Lecture name: Urethra and peniile diseases. By Dr.Salam almosawi (F.I.B.M.S)

Transcription

1 Lecture name: Urethra and peniile diseases. By Dr.Salam almosawi (F.I.B.M.S) The male urethera: Anatomy: The male urethra is about 20 cm. in length and classify into 2 parts by the urogenital diaphragm these are : A)Posterior urethera : extend from the internal uretheral meatus to the inferior layer of the urogenital diaphragm and farther classified into : 1.Prostatic urethera: about 4 cm. in length and surround by the tissue of the prostate and has transitional urothelium. 2.Membranous urethera: about 1-2 cm. in length,surrounded by the external urethral sphincter and also had transitional urothelium.

2 B)Anterior urethra: extend from the inferior layer of the urogenital diaphragm to the external uretheral meatus.it is farther classified into: 1.Bulbous urethra: surrounded by the bulbs of the penis and has transitional urothelium. 2.Penile urethra: surrounded by the erectile corporal tissues and also had transitional urothelium. 3.Glanular urethra: surrounded by the glans penis and had squamous epithelium. FEMALE URETHRA The adult female urethra is about 4 cm long and 8 mm in diameter The epithelial lining of the female urethra is squamous in its distal portion and pseudostratified or transitional in the remainder. Blood supply of the male urethra: The prostatic and membranous urethra supplied by branches from : Inf. vesicle A., internal pudendal A. and middle rectal A. While the penis and anterior urethra are supplied by the internal pudendal arteries. Each artery divides into a deep artery of the penis (which supplies the corpora cavernosa), a dorsal artery of the penis, and the bulbourethral artery. These branches supply the corpus spongiosum, the glans penis, and the urethra. PENIS Gross Appearance The penis is composed of 2 corpora cavernosa and the corpus spongiosum, which contains the urethra, whose diameter is 8 9 mm. These corpora are capped distally by theglans. Each corpus is enclosed in a fascial sheath (tunica albuginea), and all are surrounded by a thick fibrous envelope known as Buck s fascia. A covering of skin, devoid of fat, is loosely applied about these bodies. The prepuce forms a hood over the glans. Beneath the skin of the penis (and scrotum) and extending from the base of the glans to the urogenital diaphragm is Colles fascia, which is continuous with Scarpa s fascia of the lower abdominal wall. Congenital anomalies of the urethra: URETHRAL STRICTURE Congenital urethral stricture is uncommon in infant boys. The fossa navicularis and membranous urethra are the 2 most common sites. POSTERIOR URETHRAL VALVES

3 Posterior urethral valves, the most common obstructive urethral lesions in infants and newborns, occur only in males and are found at the distal prostatic urethra. The valves are mucosal folds that look like thin membranes; they may cause varying degrees of obstruction when the child attempts to void (Figure 40 2). Clinical Findings A. SYMPTOMS AND SIGNS Children with posterior urethral valves may present with mild, moderate, or severe symptoms of obstruction. They often have a poor, intermittent, dribbling urinary stream. Urinary infection and sepsis occur frequently. Severe obstruction may cause hydronephrosis which is apparent as a palpable abdominal mass. A palpable midline mass in the lower abdomen is typical of a distended bladder. In many patients, failure to thrive may be the only significant symptom, and examination may reveal nothing more than evidence of chronic illness. X-RAY FINDINGS Voiding cystourethrography is the best radiographic study available to establish the diagnosis of posterior urethral valve. consists of destruction of the valves, but the approach depends on the degree of obstruction and the general health of the child. ANTERIOR URETHRAL VALVES A rare congenital anomaly it is a urethral diverticulum rather than true valve and mostly occur in females. HYPOSPADIAS In hypospadias, the external urethral meatus opens on the ventral side of the penis proximal to the tip of the glans penis and usually associated with ventral penile curvature (chordee) and ventrally deficient skin of the prepuce(hooded prepuce). Hypospadias results when fusion of the urethral folds is incomplete. Hypospadias occurs in 1 in every 300 male children. Estrogens and progestins given during pregnancy are known to increase the incidence. Although a familial pattern of hypospadias has been recognized, DIAGNOSIS Hypospadias is diagnosed by physical examination,first suspected by the ventrally deficient prepuce and proved by ventrally site of the external urethral meatus. Hypospadias with undescended testes may indicate a disorder of sexual differentiation, indicating need for Karyotyping. For psychological reasons, hypospadias should be repaired before the patient reaches school age; now because of the advances in anesthesia, correction of hypospadias best done with in the first year with better success rate.

4 EPISPADIAS The incidence of complete epispadias is approximately 1 in 120,000 males and 1 in 450,000 females. The external urethral meatus is displaced dorsally. Urethral injuries: Urethral injuries are uncommon and occur most often in men, usually associated with pelvic fractures or straddle type fall. INJURIES TO THE POSTERIOR URETHRA: When pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the prostatic apex at the prostatomembranous junction. Patients usually complain of lower abdominal pain and inability to urinate. Blood at the urethral meatus is the single most important sign of urethral injury.

5 The presence of blood at the external urethral meatus indicates that immediate urethrography is necessary to establish the diagnosis. X-ray finding: Fractures of the bony pelvis are usually present. A urethrogram (using ml of water-soluble contrast material) shows the site of extravasation at the prostatomembranous urethra. A. EMERGENCY MEASURES Shock and hemorrhage should be treated. B. SURGICAL MEASURES Urethral catheterization should be avoided. 1. Immediate management Initial management should consist of suprapubic cystostomy to provide urinary drainage. 2. Delayed urethral reconstruction Reconstruction of the urethra after prostatic disruption can be undertaken within 3 months 3. Immediate urethral realignment Some surgeons prefer to realign the urethra immediately. The incidence of stricture, impotence, and incontinence appears to be higher than with immediate cystostomy and delayed reconstruction. However, several authors have reported success with immediate urethral realignment. INJURIES TO THE ANTERIOR URETHRA: The anterior urethra is the portion distal to the urogenital diaphragm. Straddle injury may cause laceration or contusion of the urethra. Self-instrumentation or iatrogenic instrumentation may cause partial disruption. Clinical Findings A. SYMPTOMS There is usually a history of a fall, and in some cases a history of instrumentation. There is local pain into the perineum and sometimes massive perineal hematoma. If voiding has occurred and extravasation is noted, sudden swelling in the area will be present. Bleeding from the urethra is usually present. Rectal examination reveals a normal prostate. The patient usually has a desire to void, but voiding should not be allowed until assessment of the urethra is complete. X-RAY FINDINGS A urethrogram, with instillation of ml of water-soluble contrast material, demonstrates extravasation and the location of injury. 1. Urethral contusion The patient with urethral contusion shows no evidence of extravasation, and the urethra remains intact.

6 After urethrography, the patient is allowed to void; and if the voiding occurs normally, without pain or bleeding, no additional treatment is necessary. If bleeding persists, urethral catheter drainage can be done. 2. Urethral lacerations Percutaneous cystostomy or formal open cystostomy can be used in such injuries. URETHRAL STRICTURE Acquired urethral stricture is common in men but rare in women. Most acquired strictures are due to infection or trauma. Urethral strictures are fibrotic narrowings composed of dense collagen and fibroblasts. Fibrosis usually extends into the surrounding corpus spongiosum, causing spongiofibrosis. These narrowings restrict urine flow and cause dilation of the proximal urethra and prostatic ducts Clinical Findings A. SYMPTOMS AND SIGNS A decrease in urinary stream is the most common complaint. Spraying or double stream is often noted Induration in the area of the stricture may be palpable. X-RAY FINDINGS A urethrogram or voiding cystourethrogram (or both) will demonstrate the location and extent of the stricture. A. SPECIFIC MEASURES 1. Dilation Dilation of urethral strictures is not usually curative, 2. Urethrotomy under endoscopic direct vision Lysis of urethral strictures can be accomplished using a sharp knife attached to an endoscope. 3. Surgical reconstruction If urethrotomy under direct vision fails, open surgical repair should be performed. Urethritis: It is acute inflammation of the urethra. Most cases due to infection (STD) or descending infection, but it may occur with urethral trauma for any cause.

7 A- Acute urethritis:- frequently occur as a result of infection with N.gonorrhea (gonococcal urethritis). Or infection with other pathogens as T.vaginalis or Chlamedia trachomatis.( Non gonococcal urethritis). Clinical features:- Symptoms:- irretative voiding symptoms like those of cystitis as dysuria, frequency and necturia. Signs:- urethral discharge usually present witch may be scanty or profuse,whitish or yellowish. Smears and culture of the discharge or urine establish the diagnosis. :- antimicrobial therapy with i.m. 3 rd generation cephalosporins and Azithromycine or doxycyclines. B- Chronic urethritis:- it is one of the most common urological problems in females. Clinical features: Symptoms:- resemble those of cystitis. discomfort in the urethra commonly felt. Signs:- the urethral mucosa is red and often stenotic. there is no urethral discharge. Diagnosis :- from the clinical picture and can differentiated from cystitis by bacteriological studies ( ureaplasma urealyticum) and by urethrocystoscopy and some times culture of specimen from urethral washing may reveal the microorganism. :- oral azithromycine or doxycycline is effective. Local application of antiseptic to the introitus may be helpful. PHIMOSIS Phimosis is a condition in which the contracted foreskin cannot be retracted over the glans. Chronic infection from poor local hygiene is its most common cause. Most cases occur in uncircumcised males. Edema, erythema, and tenderness of the prepuce and the presence of purulent discharge usually cause the patient to seek medical attention. The initial infection should be treated with broad-spectrumantimicrobial drugs. The dorsal foreskin can be slit if improved drainage is necessary. Circumcision, if indicated, should be done after the infection is controlled. PARAPHIMOSIS Paraphimosis is the condition in which the foreskin, once retracted over the glans, cannot be replaced in its normal position. This is due to chronic inflammation under the redundant foreskin.

8 The skin ring causes venous congestion leading to edema and enlargement of the glans, which make the condition worse. As the condition progresses, arterial occlusion and necrosis of the glans may occur. Paraphimosis usually can be treated by firmly squeezing the glans for 5 minutes to reduce the tissue edema and decrease the size of the glans. The skin can then be drawn forward over the glans. Occasionally, the constricting ring requires incision under local anesthesia. Antibiotics should be administered and circumcision should be done after inflammation has subsided. PEYRONIE S DISEASE Peyronie s disease (plastic induration of the penis) Patients present with complaints of painful erection, curvature of the penis, and poor erection distal to the involved area. Examination of the penile shaft reveals a palpable dense, fibrous plaque of varying size involving the tunica albugina. Spontaneous remission occurs in about 50% of cases. Initially, observation and emotional support are advised. If remission does not occur vitamin E tablets may be tried for several months. However, these medications have limited success. In recent years, a number of operative procedures have been used in refractory cases. Additional methods include radiation therapy and injection of steroids. TUMORS OF THE PENIS Epidemiology & Risk Factors The one etiologic factor most commonly associated with penile carcinoma is poor hygiene. The disease is virtually unheard of in males circumcised near birth. A. PRECANCEROUS DERMATOLOGIC LESIONS Leukoplakia is a rare condition that most commonly occurs in diabetic patients This lesion may precede or occur simultaneously with penile carcinoma. Balanitis xerotica obliterans is a white patch originating on the prepuce or glans and usually involving the meatus. Giant condylomata acuminata are cauliflower-like lesions arising from the prepuce or glans. The cause is believed to be viral (human papillomavirus). CARCINOMA IN SITU (BOWEN DISEASE,ERYTHROPLASIA OF QUEYRAT) Bowen disease is a squamous cell carcinoma in situ typically involving the penile shaft. The lesion appears as a red plaque with encrustations. Erythroplasia of Queyrat is a velvety, red lesion with ulcerations that usually involve the glans. INVASIVE CARCINOMA OF THE PENIS Squamous cell carcinoma composes most penile cancers. It most commonly originates on the glans, with the next most common sites, in order, being the prepuce and shaft.

9 The appearance may be papillary or ulcerative. Clinical Findings A. SYMPTOMS The most common complaint at presentation is the lesion itself. It may appear as an area of induration or erythema an ulceration, a small nodule, or an exophytic growth. B. SIGNS Lesions are typically confined to the penis at presentation. Careful palpation of the inguinal area is mandatory because more than 50% of patients present with enlarged inguinal nodes. Tumor Staging The TNM classification of the American Joint Committee is commonly used TNM Classification of Tumors of the Penis. T Primary tumor Tis: Carcinoma in situ Ta: Noninvasive verrucous carcinoma T1: Invades sub epithelial connective tissue T2: Invades corpus spongiosum or cavernosum T3: Invades urethra or prostate T4: Invades other adjacent structures N Regional lymph node N0: No regional lymph node metastasis N1: Metastasis in single superficial inguinal node N2: Metastasis in multiple or bilateral superficial inguinal nodes N3: Metastasis in deep inguinal or pelvic nodes M Distant metastasis M0: No distant metastasis M1: Distant metastasis present. : Biopsy of the primary lesion is mandatory to establish the diagnosis of malignancy. Carcinoma insitu may be treated conservatively in reliable patients. Fluorouracil cream application or neodymium:yag laser treatment is effective for CIS and is preserving of the penis. The goal of treatment in invasive penile carcinoma is complete excision with adequate margins. Patients who have inoperable disease and bulky inguinal metastases are treated with chemotherapy.