Genital Growth in Child

Article by Dr.Ramgopal Sarabu
MBBS,M.Ch
Penile implant surgeon..hyderabad

Genital growth in a child suggested by Dr. S Ramgopal Sometimes genitals appear abnormal but are still apparently male or. female Such defects in boys include abnormalities of the urethral opening (for example, being located on the bottom or, less often, the top of the penis), an abnormally shaped penis (chordee), and an undescended testicle. Defects in girls include a hymen that has no opening (imperforate hymen) and a missing or shortened vagina. Other defects result in genitals that are not clearly male or female. These are called ambiguous genitals. The most common cause of ambiguous genitals is in girls who have congenital adrenal hyperplasia. Congenital adrenal hyperplasia* is an inherited problem with the adrenal glands that causes the glands to produce too much testosterone (the adrenal glands naturally produce a small amount of testosterone in healthy girls). Children who have genital defects may have problems urinating. Later, people may have difficulties engaging in sexual intercourse, impaired fertility, social and psychologic problems, or a combination

Let us discuss all the topic one by one We can start with micro pennis

Micro penis Criteria for Diagnosis In sexual medicine Practice parents bring thier kid for examining the size of penis 1) How can we convince them whether it is normal or not
2) If the penis is abnormal what are the investigations Tobe done?
3) Is there any method to measure the length and girth of penis?
4) What treatment can be given for the child with micro penis?
5) Is there any method to increase the length and girth of the penis if treated from early childhood?

Early diagnosis of “true micropenis” is important, because it allows for various treatment options to be utilized early. The first step in the diagnosis of micropenis is the physical examination of the patient’s external genitalia. Micropenis refers to a condition which occurs only in XY males. It is characterized by a small penis and a median raphe, foreskin, as well as normal localization of the urethral meatus opening. Penis size and gain in length can b achieved at any age, by supplementing testosterone , if it were due to testosterone deficiency.

Key points about micro penis in children

1) A micro penis is a penis that is smaller than normal. A penis length of less than 0.75 inches for a newborn boy is considered micro penis.
2) It can happen on its own. But it often happens along with other disorders.
3) It can occur with a hormone disorder that causes an abnormal level of the hormones involved in the growth of the sexual organs. This can include problems with the pituitary gland or the hypothalamus.
4) Hormone therapy may be used to treat some children. This can help to cause penile growth. Sometimes surgery may be an option.
5) In some cases, a man with micro penis may have low sperm count.

Chordee is a condition in which the head of the penis curves downward or upward, at the junction of the head and shaft of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well.

A variation of hypospadias occurs when the urinary opening is in the correct location in the head of the penis, but there is only a partial foreskin. This is called “chordee without hypospadias” because the head of the penis often appears bent downwards. “Chordee” is simply another word for “curvature”.

In other boys, the foreskin is normal, but the penis is bent, usually down towards the feet. Occasionally, bending can occur to one side (almost always the left side, called lateral curvature), or even back towards the belly, called dorsal curvature. Penile curvature is a common problem in children, but the underlying cause is not known.

Surgery is often recommended to release tethering of the skin and repair the bend in the penis. At the same time, the skin can be managed either with circumcision or with the repair of the foreskin, depending on the wishes of the caregivers. If the circumcision was postponed due to the curvature but the family desires one, we recommend fixing the curvature and performing the circumcision at the same time to minimize discomfort. This can be done safely anytime after the age of 3 months in healthy, term infants with a minor procedure called a phalloplasty.

Penile curvature can cause discomfort during intercourse – for the patient, for the partner, or both – depending on the degree and the direction of the bend. Penile birth defects like curvature and foreskin abnormalities may also be a source of locker-room embarrassment. Repair for boys and men with less than 30 degrees of curvature is nearly always successful in a single surgery. Sometimes hypospadias – an abnormal position of the urinary channel – is discovered at surgery, and can be repaired at the same time. The goals of repair are to restore normal function and cosmesis.

Much less common is severe penile curvature, defined as more than 30 degrees. Evidence has shown a common way of correcting curvature, using stitches opposite the bend called plications, has a higher rate of failure when there are more than 30 degrees of bend. This curvature is more successfully repaired by lengthening the short side instead of shortening the long side with plication stitches. When the short side is lengthened, a graft may be needed to fill in space. Where the graft comes from and whether the repair can take place in one surgery or a planned two-stage approach depends on the particular anatomy – for instance, if a shortened urinary channel is acting as a bowstring, causing the severe bending, but can often be anticipated by an experienced surgeon.

Hypospadias is a common variation in fetal development of the penis in which the urethra does not open from its usual location in the head of the penis. It is the second-most common birth abnormality of the male reproductive system, affecting about one of every 250 males at birth

Do adult men with untreated ventral penile curvature have adverse outcomes?

The social and sexual life of adults operated for hypospadias during childhood has been studied by a few authors.

Aho et al.compared those who underwent hypospadias repair and circumcision. There was no significant difference in sexual and social life. Almost the same proportions reported that they were not inhibited in seeking sexual contacts. All participants reported exclusive heterosexual orientation and they were mostly satisfied with their body image. Conversely, Liu et al.[5] observed that 49 out of 102 patients complained that their penis had been ridiculed by partners. There was no control group in this study. They also observed that those with proximal hypospadias (60% vs. 36.5%, P < 0.05) and those with complications had been more often ridiculed than those in the distal group and those without complications (78.9% vs. 29.7%, P < 0.05). In a comparative study, Mureau et al.
compared 73 who underwent hypospadias repair in childhood with 50 controls. Though hypospadias patients reported a more negative genital appraisal than the controls, they did not have a different sexual adjustment. Higher patient age at final operation had a negative impact on sociosexual development.

Erection and Sexual Satisfaction

The erectile problems in hypospadias may be attributed to surgically correctable and noncorrectable causes. More commonly encountered correctable causes include persistent chordee, torsion, inadequate cosmetic outcome, etc. Commonest surgically uncorrectable cause is the size of the penis. Achieving a straight penis is one of the objectives of hypospadias correction. With a constant move toward achieving a normal-looking penis, the results of contemporary repairs are likely to be different. Sommerlad reviewed 60 adults who underwent hypospadias repair, half of which were Ombredanne repair and the unsightly redundant skin was a frequent source of complaint. Kenawi evaluated the sexual function in 82 subjects who underwent surgery for hypospadias and he noted that incomplete or incorrect surgery resulted in sexual dissatisfaction.

Bubanj et al. observed that though the frequency of intercourse during 4 weeks was significantly lesser for those who were operated for hypospadias, there were no significant difference between patients with hypospadias and controls regarding inhibition in seeking sexual contacts or patterns of sexual relationships. Those with distal hypospadias were more satisfied with their sexual life. Of the 76 sexually active adults, Liu et al. noted that the commonest sexual complaints included short penis, increased curvature, painful erection, and no erection. The erectile problems were more in those who had proximal hypospadias.

They also felt that the main reason for dissatisfaction was penile size. Mureau et al.[3] studied noted that the lesser size of the penis was noted to be a major cause for dissatisfaction. Similar observation regarding penile size was made by Moriya et al. Zaontz in his editorial comment of this article has underscored the importance of penile size.

Sexual function and satisfaction in 10 adult patients who underwent oral buccal mucosa graft urethroplasty was studied using International Index of Erectile Functioning (IIEF-15) by Nelson et al. They noted that the long-term sexual function and satisfaction were excellent, in spite of them having undergone multiple procedures.

The long-term efficacy of dorsal implication was evaluated by Chertin et al. Six of the 28 in whom the erection test was repeated later required further implication. Yucel et al. noted that 10 out of 25 who underwent re-operation for hypospadias had recurrence of chordee.

What is Epispadias

Epispadias is the development of abnormal urethral opening due to which the urethra and external genitalia are not able to function properly. It is a congenital disorder that can occur in both boys and girls, though incidence in general population is rare.Boys with epispadias have urethral opening at the top of penis instead of its tip. Likewise females born with epispadias have urethral opening more anterior (i.e. towards the clitoris or belly area)According to latest estimates, epispadias affects 1 in 484,000 female live births and about 1 in 117,000 male livebirths

How Epispadias Affects Boys?

The penis of boys who are born with epispadias is short and curved upwards. The opening of urethra is called meatus and depending upon the location of meatus on the penis, epispadias can be classified as:
1) Penopubic Epispadias: When meatus is located at or near the pubic bone
2) Glanular Epispadias: When meatus is located at the head of penis
3) Penile Epispadias: When meatus is along the shaft of penis

Meatus helps in determining the efficiency and storage capacity of bladder. If meatus point is located near the base of penis, it means that the bladder sphincters are affected and can’t hold the urine efficiently. Urinary leakage is more likely to occur in the penopubic epispadias because the pelvic bones does not come close together in this case due to which the sphincter appears to be horseshoe shaped instead of a ring, resulting in improper closing of sphincters and leaking of urine. Most men with penile and penopubic epispadias require surgical correction of sphincter complex.

In glanular epispadias, the sphincter complex is not affected therefore, most men do not experience problems in holding urine. But the curved penis with abnormal opening will require a surgery to minimize the risk of complications. The surgical options depends largely on patient overall health, severity of symptoms and associated abnormalities (such as bladder exstrophy). According to a new study, the risk of developing bladder exstrophy and epispadias is 2.15 per 1,00,000 livebirths.

How Girls Are Affected By Epispadias?

Epispadias in girls is much rarer than boys. Affected girl’s pubic bones are separated from each other by various degrees, which in turn prevents the adjoining of clitoris in the middle. As a result the clitoris divides into two halves (giving a bifid appearance). In most cases, the bladder neck is affected and leakage of urine occurs in states of high intra-abdominal pressure such as coughing, excessive laughing, strenuous activities (also known as stress incontinence). Usually surgeries can help in restoring normal urological functions.

What Is Phimosis?

Phusilogically right after birth every child is born with potential phimosis,it is bounden duty of every parent to do preputial dilatation during bath(majorty persons does not know as it is part of hygenic also
long standing phimosis leads to balanoposthitis specially more so in DM and subsequently may end with ????Ca penis also Some time in male childerens it may be cause of UTI (if no other xause found)

Treatment is simple

1) Circumcision in children and difficult cases need anesthesia
2) Otherwise it is under LA

Put some queries if they r???? More than the parents, it is the duty of the pediatrician who first sees the baby to ascertain about phimosis and educate the parents how to clean the genitals… In Children with phimosis, the symptoms may depend upon the degree of the phimosis. In severe cases there will be a typical history from the parents, whenever the child strains for micturition there will be a ballooning of preputial sac. These children are more vulnerable for UTI. When the intensity of phimosis is less severe itching and infections will be the sequences.
If it is mild, applications of mild potent steroids and slow retraction will be fruitful. If it fails circumcision is the only solution. Many adults will moderate phimosis can live with it for decades without much problem. Some may go for infections of subpreputial space with anaerobic organisms and Borrelia. Dysparunia may be a presenting symptom with some individuals. Preputial tear can occur and sometimes result in paraphimosis.
Phimosis in adults could be due to either congenital or inflammatory, Secondary to some infection S, ulcers or growth. Inflammatory phimosis could be due to swelling of glans or due to tightening of preputial orifice like in monilial balanoposthitis.
With regards to inflammatory phimosis the treatment is to treat the underlying causes. In most occasions the underlying cause could not be identified due to phimosis. Treat the infection, do the investigations to find out the cause and treat accordingly. Then phimosis got relieved.
Cleaning the inner aspect will be difficult in the presence of phimosis. In this situations, ask the patient to stretch his preputial skin and hold it tightly not to allow the urine to get out and ask him to pass urine. By doing so, the urine will get retained in the subpreputial space and then when he opened the orifice and pass urine it will be cleaned.

Frequent cleaning facilitates healing.

It is a minor surgical procedure. The prepuce forms a ring in long standing cases U may have to cut the ring if required. Never do simultaneous circumcision.Just make a nik of and cut the band on the dorsal aspect. It is a minor procedure. Mostly suture may not be necessary Tissue is edematous, distorted, prepuce is given by God. Any thing going against nature, we have to think twice

“Pearly Penile Papules are tiny papules present in rows over the coronal ridge in majority of the men. Prominence and numbers may vary with individuals. Usually appear after some sort of sexual activities either coitus or masturbation. They are nothing but hypertrophied papules without any clinical importance, without any symptoms. No treatment is required. Assurance is enough. Individuals who noticed for the first time, especially after some sexual adventures, worrying about these, thinking of STI or genital warts. Assure the patients… Dr S Murugan“

Another condition which also has no clinical importance is called as Fordyce spots or papules.. They are tiny, skin color, grouped papules mainly present over the lips and genitals skin of both sexes. They are nothing but ectopic sebaceous glands. Nothing to worry. Assurance is enough.

Prosemen otherwise called as Pre-Ejacultory fluid or Precum

Prosemen otherwise called as Pre-Ejacultory fluid or Precum. This is a scanty mucoid secretion appears at tip of urethral orifice (rarely dribbling), when the patient got Sexually excited or during the penis got erected. It is secreted by two different glands. Glands of Littre, present over the roof and sides urethral wall and also from Cowper’s glands. Many believe it’s the secretion of Cowper’s alone. It is not so. Cowper’s secretions is present both in Semen and precum.
Whereas secretions of Littre present only in the precum. The role of precum is not for the lubrication as commonly believed, if all it has lubrication function for the prepuce over glans. The main functions are two. The urethral environment is always in acidic environment due to the repeated urination and deposits of urinary salts.
This environment is inimical to the Spermatozoa. The precum makes a coating over the inner aspect of urethra and nullifies the acidity and ensures a safe delivery of semen with live motile sperms into the vagina Another function is to wash away the salt debris and clean the urethra to an extent. So it’s a boon really by the nature.
But many people after seeing the precum, thinks their semen is leaking even before insertion and got depressed and loose the erection. So when you are dealing with a case of ED, especially in young, unmarried individuals, elicit the history of fear of Dhat syndrome and precum and clear his doubts and encourage him along with other drugs…
Many Patients complain of urethral discharge/semen discharge even on talking to a woman…..many complain of persistent semen discharge .throughout the day.. .