IIYPOSPADIAS Pathological Anatomy.—Hypospadias is much more frequently met with than epispadias, the ratio being 150 :1. In this deformity there is a groove-like opening of the urethra on the under side of the penis.
According to the extent of the fissuration, the urethra terminates at various atypical places in the genital organ.
This fissuration is caused by non-union or incomplete union of the groove of the mons pubis. lts origin dates from a much later period Flu. 26.
of embryonal life than that of epispadias, which we must attribute to the first few weeks—the period when fissure of the bladder is assumed to occur. This would also account for the greater frequency of hypo spadias.
According to the position of the secondary urethral aperture we distinguish — a. Hypospadias of the scrotum (Fig. 26).
b. Hypospadias of the penis (Fig. 27).
c. Hypospadias of the glans.
In the first form, which is the most severe and also the rarest, the fissure or non-union extends not only to the urethra, hut frequently also to the scrotum. The further back toward the perineum the urethral aperture lies (perineal hypospadias),1he more extensive is the fissuration of the genital organs, \\illicit in the most pronounced cases approaches the female type (pseudo-hermaphroditism). The completely divided scrotum resembles the labia majora, at the anterior commissure the clitoris-like imperforate penis (Fig. 26). The latter is usually stunted, with a downward and a rudimentary formation of the apron-like prepuce.
In the second form, the urethral orifice is situated beyond the scrotum toward the coronary sulcus. In rare cases there are two orifices, or fistula.
In the third form, only the glans is imperforate, and the urethra as a rule opens in the vicinity of the frenum or at its physiological place. In many cases t he normal orifice is indicated by a fossa navicularis, which, however, ends in a cul-de-sac or communicates with the urethra by it very fine canal. Mict tuition takes place through the fistular opening, from which a sagitt al fold of skin runs to the scrotum.
The symptoms consist principally of the disturbances of micturition and of the impediment to the genital function, which may from mechan ical causes give rise to sterility.
The treatment endeavors to establish normal conditions. This is accomplished partly by detaching and straightening the penis and partly by the formation of a new urethra and burying it beneath the skin surface.
The plastic operation of Duplay (Thiersch), which has already been mentioned, is of importance, but better results are obtained by stretching the urethra and tunneling the glans (v. Haeker, Deck).
The first step is to expose the existing urethra on the ventral side by a longitudinal incision and to dissect it loose, together with the corpora cavernosa; then the glans is perforated with a blunt instrument or by the cross-puncture of a scalpel, after which the loosened urethra is drawn through the, perforated glans. The terminal part of the urethra, which is usually stenosed, is incised or freshened and sutured to the mucous membrane of the glans.
to V. Hacker it is possible to stretch the urethra by twice its lumen without danger, and this is an excellent way of creating nearly normal conditions in hypospadias of the glans. It is also possible to change excessive retrodisplaeement of the urethral orifice and to transform the perineal form into penile hypospadias. The remaining part might be tunneled by other kinds of plastic operations, possibly by insertion of tubes of blood-vessels united with the urethra, which should be placed as far forward as possible.
It is important to avoid excessive tension in order to preserve the suture. Bardenheuer suggests in this connection to incise the regional skin around the urethral orifice and to place the same anteriorly.
A permanent catheter should he worn for some time after operation, but as this is both inconvenient and painful, aside from its unfavorable influence upon the healing process, I'Mliet's method of resorting to a temporary perineal button-hole might be considered.
The time for operation should be seleeted in accordance with the condition of the patient. In any ease it is advisable to wait until the parts have grown to larger dimensions. On the other hand, it should be considered whether growth might not exaggerate the deformity (kinking). The middle part of ehildhood, from the eighth to the twelfth year, would be the best time for operation, if the condition achnits of waiting. In our cases the best results were attained in operations after the sixth year.
Congenital occlusions and stenosis of the urethra are rare occur rences and likewise attributable to arrest or disturbance of development. In a symptomatic respeet they entirely resemble the acquired changes of this kind and should be treated in accordance with general surgical rules.