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CASE REPORT
Year : 2001  |  Volume : 17  |  Issue : 2  |  Page : 183-184
 

Concealed epispadias


Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India

Correspondence Address:
Yogesh Kumar Sarin
Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi- 110002
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Epispadias; Prepuce


How to cite this article:
Sarin YK, Sinha A. Concealed epispadias. Indian J Urol 2001;17:183-4

How to cite this URL:
Sarin YK, Sinha A. Concealed epispadias. Indian J Urol [serial online] 2001 [cited 2019 Jul 16];17:183-4. Available from: http://www.indianjurol.com/text.asp?2001/17/2/183/20274



   Introduction Top


Epispadias is a rare urogenital malformation. Usually the prepuce is absent on the dorsal aspect of the penis. The pres­ence of a complete prepuce associated with epispadias has been described in very few patients. [1],[2],[3],[4],[5],[6] The entity is comparable to megameatus variant of distal hypospadias with a complete pre­puce. In these cases, the accurate diagnosis is difficult and may be overlooked. We report a child with epispadias associated with complete prepuce. Besides reporting a rarity, the purpose of this report is to discuss briefly the clinical signs, embryo­logical basis, and the management of this entity.


   Case Report Top


A 3-year-old boy was brought for the management of buried micro-penis. Examination revealed a short and broad penis, and appeared concealed within the prepuce. On retracing the prepuce, a balanic epispadias was revealed [Figure - 1]. The corpora cavernosa were split on either side of the urethral Groove. The raphe penis was absent on the glans. There was a slight dorsal chordee. The urinary stream was directed dorsally. The patient was continent.

An inverted U-shaped incision was made around the epispadiac urethra enclosing the abnormal urethral meatus. Byar's urethroplasty was done and the two corpora were approximated over the reconstructed urethra. No part of the prepuce was used for reconstruction: no circumcision, urinary diversion, chordee correction or de-loving of the penis was done. The child had an uneventful postopera­tive period. Review three months later revealed a good urinary stream without any fistula or any other complica­tion; the prepuce was easily retractable [Figure - 2].


   Comments Top


It is exceedingly rare for epispadias to be associated with a complete prepuce covering the entire glans. [1],[2],[3],[4],[5],[6] There are some clinical findings that may raise the suspicion of this very unusual type of epispadias. The broad, spade­like glans, and the dorsally directed prepucial opening and urinary stream are signs previously described. [1],[2] By pal­pation of the glans, one can feel a split of the corpora cavernosa and a depression between them. [4],[5],[6] The raphe penis is absent on the entire glans. It stops near the base of the glans and may design a transverse (horizontal) line. [4]

Developmentally, during the third month of intrauterine life, the coronal sulcus appears, marking the glans penis at the tip of the phallus. Then a cuff of ectodermal tissue appears at the margin of the coronal sulcus and extends for­wards to cover the glans. This tissue forms the prepuce. In the usual epispadias, where the urethral defect extend proxi­mal to the coronal sulcus, the circumferential development of prepucial skin cannot take place and the prepuce will be absent dorsally, where the urethral plate is present. Raghavaiah stated that if the urethral defect in epispadias is confined to the -tans and does not extend to the coronal sulcus, the development of prepucial skin could proceed normally, covering the entire glans. [1] However, epispadias extending proximal to coronal sulcus having complete pre­puce, have been also reported. [5],[6] Merbalo et al felt that the development of prepuce in this type of epispadias is not entirely normal; the dorsally directed prepucial opening, the absence of frenulum line on the glans, and the horizon­tal ending of the raphe penis near the glans are the result of the abnormal developement of the prepuce. [3]

Some authors recommend a simple circumcision in such a case. [1] We feel that an intact prepuce provides a better psychofunctional status to a subject in our society where circumcision is not routinely performed. Based on the personal preference and experience, any of the surgical procedures described for the megameatus variant of distal hypospadias, such as GAP, Pyramidal procedure or King procedure may be used. [7]

 
   References Top

1.Raghavaiah NV. Epispadias associated with phimosis. J Urol 1976: 116:671-672.  Back to cited text no. 1    
2.Bhattacharya V. Sinha JK, Tripathi FM. A rare case of epispadias with normal prepuce. Plast Reconstr Surg 1982; 70: 372-374.  Back to cited text no. 2    
3.Willams DJ, Johnston JH. Pediatric Urology. Butterworth Scientific. London. 1982: 306.  Back to cited text no. 3    
4.Merlob P, Mor N, Reisner SH. Epispadias with complete prepuce and phimosis in a neonate. Clin Pediatr 1987; 26: 43-45.  Back to cited text no. 4    
5.Krishna A. Iyer PU. Epispadias with complete non-retractile prepuce. Indian Pediatr 1989; 26: 1055-1056.  Back to cited text no. 5    
6.McCahill PD, Leonard MP, Jeffs RD. Epispadias with phimosis: an unusual variant of the concealed penis. Urology 1955; 45: 158­-160.  Back to cited text no. 6    
7.Belman AB. Hypospadias and other urethral abnormalities. In: Kelalis PP, King LR, Belman AB (eds.). Clinical Pediatric Urol­ogy, 3rd ed. Saunders, Philadelphia, 1992: 1: 619-663.  Back to cited text no. 7    


    Figures

  [Figure - 1], [Figure - 2]



 

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