CONGENITAL DEFORMITIES OF THE GENITAL TRACT Epispadias is a fissure of the lowest part of the bladder or of the urethra, caused by premature arrest of the advancing growth of the abdominal walls (Kaufmann).
According to whether the fissure involves the entire urethra or only parts of it, we distinguish 1. Fissure of the vesical neck.
2. Epispadias of the penis.
3. Epispadias of the glans.
The first form commences close to the fissure of the bladder. The entire urethra is fissured, the mucous membrane is in flat tension and at the symphysis passes direct into the bladder by an infundibular deep ening; and if there is simultaneous fissure of the symphysis, the bladder may be readily seen.
The corpora cavernosa are divided, the glans is imperforate and solid, with a groove-like depression. The prepuce extends beyond the stunted penis at the ventral side in the shape of an apron (Figs. 24a and 24 b).
In the second form the fissure extends only to a narrow infundi bulum at the mons pubis, in which the groove gradually disappears under the unfissured symphysis.
In the third form, which is very rare, only the glans has a groove, while the proximal part of the urethra is intact.
The subjective symptoms depend upon the extent of the deformity. In fissure of the neck of the bladder the sphincter is generally' involved. with consequent incontinence.
In minor degrees, too, micturition and later sexual function are interfered with.
Similar conditions have in rare cases been found in the female, and are characterized by arch-like divergence of the labia majora and minora, absence of the corresponding and fissure of the clitoris. The infundibulum which deepens the arch-like distention of the labia majora leads directly into the bladder, the mueosa of which is often prolapsed. The outward changes are not very noticeable to the layman, and it is often only the concomitant incontinence that causes parents to consult a physician (Figs. 25a. and 25b, Plate 3).
The treatment should endeavor to bring about normal conditions as far as possible. The groove is transformed into a canal by a plastic flap (Duplay, Thicrsch).
Thiersch first provides a urinary fistula at the perineum (a button hole) for the urine to flow off, thus allowing the field of operation to have undisturbed rest. This preliminary operation has again recently been strongly recommended by Thiersch transforms the groove of the glans into a canal by dividing the glans into three parts through two longitudinal incisions, suturing the middle part to form a canal which he embeds deeply into the tissue, and closing the two lateral parts over it. By an appropriate plastic flap the groove of the penis is changed into a canal, and both canals are united with the aid of the prepuce. In establishing communication between the urethra and the neck of the bladder, flaps are used taken from the skin of the abdomen.
Beck proposed a similar method resembling his operation for hypo spadias. The mucous membranes of the groove of the penis and of the neck of the bladder are dissected free, then united by a purse-string suture, drawn through the tunneled glans and fixed in that position.
1 have succeeded in correcting female epispadias in a similar way, by dissection of the mucous membrane of the visible vesical neck, reformation of the large and small commissures by rotation of the new formed urethra through 00 degrees, and fixation of the latter in the angle of the commissure, enlarging at the same time the urethro-vaginal septum, with resulting continence of several hours.