basic knowledge of male genitalia diseases for plastic surgeon

1. CCongenital genital defects
ZoReKh
C

2. • embryos of both sexes develop identically for approximately 6 weeks’ gestation, known
as the indifferent stage.
• At the 6th week, the urorectal septum begins to grow downward and inward from the
sides into the cloacal cavity, thereby separating the cloaca into the bladder and
rectum.
• differentiated stage begins at the 7th week of intrauterine life many genes are responsible
for gonadal defrintiation.

3. • The tunica albuginea fascia envelops the corporal bodies tightly but is perforated by
an intercavernosal membranous septum that allows blood flow between the corpora
cavernosa.
• Buck fascia is a strong laminar structure that tightly surrounds and binds the corpora
cavernosa together and, in the case of the corpus spongiosum, envelops these tissues
into a single-functioning entity. The urethra and its overlying corpus spongiosum are
also protected proximally by surrounding muscles and by their location within the
intercorporal groove distally.
• The penile glans itself is a vascular spongiosum containing unique sensory endings
that are erogenous and tactile. The glans epithelium is a unique uroepithelium that
contains sensory cells, particularly around the corona.

4. • Cryptorchidism - absence of one or both testes from the scrotum. This includes undescended testes.
• Hypospadias - an abnormally placed urinary meatus (opening).
• Chordee - a condition in which the head of the penis curves downward (that is, in a ventral direction) or
upward, at the junction of the head and shaft of the penis.
• Micropenis - an unusually small penis. Sometimes defined as being 2.5 times the standard deviation
smaller than the mean size.
• Aphallia - the phallus (penis or clitoris) is congenitally absent. 75 cases are known worldwide as of
2005.
• Diphallia, penile duplication (PD), Diphallic Terata, or Diphallasparatus, is a medical condition in which
a male infant is born with two penises.
• Bladder exstrophy exstrophy-epispadias complex - a spectrum of anomalies of the lower abdominal
wall, bladder, anterior bony pelvis, and external genitalia.
Most common male genitala defects

5. • Exstrophy of the bladder is an uncommon condition that occurs in approximately 1 of every 30
000 live births, of which boys predominate in 3 : 1
• The defining features of epispadias and exstrophy are an open and protruding bladder, an open
urethra, and a foreshortened epispadiac penis.
• anomalies may extend to involve the musculoskeletal structures and the gastrointestinal tract.
• Classic exstrophy –defined by bladder exstrophy, epispadias (epispadias alone occurs in 30% of
cases), diastasis recti, absence of fusion of the pubic symphysis, and deformed pubic
escutcheon.
• The pubic rami are widely separated, and the inferior pubic rami are consequently laterally
rotated. This defect produces a widened and foreshortened urethra and bladder neck. It also
produces an incompletely formed penis that remains rudimentary.
• The crural bodies are attached to the splayed pubic tubercles, producing a penis that is short,
wide, and with dorsal chordee.
• As they pass through their post-adolescent period, many of these young men will benefit from
further lengthening procedures or even complete penile reconstruction. In some patients
correction of unaesthetic scars and further release of insufficiently released corpora can help to
gain length.
Exstrophy and epispadias

6. Scar removal may help
in gain lenth of peinus
,some patient with no
umblicus which will need
reconstruction
(A)Bladder dystrophy with very small gentalia
(B)Free Radial forarm flap was done
(C)Glans of the redimantry peines was left for sensation

7. The reconstruction of a penis with
a pedicled ALT flap used as a
tube-within-a-tube technique (only
possible in thin ‘boys without a
penis’ and after defatting). No real
urethra was reconstructed here
since the patient had a urostomy.
(A) Preoperative view. (B) After flap
dissection. (c) The flap is tunneled
underneath the rectus femoris
muscle. (D) Suturing and nerve
connection (ilioinguinal nerve to
lateral femoral cutaneous nerve).

8. • The buried penis deformity is present in both the pediatric and adult populations.
• A buried penis is defined as a penis that is of normal size for age but hidden within the
peripenile fat and subcutaneous tissues.
• buried penis must be differentiated from a micropenis in this group of obyse patient.
• In adults, the problem is almost always associated with obesity and the development of pubic,
scrotal, and peripubic ptosis, Liposuction and lipectomy are part of the treatment.
• However in children the fat resection is abandoned. With pubertal development the prepubic
fat deposit often decreases in size. The focus is on the release of the penis from the fibrotic
dartos tissue Many techniques are described but the most important steps include keeping all
available skin from the start of the procedure, to resect all dartos tissue and to recover the
released corpora with the skin.
Buried penis

9. (A) Typical buried penis in
an infant. (B) Ventral
incision of the skin with
maximal preservation of skin
at the start of the
procedure. (c) After
complete resection of the
fibrotic dartos tissue the
penis is released from its
buried position and the skin
is extendable. (D) Coverage
of the released corpora with
the extended skin creating
a penis with normal length.

10. • Chordee is a condition in which the head of the peius curves downward or upward, at the junction of
the head and shaft of the penis.
• The curvature is usually most obvious during erection
• Chordee may be caused by disorder of sex development or as a complication of circumcision though
some medical professionals do not consider it to be true chordee because the corporal bodies are
normally formed.
• The curvature of a chordee can involve (1)tethering of the skin with urethra and corpora of normal
size,(2)curvature induced by fibrosis and contracture of the fascial tissue (Buck's fascia or dartos)
,(3)fibrotic urethra that tethers the penis downward
• the preferred method of surgical treatment is a z-plasty,The preferred time for surgery is between the
ages of 6 and 18 months .
Chordee

11. • Hypospadias is an abnormality of anterior urethral and penile development in which the urethral opening is
ectopically located on the ventral aspect of the penis proximal to the tip of the glans penis
• The urethral opening may be located as far down as in the scrotum or perineum it’s likely to have
associated ventral shortening and curvature (chordee) with more proximal urethral defects.
• Hypospadias is a congenital defect that is thought to occur embryologically during urethral development,
between 8 and 20 weeks' gestation.
• Hypospadias occurs in approximately 1 in every 250 male births in the US incidence doubled from 1970 to
1993. suggestions that this doubling actually reflects increased reporting of minor grades of hypospadias,
increases in severe hypospadias have also been noted.
• The more proximally ectopic the position of the urethral meatus, the more likely the urinary stream is to be
deflected downward, which may necessitate urination in a seated position.chordee can exacerbate this
abnormality. Fertility may be affected. The abnormal deflection of ejaculate may preclude effective
insemination, and significant chordee can preclude vaginal insertion of the penis or can be associated with
inherently painful erections.
• Minor cases of hypospadias, in which the meatus is located up toward the tip of the glans, may not require
surgical repair and may simply be managed with observation.
Hypospadias

13. • The goals of surgical treatment of hypospadias are as follows:
1. Widening of the meatus
2. Correction of the curvature
3. Reconstruction of the missing portion of the urethra
4. Restoration of the normal aspect of the external genitalia
• Hypospadias repair was performed in children older than 3 years because of the larger size of the phallus
and a technically easier procedure; however, genital surgery at this age (genital awareness occurs at about
age 18 months) can be associated with significant psychological morbidity, including abnormal behavior, guilt,
and gender identity confusion.
• Currently, most physicians attempt to repair hypospadias when the child is aged 4-18 months.
• A meatotomy is required if the size of the external urethral meatus is inferior to that considered normal
according to the age of the patient.
• The distal urethra missing in glanular hypospadias, usually without recurvatum, is well reconstructed with
local flaps based on the meatus (eg, Santanelli procedure, Flip Flap, MAGPI [meatal advancement and
glanuloplasty]), including preputium plasty at the same sitting.

14. Preservation of urethral plate
• Distal hypospadias
1. MAGPI (Meatal Advancement and Glanuloplasty) Duckett
2. TIP (Tubularized incised plate urethraplasty) Snodgrass
3. Mathieu
• Middle Hypospadias:
1. Onlay island flap
• Proximal hypospadias:
1. Onlay island flap
2. Buccal mucosa graft Two-stage procedure

16. TIP (Tubularized incised plate
urethraplasty)

19. • Complications:
1. Urethral-cutaneous fistula (<10%).
2. Meatal stenosis spraying of urine.
3. Urethral stricture.
4. Urethral diverticulum.
5. Hair in urethra: UTI and stone formation.
6. Dissatisfaction with penile size.

20. THANK YOU