Micropenis

• Penile length smaller than 2.5

standard deviations (SD)
below the mean
• May occur as an independent
abnormality by itself or as a
clinical finding of many
syndromes
• Caused by a hormonal
abnormality that occurs after
Characteristic: small penis and a median
the 12th week of gestation raphe, foreskin, as well as normal
localization of the urethral meatus opening
• May have a retracted or flaccid
appearance
• The scrotum is present and fused
normally, but it may be underdeveloped
(hypoplastic)
• Testicular volume is also expected to be
below normal measurements
• There often is no evidence of
feminization
DDx
• Buried penis
• Webbed penis
• Penile agenesis
• Imaging Tests
• Pelvic ultrasound : visualize internal genital organs in suspicious cases
• MRI: investigate structural midline defects,
• such as pituitary stalk dysplasia syndrome, central diabetes insipidus characterized by
absence of the pituitary bright spot in the posterior neurohypophysis, and pituitary
dysplasia
• Genetic Tests
• chromosomal analysis or Y-fluorescence in order to determine the sex
Treatment
• Testosterone Treatment
• Topical 5-ɑDihydrotestosterone (DHT) Gel
• LH-FSH Applications
• Surgical Treatment
 Buried Penis
• congenital anomaly •
• the penis is normal in
size but appears to be
small (i.e., the
external genitalia
appear small)
Classification:
• Type 1: congenital
• Type 2: because of
scarring from a
previous surgery
• Type 3: complex
cases involving
excessive obesity

The penis usually has a normal anatomy, but it is

tethered and shortened by abnormal fibrous bands
connected to the Dartos
Diagnosis
• Through inspection
• Size of the phallus is normal
• DDx:
• Micropenis
• Hypospadias
• Obesity
• Congenital adrenal hyperplasia in females and other chromosomal
abnomrlalitis
Symptoms
• Older children
• Difficulty maintaining hygiene  repeated balanitis and UTI
• Difficulty holding the penis during voiding
• Embarrassment when naked with peers
• Some: ballooning of the foreskin with voiding may be frequently wet if
voiding into the preputial sac (megaprepuce) occurs
• Adults:
• Painful erection
• Sexual embarrassment
• Difficulty with vaginal penetration
Treatment
• degloving the penis, dissecting the skin and subcutaneous tissue from
the corpora,
• releasing any band of dysplastic tissues tethering the penis,
• reconstructing the penile skin
• Multiple Z-plasties
• release of tethering bands from the Dartos through an S-shaped skin
incision on the dorsum of the penis
 Hypospadias
• abortive
development of the
urethral spongiosum
and ventral prepuce
along with an arrest in
the normal
embryological
correction of penile
curvature
Treatment
• Surgical repair of the
anatomical defect
• Object of surgical
treatment:
• Reconstruct a straight
penis
• To allow a forward-
directed stream
• Normal coitus
Anterior hypospadias
• Meatal advancement
glansplasty (MAGPI)
• The glans approximation
procedure (GAP)
• The Mathieu or flip-flap
• The Snodgrass
modification or
tubularized incised plate
urethroplasty
Posterior hypospadias
• The urethral plate
• Onlay island flap
• Two-stage hypospadias repair
• Bracka buccal 2-stage repair
 Epispadias
• Failure of the urethral plate to
tubularize on the dorsum with
the defect ranging from a
glandular to a penopubic
location
• Male and female
• Male: additionally
demonstrate a dorsal chordee
with varying degrees
• Female: exhibit a bifid clitoris
Diagnosis and initial management
• Boys: diagnosed at birth
• Appearance of a split dorsal urethra with dorsal chordee and a venral foreskin
hood
• Phallus: short
• Penopubic forms: diastasis of the pubic bone
• Female: Outer genitalia displays
• incomplete development of labia minora
• A nontubularized urethra
• Bifid clitoris
• A flat appearing mons pubis
 Surgical reconstruction
• Goals
• Female:
• Attaining continence
• Reconstruction of the outer genitalia
• Bladder neck surgery
• Male:
• Bladder neck surgery is not always
necessary
• Phallic reconstruction
• Penopubic: penile lengthening
• Tubularization of the urethral plate with
placement of the meatus into the glans
• Techniques: Cantwell-Ransley
technique, Mitchell-Bagli technique
Phimosis
• inability to withdraw the
narrowed penile foreskin or
prepuce behind the glans penis
• Poor hygiene and recurrent
balanitis (infection of glans
penis), posthitis (inflammation
of foreskin), or both
 difficulty in retraction of
foreskin and consequent true
phimosis.
• Ballooning during urination
• Gentle traction: the prepuce puckers
and the overlying tissue are pink and
healthy
• Pathologic phimosis:
• Pain
• Skin irritation
• Local infections
• Bleeding
• Dysuria
• Hematuria
• Frequent episodes of urinary tract
infections
• Preputial pain
• Painful erection
• Weak urinary stream
Treatment
• Topical Steroids
• Betamethasone 0.05% applied twice a day over a 4-week period
• Dilation and Stretching
• Eutectic mixture of local anaesthetics (EMLA) used prior to attempts at
release of the preputial adhesions
• Surgical
• Conservative surgical alternatives: Preputioplasty, Y-plasties, V-plasties
• Conventional male circumcision
Paraphimosis