UROLOGY

PENIS & URETHRA

Dr. U. VENKATESH MCh (Uro)., DNB(Uro).,
Consultant Urologist and Transplant Surgeon,
Kauvery Multispeciality Hospitals,
Hosur
1. Which of the following is INCORRECT concerning the anatomy of the penis?

A. The paired corpora spongiosum functions as one compartment due to vascular

interconnections.

B. Priapism is defined as a persistent erection of more than 4 hours' duration.

C. The corpora cavernosum are enclosed by the tunica albuginea.

D. The corpora cavernosum and spongiosum are surrounded by Bucks fascia.

1. Answer: A
The corpora cavernosum are the paired, cylinder-like structures that are the main erectile
bodies of the penis. The corpora cavernosum consist of a tough outer layer called the tunica
albuginea and spongy, sinusoidal tissue inside that fills with blood to result in erection. The two
corpora cavernosum have numerous vascular interconnections, so they function as one
compartment. Surrounding all three bodies of the penis are the outer dartos fascia and the inner
Buck fascia.
2. All of the following are true concerning priapism EXCEPT

A. Priapism is defined as a persistent erection for >4 hours unrelated to sexual stimulation.

B. Etiologic factors include sickle cell disease, malignancy, total parenteral nutrition, penile shaft
fractures.

C. Low flow priapism can be confirmed with a penile blood gas determination.

D. Treatment may require injection of phenylephrine.

2. Answer: B
Priapism is a persistent erection for more than 4 hours unrelated to sexual stimulation.
Risk factors include sickle cell disease or trait, malignancy, medications, cocaine abuse, certain
antidepressants, and total parenteral nutrition.
Low-flow priapism can be confirmed with a penile blood gas of the cavernosal bodies
demonstrating hypoxic, acidotic blood.
Injection of phenylephrine (up to 200 mg in 20 mL normal saline) into the corporal
bodies may be required. (See Schwartz 11th ed. , p. 1 770.)
Anatomy
3. Which of the following statements are true?

A The verumontanum is situated in the membranous urethra.

B The membranous urethra is the primary location of continence.

C The anterior urethra is composed of a bulbar and a penile part.

D The posterior urethra comprises of preprostatic, prostatic and membranous segments.

E The major portion of the female urethra is lined by stratified squamous epithelium.
3. B, C, D, E
The membranous urethra, about 1.5 cm long, lies distal to the verumontanum and is the primary site of
urinary continence. The urethral sphincter mechanism consists of the intrinsic striated and smooth muscle of the
urethra and the pubourethralis component of the levator ani, which surrounds the membranous urethra in the male
and the middle and lower thirds of the female urethra. In the female, it blends proximally with the smooth muscle of
the bladder neck and distally with the lower urethra and vagina.
The anterior urethra is subdivided into a proximal bulbar part that is surrounded by the bulbospongiosus and
situated within the perineum and a distal penile part, the tip of which is the navicular fossa. The posterior urethra is
constituted by the preprostatic, prostatic and membranous segments.
The female urethra, about 4 cm long, is lined proximally by transitional epithelium whereas the major portion
is lined by stratified squamous epithelium distally. In pregnancy, the urethra is considerably elongated.
The verumontanum (colliculus seminalis) is an important endoscopic landmark situated in the prostatic
urethra that is 3 to 4 cm long; this is much elongated in benign prostatic hypertrophy when there is a considerable
intravesical projection of the prostate. The verumontanum is a midline-rounded eminence that marks the proximal
extent of the external urethral sphincter and is a very important landmark for the urologist performing transurethral
resection of the prostate; all resection must be proximal to this vital landmark.
Congenital abnormalities
4. Which of the following statements is false?

A Posterior urethral valves causing obstruction can be diagnosed antenatally.

B The incidence of hypospadias is 1 in 200–300.

C Hypospadias is the most common congenital urethral anomaly.

D Glandular hypospadias should be surgically treated early in life.

E Circumcision must be avoided in boys with hypospadias.

4. D
Glandular hypospadias does not need surgical treatment unless the meatus is stenosed,
in which case a meatotomy is performed. Posterior urethral valves can be diagnosed at antenatal US
when proximal urinary tract dilatation will be seen. Treatment is endoscopic valve destruction and
treatment of any concomitant infection or renal impairment.
The incidence of hypospadias is 1 in 200–300 live male births and is the most common
congenital abnormality of the urethra. Once diagnosed the baby must be referred to a paediatric
urologist. According to the position of the meatus, the condition is classified in order of severity as
glandular, coronal, penile and perineal. Surgery is undertaken before the age of 1 year. Circumcision
should be avoided in these boys, as the prepuce would be invaluable in the repair of the deformity.
5. In bulbous urethral rupture, which of the following statements are true?

A Urethral rupture is caused by direct blow to perineum.

B Acute retention occurs.

C There is perineal haematoma with blood at the urethral meatus.

D In a full bladder, suprapubic catheterisation is carried out.

E Urethral catheterisation might be attempted as an alternative.

5. A, B, C, D
A fall astride a projecting object, such as might occur in scaffolders, gymnasium accidents
caused by a fall across a beam, or cycling accidents, are the usual causes of direct blow to the perineum.
Recently skateboarding injuries have become a recognised cause of rupture of the bulbar urethra. (Figure
78.2). The clinical triad is acute urinary retention, blood at the external meatus and perineal haematoma.
In delayed cases, urinary extravasation occurs. The anatomical attachments of the Colles’ fascia to the
triangular ligament and Scarpa’s fascia just below the inguinal ligament cause the extravasated urine to
collect in the scrotum and penis and beneath the deep layer of the superficial fascia of the abdominal
wall.
Diagnosis is confirmed by retrograde cystourethrogram. A suprapubic cystostomy is carried out
to divert the urine and allow the damaged urethra to heal. Significant urinary extravasation is drained. The
patient is placed on an antibiotic and referred to the urologist for definitive treatment. This would be
delayed urethroplasty in complete rupture. In partial rupture the patient will require treatment for a
stricture, which would be internal visual urethrotomy or dilatation. Urethral catheterisation, rarely
advocated, is best avoided for fear of converting a partial tear into a complete tear.
6. In rupture of the membranous urethra,the following statements are true except:

A It is almost always associated with a pelvic fracture.

B In fractured pelvis 5% will have associated urethral injury.

C It is usually a part of multiple trauma.

D The prostate might be high-riding and out of reach on rectal examination.

E A urethral catheter is inserted as a part of initial resuscitation.

6. E
In a fractured pelvis as seen on a plain x-ray, a urethral catheter should not be passed as
more damage might be created by converting a partial rupture into a complete one; in the majority it is
a complete rupture to start with. When a patient has not passed urine and there is blood at the
meatus, ruptured urethra should be suspected unless otherwise proved. The diagnosis is confirmed by
an ascending urethrogram. A suprapubic catheter is inserted. As the membranous urethra passes
through the bony pelvis, a fracture more often results in complete tear with an interposed
haematoma. It is almost always a part of multiple trauma, the most common cause being a road-traffic
accident.
Rectal examination will reveal a high-riding prostate, which would not be felt. Treatment
is suprapubic cystostomy, the procedure being straightforward in a distended bladder; if a distended
bladder cannot be felt, ultrasound guidance will be required. If there is coincidental extraperitoneal
rupture of the bladder, emergency surgical repair is carried out along with suprapubic catheter
drainage and drainage of the retropubic space. Delayed urethroplasty is carried out by the urologist 3
to 6 months later.
Urethral stricture
7. The following statements are true except:

A Urinary flow trace will show a prolonged flow with a plateau-shaped curve.

B In acute retention suprapubic catheterisation is required.

C Causes are inflammatory, traumatic and iatrogenic.

D Traumatic strictures are best treated by urethroplasty.

E The ideal treatment in the majority is urethral dilatation.

7. E
In the majority the ideal treatment is not urethral dilatation, a mode of treatment reserved for the
elderly man with a short stricture that needs infrequent dilatation. It is also used for a bladder neck stricture
following radical prostatectomy.
The usual sufferer is a young man with features of BOO with prolonged micturition and post-
micturition dribbling. Urinary flow rate shows a decrease in the maximum and average rate of <10
mL/second, with the trace showing a prolonged flow with a typical plateau-shaped curve. Rarely the patient
might present with acute retention when attempts at urethral catheterisation will result in a false passage;
hence suprapubic catheterisation should be done.
Causes of urethral strictures are inflammatory, such as secondary to urethritis, traumatic as after
external trauma as in fractured pelvis, or blunt perineal trauma and iatrogenic secondary to TURP or radical
prostatectomy. When the cause is due to external trauma, urethroplasty should be the treatment of choice.
Female urethra
8. Which of the following statements are true?

A The bladder neck is the most important entity for urinary continence.

B Urethral prolapse occurs as a result of childbirth.

C Fowler’s syndrome is best treated by urethral dilatation.

D Urethral caruncle is premalignant.

E Urethral diverticulum is more common in women than men.

8. B, E
Urethral prolapse, also called urethrocele, often occurs with cystoceles. The condition
occurs in later life and is partly due to trauma at childbirth. Weakening of the tissue that hold the
urethra in place cause it to move, producing pressure on the vagina and resulting in prolapse
of the anterior vaginal wall.
Urethral diverticulum is much more common in women. It occurs due to rupture of a
distended urethral gland or urethral injury during labour. It causes local pain and repeated cystitis.
Diagnosis is by MRI or transvaginal US. Excision is the treatment that should be carried out with great
caution, as it might damage the urethral sphincter.
Bladder neck has hardly any role in maintaining urinary continence, which is maintained
by the external urethral sphincter, which consists of striated muscle that envelops the whole length
of the female urethra.
Fowler’s syndrome causes urinary retention. It is caused by abnormal myotonic discharge
in the striated urethral sphincter. Treatment is by intermittent self-catheterisation, as urethral
dilatation is ineffective. Urethral caruncle is a pedunculated granuloma and is not premalignant.
 CLINICAL SCENARIOS
MATCH THE DIAGNOSES WITH THE SCENARIOS THAT FOLLOW:

9. A 68-year-old man complains of bloody, foul-smelling discharge from his penis. He has a hard
ulcerated lesion under his prepuce (Figure 78.1). He also complains of lumps in his groin.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
3. Carcinoma of penis
10. A 45-year-old man complains of progressive deformity of his penis, which is very pronounced during
erection; this has been going on for the past 2 years. On examination, indurated plaques can be
palpated around the penile shaft. On questioning he has thickening of his palmar fascia on both hands.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
6. Peyronie’s disease
11. A 60-year-old man who is under treatment for leukaemia recently started developing penile
erection without any reason. This is prolonged and painful and is now distressing him.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
5. Persistent priapism
12. A 22-year-old man complains of itching around his glans penis and prepuce. Recently, he has developed
purulent discharge from the subpreputial area. His glans and foreskin look red and inflamed. He is a type I
diabetic on insulin.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
2. Balanoposthitis
13. A 32-year-old man was involved in a road-traffic accident in which he sustained polytrauma, chief
among which was fracture of pelvis with fractured femoral shaft. After stabilisation according to the
ATLS protocol, it became apparent that he has a distended bladder and unable to pass urine.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
8. Rupture of membranous urethra
14. A 24-year-old man while performing on a Pommel Horse in a gymnastics competition, slipped
and fell astride on the Pommel Horse. He complains of severe perineal pain in the penoscrotal
junction where there is a haematoma. He has blood in his external urinary meatus.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
7. Rupture of bulbous urethra
15. A 52-year-old man complains of thickening of his foreskin over a period of 2 years. During this period he
has had difficulty in retracting his foreskin, as a result of which he has been having difficulty in maintaining
good hygiene. He finds that his urinary stream tends to spray around.

Diagnoses
1 Balanitis xerotica obliterans (BXO)
2 Balanoposthitis
3 Carcinoma of penis
4 Chordee
5 Persistent priapism
6 Peyronie’s disease
7 Rupture of bulbous urethra
8 Rupture of membranous urethra
1. Balanitis xerotica obliterans (BXO)