Duplication of accessory phallic urethra (urethra triplication) in the female, signaling mesenchymal interruptions of the cloacal membrane as a cause for sagittal urethral duplications

Anatomical Variations of the External Genitalia in Posterior Cloaca: Clinical Consequences of Misdiagnosis-A Systematic Review of the Literature and the ARM-Net Consortium Experience

PURPOSE

 All types of cloacal malformations may be associated with anatomic variations of the external genitalia, including hypoplasia of the labia minora and enlarged clitoris; these variations could be even higher in posterior cloacas (PCs). If a careful physical examination is not performed, patients may be misdiagnosed with ambiguous genitalia (AG), leading to subsequent unnecessary testing, surgeries, or even wrong gender assignment. The aim was to analyze data of patients with PC within the ARM-Net registry, focusing on the description of the genitalia, gender assignment, and its consequences. Additionally, we investigated the presence of AG diagnosis in utero or at birth in patients with PC in the literature.

METHODS

 The ARM-Net registry was scanned for PC cases and data on diagnosis were collected. A systematic literature search was conducted using the PubMed, EMbase, and Web-of-Science databases. Descriptive statistics was used to report data.

RESULTS

 Nine patients with PC were identified in the ARM-Net registry. Five patients (55%) were diagnosed with AG, two (22%) were assigned as males and only two patients were correctly assigned as females and diagnosed with PC with respective variations of external genitalia. All patients diagnosed with AG had extensive blood testing including karyotype and hormonal studies. One of the patients who was diagnosed as a male, had surgery for pelvic cystic mass removal, which ultimately led to unaware salpingo-oophorectomy, hysterectomy, and vaginectomy. In the literature we identified 60 patients, 14 (23%) with AG, 1 with clitorolabial transposition and 1 with undeveloped vulva and vagina; 4 patients had normal anatomy. In 40 (67%) patients the anatomy of genitalia was not mentioned.

CONCLUSION

 Patients with PC are at high risk of being diagnosed with AG or even assigned the wrong gender at birth. In our series two patients were assigned as males, and consequently one of them underwent a highly mutilating surgery. A thorough physical examination together with a high index of suspicion and laboratory workup are mandatory to identify these variations, avoiding further investigations, unnecessary surgeries, and parental stress.

Urethral Triplication With Diverticulum Malformation: A Case Report and Literature Review

A 3-year-old boy presented to our pediatric urology with a history of urine flow under the scrotum when voiding in a squatting position but not when standing. And the ventral side of the front penis became enlarged during urination and dribbled afterward. Physical examination revealed the boy had 2 urethras opening at the tip of glans, and another accessory urethra opening at perineum. Rigid cystoscopy and voiding cystourethrography confirmed it to be a urethral triplication malformation. This condition, the combination of urethral diverticulum and urethral triplication, consisting of urethro-perineum fistula, has not been previously reported.

Urethral duplication in girls: Three cases associating an accessory epispadiac urethra and a main hypospadiac urethra

INTRODUCTION

Urethral duplication is extremely rare in girls, with less than 40 cases reported so far. Most of them present as a prepubic sinus. Literature is scare regarding aetiology, classification and management in other forms. This study presents three cases of sagittal urethral duplication in girls presenting a main hypospadiac urethra and an accessory epispadiac urethra.

PATIENTS AND METHODS

Medical records were retrospectively reviewed of three girls with urethral duplication managed over a 30-year period at a single institution. Circumstances of diagnosis, management and outcomes were analysed.

RESULTS

The oldest case presented as a neonatal retrovesical mass with an accessory clitoral stream, whereas the two more recent cases presented with antenatal hydrocolpos and bilateral ureterohydronephrosis. Cases 1 and 3 had an incomplete duplication, while Case 2 had a complete form. In Case 3, the duplication was associated with a urogenital sinus and an anteriorly placed anus. Management involved resection of the epispadiac accessory urethra to achieve continence, with dilatation and/or mobilisation of the hypospadiac one. All girls are now aged >5 years old and are continent, and one is old enough to have normal menstruation. Renal function is normal in all. The summary table presents the schematic anatomical description as shown on micturating cystourethrogram and endoscopy, as well as the management for each patient.

DISCUSSION

Step-by-step management is necessary in urethral duplication. The neonatal emergency is to release the urinary tract compression by evacuating urinary retention or hydrocolpos. Later in infancy, decision has to be taken regarding the urethras. If the resection of the epispadiac accessory urethra seems acceptable to achieve continence, the attitude towards the hypospadiac channel is more controversial and should be individualised. Embryologic and aetiopathogenic pathways are still missing to uniformly characterise the malformation.

CONCLUSION

Paediatric urologists should remember that there is a wide spectrum of urethral duplication in girls, and that various presentations exist beside the more classic prepubic sinus.

Treatment and medical follow-up of a boy with urethral triplication

A 17-month-old boy presented with a mild abnormal appearance of the foreskin and was enrolled into our department. The boy had one normal urethra, one accessory urethra originating from the bladder neck and opening into dorsal pennies, and one accessory urethra opening into glans penis but not communicating with the other two urethras. At surgery, the midshaft epispadias was excised and two meatal openings remained untouched. Two weeks after operation, a repeat voiding cystourethrogram showed no signs of abnormality. During the past 4-year follow-up, the patient reported good urethral voiding, with no complications such as urodynia or urinary tract infection.

Urethral triplication and urethrovasal reflux in 5-day-old male infant

To present the case of a 5-day-old male infant referred to our clinic with complaints of huge swollen testes, recurrent urinary tract infection, and diarrhea. The imaging studies and surgical assessments revealed a urethrorectal fistula and 2 nonfunctional urethras. Cutaneous vesicostomy was performed urgently to avoid additional renal infection. At the age of 6 months, the anterior anal insertion was repaired by perineal access. Eventually, urethral reconstruction was performed when the boy was 3 years old. The patient was asymptomatic at the last follow-up examination without additional urinary tract infections. The combination of urethrovasal reflux and congenital urethral triplication, consisting of urethrorectal fistula, has not been previously reported.