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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 15  |  Issue : 1  |  Page : 22-24

Congenital anterior urethral diverticulum co-existing with phimosis: A case report and review of literature


1 Department of Surgery, Bayero University Kano and Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Clinical Services, Abubakar Imam Urology Centre, Kano, Nigeria

Date of Web Publication22-Sep-2014

Correspondence Address:
Dr. A Abdulkadir
Bayero University Kano and Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1595-1103.141389

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  Abstract 

Congenital anterior urethral diverticulum (CAUD) is a rare congenital blind ended out pouching of the urethral through the corpus spongiosium. We report its coexistence with phimosis in a 7-year-old boy who presented with difficulty in passing urine. His prepuce was not retractable and balloons at voiding. Suspected associated CAUD was confirmed at circumcision. His voiding became normal with resolution of lower urinary tract symptoms after treatment. The related literatures were reviewed. The symptoms of the two conditions mimic one another and the diagnosis of phimosis which is clinical may overshadows CAUD with its needed confirmatory imaging studies. CAUD can coexist with phimosis and high index of suspicion helps in the management. Diverticulectomy and urethroplasty with circumcision at the same sitting is curative.

Keywords: Congenital urethral diverticulum, Primary urethral diverticulum anterior urethral diverticulum, phimosis, urethral diverticulum


How to cite this article:
Abdulkadir A, Abubakar A. Congenital anterior urethral diverticulum co-existing with phimosis: A case report and review of literature. Niger J Surg Res 2013;15:22-4

How to cite this URL:
Abdulkadir A, Abubakar A. Congenital anterior urethral diverticulum co-existing with phimosis: A case report and review of literature. Niger J Surg Res [serial online] 2013 [cited 2019 Jul 19];15:22-4. Available from: http://www.njsrjournal.org/text.asp?2013/15/1/22/141389


  Introduction Top


CAUD is a congenital anomaly of the anterior urethra characterized by blind ended out pouching of the anterior urethral that bleaches through the Corpus spongiosium. Patient presents with obstructive and irritative lower urinary tract symptoms including post micturation dribbling. Patient with CAUD also have associated penile swelling covered by the prepuce that is predominantly ventral and more prominent at voiding with or without other attendant complications. Despite the emphasis on accurate diagnosis for appropriate intervention; CAUD coexisting with phimosis [1] could pose a diagnostic challenge and easily missed with an inherent risks during circumcision. The clinical presentations of CAUD mimic pathological phimosis [1] which is common and presents with lower urinary tract symptom plus ballooning of the prepuce but easily treatable with circumcision.


  Case Report Top


A 7-year-old boy who presented at Abubakar Imam Urology Centre with difficulty in passing urine characterized by predominantly obstructive lower urinary symptoms that progressively worsen. His prepuce ballooned at micturation and he had associated post micturition urine dribbling with painless progressive penile swelling. On examination he had circumferential penile swelling extending distally from mid penile shaft that was more ventrally. The swelling was cystic, fluctuant and the prepuce non retractable [Figure 1]. His urine M/C/S yielded no bacterial growth, Pack cell volume, urea and electrolytes were normal. He was prepared for circumcision. Intraoperatively, non retractability of the prepuce was confirmed with the coexisting blind ended out pouching of the urethral through the corpus spongiosus. The CAUD was treated by diverticulectomy with Urethroplasty in addition to the circumcision [Figure 2] and [Figure 3]. The urethral stent was removed after 3 weeks and patient's voiding has remained normal at follow-up.
Figure 1: Penile ballooning with non retractable prepuce

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Figure 2: Congenital anterior urethral diverticulum demostrated intraop

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Figure 3: After diverticulectomy, urethroplasty and circumcision

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  Discussion Top


Anterior Urethral diverticulum is quite rare and only in 20% cases are congenital; [1] this is the first case seen in the centre. The exact aetiology is unknown but most commonly acceptable theories include cystic dilations of the periurethral glands, rupture of syringocoele, and incomplete hypospadias [5] other theories includes sequestration of an epithelial nest after closure of the urethral folds and that diverticulum of the urethra develops because of epidermal pockets communicating with the ventral urethral wall. [11] Our patient presented at the teenage age [4] with lower urinary tract symptoms including post micturition urine dribbling. He had poor urinary stream, and penile swelling that was more prominent while voiding [2] contributed by both the phimosis and the CAUD. Other presentations could be at neonatal period, infancy [2],[3] and childhood. The Clinical diagnosis of the CAUD in our patient was overshadowed by the coexisting phimosis and the diagnostic retrograde urethrogram, voiding cystourethrogam and Urethroscopy [6],[7] were not done. The commoner [8] narrowed neck saccular CAUD was seen at operation. Circumcision remains the commonest surgical procedure performed in most part of the world [9] and missing such diverticulum could be catastrophic and leads to distressful lifelong disability of urethrocutaneous fistulae in the patient. The patient had no features of urosepsis or impaired renal functions that may necessitate the initial urine diversion before the definitive surgical treatment. [10]

Our treatment for the CAUD was open diverticulectomy and urethroplasty with circumcision done for the Phimosis at the same sitting. Endoscopic incision of the lip of the diverticulum was reported for smaller diverticuli [10],[11] Endoscopic incision is minimally invasive though the residual pouch can develop into a flap requiring repeated procedures. Advantages of our open procedure includes it's a one stage procedure and it gives uniform urethral calibre. Also paediatric Endourological practice is still rudimentary in our part of the world.


  Conclusion Top


CAUD can coexist with phimosis. High index of suspicion helps in the management since clinical features of phimosis may overshadow those of CAUD; also the needed RUG and VCUG/urethroscopy that confirms CAUD are not required before circumcision for phimosis. Diverticulectomy and urethroplasty with circumcision at the same sitting is curative.

 
  References Top

1.Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999;84:101-2.  Back to cited text no. 1
    
2.Arena S, Romeo C, Borruto FA, Racchiusa S, Di Benedetto V, Arena F. Anterior urethral valves in children: An uncommon multipathogenic cause of obstructive uropathy. Pediatr Surg Int 2009;25:613-6.  Back to cited text no. 2
    
3.Rawat J, Khan TR, Singh S, Maletha M, Kureel S. Congenital anterior urethral valves and diverticula: Diagnosis and management in six cases. Afr J Paediatr Surg 2009;6:102-5.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Sadat HQ, Faisal K, Dler B, Krishna P. "Congenital anterior urethral diverticulum in a male teenager: A Case reports and review of the literature" case reports in urology. Vol. 2011. Available from: http://www.hindawi.com/journals/criu/2011/738638/ [Last viewed on 2014 Jul 10].  Back to cited text no. 4
    
5.McLellan DL, Gaston MV, Diamond DA, Lebowitz RL, Mandell J, Atala A, et al. Anterior urethral valves and diverticula in children: A result of ruptured Cowper′s duct cyst? BJU Int 2004;94:375-8.  Back to cited text no. 5
    
6.Rawat J, Khan TR, Singh S, Maletha M, Kureel S. Congenital anterior urethral valves and diverticula: Diagnosis and management in six cases. Afr J Paediatr Surg 2009;6:102-5.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Pavlica P, Barozzi L, Menchi I. Imaging of male urethra. Eur Radiol 2003;13:1583-96.  Back to cited text no. 7
    
8.Johnson FB. Dierticula and cysts of the urethra. J Urol 1923;10:295-310.  Back to cited text no. 8
    
9.Magoha GA. Circumcision in various Nigerian and Kenyan hospitals. East Afr Med J 1999;76:583-6.  Back to cited text no. 9
[PUBMED]    
10.Paulhac P, Fourcade L, Lesaux N, Alain JL, Colombeau P. Anterior urethral valves and diverticula. BJU Int 2003;92:506-9.  Back to cited text no. 10
    
11.Kajbafzadeh A. Congenital urethral anomalies in boys. Part II. Urol J 2005;2:125-31.  Back to cited text no. 11
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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