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Penile duplication
PENILE DUPLICATION MICHAEL D . MELEKOS, M .D . GEORGE A . BARBALIAS, M.D. HANS W ASBACH, M .D. From the Departments of Urology University of Patras School of Medicine, Patras, and General Hospital of Chios, Chios, Greece
ABSTRACT-We report on a case of penile duplication in an eight-year-old boy . While diphallia was incomplete, there was a common root of the penis which divided into two shafts of different size, doubling in frontal plane . Only one urethra left the bladder along the lower and smaller penile shaft and ended with a hypo .spadiac meatus . After surgical plastic repair, the patient had a good functional and cosmetic result . In addition, this patient had a horseshoe kidney .
Diphallia, which was first mentioned by Wecker in 1609, 1 is one of the rarest congenital anomalies of the urogenital tract . It is believed to occur once in every 5-6 million births . 2 7 Penile duplication also can occur in combination with additional abnormalities of the urogenital tract or other ograns .2-9 According to Schneider, diphallia can be divided into three categories : (1) diphallia of the glans alone, (2) bifid diphallia, and (3) complete diphallia or double penis . 10 Case Report An eight-year-old boy was admitted with diphallus . On examination, the boy was found to be in good general condition . Physical examination revealed no pathologic findings except diphallia . The patient was born by normal delivery. The mother had not taken oral contraceptives, and there was no history of x-ray exposure or infection during gestation . The family history revealed no malformations . The penile shaft was distally divided into 2 branches lying one upon the other (Fig . 1) . Each had a normal-appearing glans with a very shallow depression at its tip representing a blind
258
meatus . The singular urethra was running along the lower penile branch which was smaller in size . Coronal hypospadias was present (Fig . IA) with mild-degree chordee . Erection took place simultaneously in the two phalli. At endoscopy, urethra and bladder were normal . Two ureteral orifices were present . The testes were in normal position. An intravenous urogram showed a horseshoe kidney with good excretory function and with no duplication of either renal pelvis or ureters . The single urinary bladder was normal in size without residual urine after voiding . Operative repair was planned to fuse the upper penile branch and urethra together . Dissection revealed that each branch consisted of one corpus cavernosum only. The urethra was carefully dissected from the lower phallus preserving its ventral skin . The lower penile branch was then removed from the common root of the phallus . Triangular strips of epithelium were excised from the remaining glans in preparation for placement of the neo-urethral meatus . The urethra, after excision of its stenotic meatus, was fixed to the ventral side of the upper penile
UROLOGY"
1
MARCH 1986
!
VOLUME xXVII, NUMBER 3
(A and B) Incomplete penile duplication with hypospadiac urethra in lower penile branch . (C) Good functional and cosmetic result after surgical plastic repair . FIGURE 1 .
branch . Suprapubic urinary diversion was performed for some days . On postoperative day 6 the boy showed a strong urinary stream (Fig . IC) . The cosmetic result was favorable .
C/o Vas . Prantsidis
Skra 23 Holargos 15562 Athens, Greece (DR . MELEKOS)
Comment
References
According to the published cases, complete true diphallia with two penile organs, each consisting of two corpora cavernosa, one corpus spongiosum, and one urethra is rare . In some cases the penile branches either can be of equal size or one branch can be atrophic consisting of glans only or a small piece of erectile tissue . Glandular duplication (bifid glans) is rarely encountered as well . In most cases, however, diphallia is incompelete with structural deficiency of both penile branches, i .e ., only one corpus cavernosum in each penile branch with or without urethral duplication, one of which, as a rule, is rudimentary. The cause of diphallia is not entirely understood . It is believed to result from failure of fusion of the paired mesodermal anlagen of the genital tubercle . 2-4,6.8,9
1 . Wecker S : Pene gemino vises quidam . Obs .med .admirab .Lih .4 . De partihus genitalibus, Francoforti, 1609 . 2 . Adair EL, and Lewis EL : Ectopic scrotum and diphallia, j Urol 84 : 115 (1960) . 3 . Alcem AA : Diphallia : report of a case . J Urol 108 : 357 (1972) . 4 . Hollowell JG, Witherington R, Ballacas AJ, and Burt JN : Embryologie considerations of diphallus and associated anomalies, ibid 117 : 728 (1977) . 5 . Ran TV, and Chandrasekharam V: Diphallus with duplication of cloacal derivatives : report of a rare case, ibid 124 : 555 (1980), 6 . Rodriguez C : Report of a ease of diphallus, ibid 94 : 436 (1965) . 7 . Smith JR, and Sherer JF : Diphallia : report of a case, ibid 94 : 586 (1965) . 8 . Savir A, Lurie A, and Lazebnik J : Diphallia, report of a case, Br J Urol 42 : 498 (1970) . 9 . Wujcwski A, and Kussowski W : Total diphallia : a case of plastic repair, j Urol 91 : 84 (1964) . 10 . Schneider P : Cited by Lattimer JK, Uson AC, and Melicow AC : The male genital tract, in : Mustard WT, et of (Eds) : Pediatric Surgery, ed 2, Chicago, Year Book Medical Publishers, Inc . . vol 2, chap 77, 1969, p 1263 .
UROLOGY
i
MARCH 1986
!
VOLUME XXVU, NUMBER 3
259
ABSTRACT-We report on a case of penile duplication in an eight-year-old boy . While diphallia was incomplete, there was a common root of the penis which divided into two shafts of different size, doubling in frontal plane . Only one urethra left the bladder along the lower and smaller penile shaft and ended with a hypo .spadiac meatus . After surgical plastic repair, the patient had a good functional and cosmetic result . In addition, this patient had a horseshoe kidney .
Diphallia, which was first mentioned by Wecker in 1609, 1 is one of the rarest congenital anomalies of the urogenital tract . It is believed to occur once in every 5-6 million births . 2 7 Penile duplication also can occur in combination with additional abnormalities of the urogenital tract or other ograns .2-9 According to Schneider, diphallia can be divided into three categories : (1) diphallia of the glans alone, (2) bifid diphallia, and (3) complete diphallia or double penis . 10 Case Report An eight-year-old boy was admitted with diphallus . On examination, the boy was found to be in good general condition . Physical examination revealed no pathologic findings except diphallia . The patient was born by normal delivery. The mother had not taken oral contraceptives, and there was no history of x-ray exposure or infection during gestation . The family history revealed no malformations . The penile shaft was distally divided into 2 branches lying one upon the other (Fig . 1) . Each had a normal-appearing glans with a very shallow depression at its tip representing a blind
258
meatus . The singular urethra was running along the lower penile branch which was smaller in size . Coronal hypospadias was present (Fig . IA) with mild-degree chordee . Erection took place simultaneously in the two phalli. At endoscopy, urethra and bladder were normal . Two ureteral orifices were present . The testes were in normal position. An intravenous urogram showed a horseshoe kidney with good excretory function and with no duplication of either renal pelvis or ureters . The single urinary bladder was normal in size without residual urine after voiding . Operative repair was planned to fuse the upper penile branch and urethra together . Dissection revealed that each branch consisted of one corpus cavernosum only. The urethra was carefully dissected from the lower phallus preserving its ventral skin . The lower penile branch was then removed from the common root of the phallus . Triangular strips of epithelium were excised from the remaining glans in preparation for placement of the neo-urethral meatus . The urethra, after excision of its stenotic meatus, was fixed to the ventral side of the upper penile
UROLOGY"
1
MARCH 1986
!
VOLUME xXVII, NUMBER 3
(A and B) Incomplete penile duplication with hypospadiac urethra in lower penile branch . (C) Good functional and cosmetic result after surgical plastic repair . FIGURE 1 .
branch . Suprapubic urinary diversion was performed for some days . On postoperative day 6 the boy showed a strong urinary stream (Fig . IC) . The cosmetic result was favorable .
C/o Vas . Prantsidis
Skra 23 Holargos 15562 Athens, Greece (DR . MELEKOS)
Comment
References
According to the published cases, complete true diphallia with two penile organs, each consisting of two corpora cavernosa, one corpus spongiosum, and one urethra is rare . In some cases the penile branches either can be of equal size or one branch can be atrophic consisting of glans only or a small piece of erectile tissue . Glandular duplication (bifid glans) is rarely encountered as well . In most cases, however, diphallia is incompelete with structural deficiency of both penile branches, i .e ., only one corpus cavernosum in each penile branch with or without urethral duplication, one of which, as a rule, is rudimentary. The cause of diphallia is not entirely understood . It is believed to result from failure of fusion of the paired mesodermal anlagen of the genital tubercle . 2-4,6.8,9
1 . Wecker S : Pene gemino vises quidam . Obs .med .admirab .Lih .4 . De partihus genitalibus, Francoforti, 1609 . 2 . Adair EL, and Lewis EL : Ectopic scrotum and diphallia, j Urol 84 : 115 (1960) . 3 . Alcem AA : Diphallia : report of a case . J Urol 108 : 357 (1972) . 4 . Hollowell JG, Witherington R, Ballacas AJ, and Burt JN : Embryologie considerations of diphallus and associated anomalies, ibid 117 : 728 (1977) . 5 . Ran TV, and Chandrasekharam V: Diphallus with duplication of cloacal derivatives : report of a rare case, ibid 124 : 555 (1980), 6 . Rodriguez C : Report of a ease of diphallus, ibid 94 : 436 (1965) . 7 . Smith JR, and Sherer JF : Diphallia : report of a case, ibid 94 : 586 (1965) . 8 . Savir A, Lurie A, and Lazebnik J : Diphallia, report of a case, Br J Urol 42 : 498 (1970) . 9 . Wujcwski A, and Kussowski W : Total diphallia : a case of plastic repair, j Urol 91 : 84 (1964) . 10 . Schneider P : Cited by Lattimer JK, Uson AC, and Melicow AC : The male genital tract, in : Mustard WT, et of (Eds) : Pediatric Surgery, ed 2, Chicago, Year Book Medical Publishers, Inc . . vol 2, chap 77, 1969, p 1263 .
UROLOGY
i
MARCH 1986
!
VOLUME XXVU, NUMBER 3
259