Diseases Of External Genitalia In Male Children

Diseases of external genitalia are quite common disorders in male children.

Most of the data about the incidence rate of diseases such as hypospadias, undescended testicle, inguinal hernia and/or hydrocele in childhood period have been obtained from studies conducted abroad. Different rates are reported in studies carried out in our country and those rates are stated under the titles. Now, let us try to understand those diseases one by one.

UNDESCENDED TESTICLE (0.8 to 3.7%)
If the testicles of a newborn boy are not in the scrotum, this condition is called undescended testicle. This is the most common anomaly of genital organs in male children. Both testicles are located in the abdominal cavity before the male baby is born. While the baby continues growing in the intrauterine period, the testicles start to descend to the scrotum. After the abdominal cavity, they pass the inguinal region and come to the scrotum shortly before the birth. Rarely, descending to the scrotum continues for the first 6 months after birth. A part of undescended testicles also descend until the end of this 6-month period. However, they stop descending after this period. The condition should necessarily be treated as soon as possible after the first 6 months. An important characteristic of a real undescended testicle is that one or both testicles are never located in the scrotum. The condition is mostly unilateral, but sometimes it occurs in both testicles. Statistically, undescended testicle is 3 times more common in premature male babies comparing to others.

Why should undescended testicle be treated? There are four main reasons.

1-) It hinders having children in the feature: It is a well known cause of infertility. The earlier the testicles descend to the scrotum, the lower this risk becomes.

2-) It may cause cancer: The risk of testicle cancer in the future is 15 times higher in patients with undescended testicle comparing to other men.

3-) It may be associated with inguinal hernia: Although it does not always show symptoms, hernia is detected in around 65% patients with undescended testicles and it requires surgical management.

4-) It causes physiological and aesthetic problems.

When should the condition be treated? The ideal time for treatment is between 6 months and 1 year of age. However, treatment should be completed at the end of 2 years at latest. Treatment of undescended testicle should be performed no later than 2 years of age irrespective of the reason. If it is delayed and the patient is older than 2 years of age, the condition should be treated as soon as possible. If the undescended testicle is associated with hernia, then, surgical treatment should be immediately performed even for a 1 month old baby. The success rate of surgery for undescended testicle is quite high when the procedure is performed by skillful specialists from different branches such as urology, pediatric urology and pediatric surgery.

For detailed information, please consult your doctor.

HYPOSPADIAS (0.2 to 1%)
Hypospadias can be colloquially called as “prophet circumcised”, “congenitally circumcised” and “half circumcised” (This is mainly because the foreskin in front of the penis does not develop in these patients. The foreskin is only present at the posterior segment). The main problem in hypospadias is that the opening of the urethra is not at the tip of the penis but beneath it. Children with hypospadias prefer urinating in sitting position because when they urinate at standing position they urinate downwards instead of frontwards. The urinary canal in the region between this orifice and tip of the penis is underdeveloped. Hypospadias can be classified differently depending on the location of the urethral orifice. Hypospadias cases in which the urethra is on the head of penis, in close proximity to its normal position, are called glandular hypospadias. If it is located at the junction of head and shaft of penis, the condition is called coronal hypospadias. These two conditions are called “distal hypospadias” in general and this group is the most common one among children and has the highest surgical success rate. There are also hypospadiases at lower locations. The urethral orifice may be located at any part of the penile shaft, at the junction of penis and scrotum and even in the region called the perineum which is near the anus. Of course, surgical management of hypospadiases with lower location is more challenging.

As I stated above, the most important sign is the location of the urethral orifice at a lower location in the penile shaft instead of the tip of penis. A condition called chordee which is characterized with the curvature of the penis during erection. The more the hypospadias anomaly is severe, in other words the farther is the urinary orifice located from the tip of the penis, the more obvious this curvature becomes. One of the basic stages of treatment in hypospadias surgery is the correction of this curvature.

Hypospadias is a congenital condition. The exact cause of the condition is not known. While there are some studies focusing on insufficient hormonal stimuli in the intrauterine period, some studies totally reject this. The fact that there are associating urogenital system anomalies in hypospadias –especially in severe cases- also suggests that the condition is congenital. The cases with the urinary canal located near the tip of penis, which are called distal hypospadias, are more common.
The condition can be easily diagnosed with a meticulous physical examination after the baby is born.

Should further investigations made after hypospadias is diagnosed?

The risk of other urogenital system disorders is higher in cases with hypospadias especially in advanced ones. Therefore, especially the urinary system (kidneys, urinary canals and urinary bladder) should necessarily be examined especially for severe cases. If hypospadias is associated with bilateral undescended testicle, chromosomal investigations should be made and it should necessary be searched whether there is a sexual differentiation problem (such as hermaphroditism).

The only treatment for hypospadias is surgery. Painful interventions to penis should be avoided between 2 and 6 years of age –the phallic period which is the period when the child discovers his sexual identity. Therefore, hypospadias surgery should be performed before the child discovers his sexual identity. Postoperative care is easier if this intervention is made in the period while diapers are used. Hypospadias surgery can be performed by specialists of various branches such as urology, pediatric urology and pediatric surgery. However, the current data show that one out of every three surgeries performed by inexperienced individuals results in complication. For detailed information, please consult your doctor.

INGUINAL HERNIA AND/OR HYDROCELE (approximately 4%)
While male babies are in the intrauterine period, their testicles are in their abdominal cavities. The testicles descend to the scrotum in the last 2 months of pregnancy. They pass through a canal. The testicles in the abdomen reach to the scrotum through two different canals in both inguinal regions. These canals generally close before birth. Therefore, no connection remains between the inner and outer parts of abdominal cavity. However, if one or both of these canals are not close, herniation occurs. If a relatively narrow canal opening remains, the intraabdominal fluid leaks to the inguinal region and scrotum through these canals and causes swelling. This swelling worsens when the child is awake and mobile. It regresses or disappears when the child sleeps or lies calmly. This condition is called hydrocele in medical literature. It is colloquially known as “water hernia”. This type of hydrocele highly possibly recovers spontaneously until the age of 1. Some hydroceles can be associated with hernia since they are related to peritoneum. In this type of hydroceles called communicating hydrocele, swelling regresses when the child lies down while it worsens in conditions increasing intraabdominal pressure such as crying. If the condition does not recovery spontaneously, it should be treated with surgery and hernia should also be repaired in the same session. If the exposing canal is large, a part of intestines bursts from the intraabdominal cavity through this canal in movements such as crying or straining, the inguinal region or scrotum swells and causes discomfort. This condition is called inguinal hernia. Hernia is more common in premature babies or babies with low birth weight. Inguinal hernia is treated with surgery. It does not disappear spontaneously. The most suitable approach is to operate the patient as soon as possible after the condition is diagnosed. Young age of the child does not contraindicate the surgery. Since the risk of strangulation of hernia (incarceration) is higher in younger ages, it is crucial that those babies are operated without wasting time. Premature babies can be operated after waiting for a short time following diagnosis. Since the organs, especially the liver, are not fully developed yet in these babies, it is suitable to wait until the baby reaches to the normal birth age unless there is an emergency such as strangulation of hernia. However, it should be remembered that the family should keep in touch with the surgeon during this waiting period!