Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This is a condition that is specific for boys. The anomaly is always present from birth, and in most cases is without any symptoms till about 2 ? 3 years. In this anomaly, the external urinary meatus is not at the tip of the penis as is normal. The meatus is on the underside of the penis and can be seen at various sites ? just below the normal site; in the shaft of the penis; at the junction of the penis and the scrotum; or even at the base of the scrotum. This abnormality should be easily noticed by the parents and a doctor must be consulted.
|Distal meatus just below normal
||Proximal meatus at perineum
WHY? This is caused by a defect in the formation of the urinary tube called the urethra. The incomplete formation of the urethra makes the urinary opening on the underside of the penis. The severity of the deformity depends on the length of the urethra formed. The lessor the length, the more proximal the opening.
WHAT HAPPENS? There are no regular symptoms or complains like pain, swelling, redness or straining to pass urine, and hence the anomaly can be easily overlooked early after birth. As the boy begins to grow, stand, walk, run, he also begins to pass urine standing up. At this time, an observant parent will notice that the child passes urine in a stream that is not directed away from the body, but downwards and on his own feet or clothes.
As this deformity causes no obvious discomfort, there is no need for early correction. The ideal age for operative correction is about 1 ½ years. By this time the tissues and the skin of the penis are more supple, mature, firm and can be properly sutured. Delay in timing of surgery can cause the boy to become genital conscious since he realizes something is wrong with his penis as compared to his elder brother or cousins. He needs to squat to pass urine and can become the target of fun by other boys of his age.
WHY SURGERY? This is very vital question in the minds of the parents of these children ? specially when the child is asymptomatic. Firstly, associated with the abnormal urethral opening, there is also a bending of the shaft of the penis called chordee. When this boy becomes an adult, the chordee will persist and increase if uncorrected. This causes difficulty in penetration for sexual intercourse. Secondly, even after penetration, due to abnormal position of the opening, the ejaculate will not be deposited in the correct place in the vagina of the woman and conception can be difficult ? leading to infertility. Lastly, for cosmetic reasons ? this deformity needs to be corrected to allow this boy to pee standing and not squatting.
Upper thin skin used to make a long tube(arrow)
The ideal age for surgery is 1 ½ years of age. A number of surgical operations have been described ? all of them have a common goal i.e use of the thin skin of the penis and the prepeuce to form the new urethral tube and join it to the already present urethra to bring the opening to the tip of the penis. This is a very delicate surgery and takes 2 ? 3 hours. It requires fine sutures and magnification for doing it perfectly. The type of operation depends on where the original opening is; the nearer the tip, less complicated is the surgery.In cases with a chordee, the choice is to do a two stage surgery with correction of chordee in the first stage and then 6 months later a second stage with reconstruction of the urethral tube and bringing it to the tip of penis. The alternative is a one stage surgery in which both correction of the chordee and reconstruction of the urethra is done in one stage. The choice of operation depends on technical considerations and the experience and training of the surgeon. A tube or catheter is kept thru the urethra in the bladder that drains urine directly into a uro bag for 7 days to allow the sutures to heal without getting wet. After 7 days, the tube is removed and the boy is asked to pass urine from the new tip opening.
Final result with the meatus at the tip of penis
Complications following this operation are possible in 20% of the boys. The most common is called Fistula. After the reconstruction ? urine must flow from the tip of the penis, but there may be an additional hole that develops from the site of the original opening from which urine escapes ? this is a fistula. The reason is simple, the urethral tube that is already present is thick spongy; the tube made by the surgeon is thin skin of the penis. The junction of the two tubes sutured together with very fine sutures is always a weak area and can tear with the force of the urine coming out from the urethra giving rise to a fistula. This is not a life threatening complication , but it needs to be corrected after a wait of 6 months for the local tissues to become supple once again. At times a small leak that occurs may gradually close on its own and no surgery is required to close it. The other complication due to healing and contraction at the tip to cause a narrowing leading to a tiny urinary stream called meatal stenosis. This needs a correction by dilatation of the meatus and the stream will improve. A similar process occurs at the junction of the original tube and the skin tube where a stricture occurs and the stream narrows ? again dilatation is required to increase the lumen size of the urethra.
The entire urethra will grow with the child as a whole and there will be no further surgery required when the child grows into an adult.
Post operative results after a few months with meatus at the tip
Last Updated: 27th January 2009