penile urethra is often narrow, inelastic, and functions poorly, if at all. As an adult, ejaculation would also occur out of the anal urethra, not necessarily diminishing sexual pleasure, but certainly affecting fertility.

Not all cases of duplex urethras need surgery, or any treatment at all. Perianal urethras should be repaired; the surgery is complicated and usually involves trying to move that urethra forward. If both openings are on the penis, as in your son, surgery is only indicated if there is a problem with incontinence, infections, or reflux (the backward flow of urine). Incontinence or isolated infections are usually present early on if they will be present at all. Reflux can be present early on, but then disappear on its own. It can, however, develop or re-develop at any time, even in adulthood, leading to infections and pressure-related kidney problems. If the two urethras lie right next to each other, the thin wall between them can give way. When the person urinates, this perforated wall can act as a flap-valve to obstruct urine flow, causing pressure back up. When undetected, this pressure can, over years, lead to renal failure, and even to kidney transplant.

For most of us, the medical conditions that afflict us as adults have their roots in childhood. Attention and appropriate medical care can prevent many of these conditions. For your son, close attention is even more important. His situation might cause him no problems (some cases of double urethra are only noticed incidentally, late in life). It could, however, progress to something serious if not followed carefully. Stay in close contact with your pediatrician and/or urologist, so that infections or reflux can be quickly treated.

Alan Greene MD FAAP, July 17, 1996"

Now, some more technical information from Wikipedia:

"Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus (the opening, or male external urethral orifice). Instead of opening at the tip of the glans of the penis, a hypospadic urethra opens anywhere along a line (the urethral groove) running from the tip along the underside (ventral aspect) of the shaft to the junction of the penis and scrotum or perineum. A distal hypospadias may be suspected even in an uncircumcised boy from an abnormally formed foreskin and downward tilt of the glans.
The urethral meatus opens on the underside of the glans penis in about 50–75% of cases; these are categorized as first degreehypospadias. Second degree (when the urethra opens on the shaft), and third degree (when the urethra opens on the perineum) occur in up to 20 and 30% of cases respectively. The more severe degrees are more likely to be associated with chordee, in which the phallus is incompletely separated from the perineum or is still tethered downwards by connective tissue, or with undescended testes (cryptorchidism).

[Image description: penis with hypospadias 1 and fistulae 2 & 2; courtesy & © Wikipedia]

A much rarer and unrelated type of urethral malformation is an epispadias. This is not a problem of the urethral groove or meatus, but a failure of midline penile fusion much earlier in embryogenesis. An isolated opening of the dorsal ("top") side of the penis is rare, and most of these children have much more severe defects, involving a small and bifid phallus with bladder exstrophy or more severely, cloacal exstrophy involving the entire perineum. The cause of this defect of early embryogenesis is unknown but does not involve androgens. … In most cases, the cause of this birth defect is not fully understood. 

[image description: an erect penis with hypospadias; courtesy & © Wikipedia]

First degree hypospadias are primarily a cosmetic defect and have little effect on function except for direction of the urinary stream. If uncorrected, a second or third degree hypospadias can make male urination messy, necessitate that it be performed sitting, impair delivery of semen into the vagina (possibly creating problems with fertility), or interfere with erections. In developed countries, most hypospadias are surgically repaired in infancy. Surgical repair of first and second degree hypospadias is nearly always successful in one procedure, usually performed in the first year of life by a pædiatric urologist or a plastic surgeon.
When the hypospadias is third degree, or there are associated birth defects such as chordee or cryptorchidism, the best management can be a more complicated decision. A karyotype and endocrine evaluation should be performed to detect intersex conditions or hormone deficiencies. If the penis is small, testosterone or human chorionic gonadotropin injections may be given to enlarge it prior to surgery.
Surgical repair of severe hypospadias may require multiple procedures and mucosal grafting. Preputial skin is often used for grafting and circumcision should be avoided prior to repair. In a minority of patients with severe hypospadias surgery produces unsatisfactory results, such as scarring, curvature, or formation of urethral fistulas, diverticula, or strictures. A fistula is an unwanted opening through the skin along the course of the urethra, and can result in urinary leakage or an abnormal stream. A diverticulum is an "outpocketing" of the lining of the urethra which interferes with urinary flow and may result in post-urination leakage. A stricture is a narrowing of the urethra severe enough to obstruct flow. …
Hypospadias are among the most common birth defects of the male genitalia (second to cryptorchidism), but widely varying incidences have been reported from different countries, from as low as 1 in 4000 to as high as 1 in 125 boys.
The incidence of hypospadias around the world has been increasing in recent decades. In the United States, two surveillance studies reported that the incidence had increased from about 1 in 500 total births (1 in 250 boys) in the 1970s to 1 in 250 total births (1 in 125 boys) in the 1990s. Although a slight worldwide increase in hypospadias was reported in the 1980s, studies in different countries and regions have yielded conflicting results and some registries have reported decreases."

There is information aplenty on the 'net; but the opinion of an experienced professional is more likely to re-assure and/or assist.

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