General anesthesia is used for children. The aim is to dilate the stenosed urethral opening, and a small incision is required. Meatotomy is usually performed by crushing the scar tissue adjacent to the meatus with a clamp and then incising it longitudinally. Sutures are occasionally required for any problematic bleeding. Meatal stenosis is narrowing of the urethral meatus, which can be associated with a previous circumcision as a newborn or infant or can be associated with balanitis xerotica obliterans of the foreskin causing phimosis. The usual presentation is with a fine urinary stream that may spray or be difficult to direct, often with a change in bladder control associated with frequency, urgency, and occasionally incontinence.

The urethral meatus may become stenosed either at the 6 o’clock position alone or at both the 6 and 12 o’clock positions equally.

See Table 7.2. Complications are generally minor and/or infrequent; however, some may be more significant on occasions. These include cosmetic deformity, recurrent meatal stenosis, and bleeding. Brief meatal ulceration is a consequence of surgery and usually heals rapidly. Acute dysuria is a typical feature until the skin and mucosa heal.

In perspective, there are usually no major complications associated with meatotomy. Pain may rarely be significant requiring regular bathing and pain relief. Acute dysuria is a consequence of surgery and is expected, but if prolonged beyond 72 h, it is abnormal. Urinary tract infection is very rare and may signify other underlying abnormalities, should it occur. Bleeding is rarely severe. Recurrent meatal stenosis is occasionally a problem that may require further surgical division.

General anesthesia is used. Hypospadias encompasses a range of congenital malformations of the position of the urethral opening on the ventral aspect of the penis. Hypospadias is usually identified at birth but may present with problems directing the stream of urine during micturition. The aim of surgery is to reposition the urethral opening closer to the tip of the penis and correct any chordee (curvature), and the associated dorsal hood of foreskin may be excised or used as skin flaps on the ventral aspect of the shaft of the penis after release of the chordee. The extent and type of surgery required depends on the type of hypospadias present, as does the range and severity of complications encountered after surgery. Glanular forms may require meatotomy alone with or without circumcision, whereas perineal or penoscrotal forms may require extensive, multiple, staged surgical procedures. Transposition skin/mucosal flap repairs may be required. The relative risks and complications increase with the extent of surgery performed.

Hypospadias is one of the most common congenital anomalies, occurring in about 1 in 300 male births. The anatomy can vary considerably, and the classification of hypospadias relates to the position of the urethral meatus. Four common types occur: glanular, penile, penoscrotal, and perineal, in descending order of frequency, with glanular and penile accounting for about 80 % of cases. The more severe the hypospadias, the more the downward curvature of the penis (chordee). In contrast, epispadias is where the urethral opening is on the dorsal surface of the penis and is very rare (sometimes associated with exstrophy of the bladder in severe forms).

See Table 7.3. Complications are generally minor; however, some may be more significant on occasions. These include infection, skin necrosis, cosmetic deformity, meatal ulceration, meatal stenosis, and bleeding. Urinary retention is not uncommon and occasionally requires catheterization (which may be done as part of some procedures to stent the urethra). Acute dysuria is a typical feature until the skin and mucosa heal. Bandaging in older boys should allow for expansion with erection, which can cause severe constrictive pain and require loosening and re-bandaging. Urethral fistula formation and meatal stenosis are the most common postoperative complications.

Pain may be significant and may require loosening of dressings and pain relief. Acute dysuria is a consequence of surgery and expected, but if prolonged beyond 5 days, it is abnormal. Urinary tract infection is rare. Bleeding is rarely severe. Wound infection usually responds to local dressings and oral antibiotics, if required. Infection may increase scarring and create poor cosmesis. Meatal ulceration may lead to meatal stenosis on occasions, which may require further surgery. Urethral stenosis can occur, depending on the degree of hypospadias, the surgery performed, and any infection. Urethral fistula can be a significant problem to deal with and may require repeated surgery. Further revisional surgery may be required, depending on the procedure performed and healing resulting in a poor cosmetic result.

General anesthetic is used. The aim is to locate the testis that has partially descended or has failed to descend and attempt to mobilize the gonad into the scrotal sac, if this is achievable. In some cases, where this is not possible, orchidectomy is required, because of the increased risk of testicular carcinoma in an undescended testis. A transverse inguinal incision on the side of the undescended testis is usually used. The testis is usually surgically fixed in the scrotum by creating a dartos pouch. Laparoscopic approaches are progressively being used to locate an intra-abdominal testis as part of a first-stage procedure when high ligation of the testicular vessels is performed followed at a later date by an orchidopexy.

The testis develops from the gonadal ridge, in a retroperitoneal position in the posterior abdominal wall, and usually descends caudally along the posterior abdominal wall across the ureter to reach the deep inguinal ring by about the 28th week of gestation. It carries with it its vascular and nerve supplies from the L1 and T10 levels, respectively. Migration of the testis then proceeds through the inguinal canal, collecting layers of spermatic fascia, and enters the scrotum at about the 32nd week. By full term, both testes are well down within the scrotum in 97 % of males and an even higher proportion by 3 months of age. True agenesis of the testis is very rare. The undescended testis usually lies in the upper scrotum or inguinal canal in the line of normal descent, in most cases. Ectopic testicular positioning occurs, with migration of the testis into the anterior abdominal, pubic, perineal, or thigh subcutaneous fatty tissues. The vascular supply to the testis is critical for the continued viability and function of the gonad.

See Table 7.4. Complications are generally minor; however, on occasions some may be more significant. These include bleeding, hematoma formation, infection, skin necrosis, wound dehiscence, acute and chronic pain, testicular ischemia, and atrophy. Infertility may be related to the initial maldescent, rather than the surgery. Urinary retention is rare and occasionally requires catheterization. The increased risk of testicular carcinoma is a consequence of the maldescent, not surgery.

Pain may be significant and may require support dressings and pain relief. Bleeding is rarely severe but can produce a large hematoma requiring surgical evacuation. Testicular ischemia and atrophy may occur and create infertility if the other testis is nonfunctional for any reason. Testicular carcinoma is a potential consequence of a residual intra-abdominal testis, including the decision to defer or not operate. Even with orchidopexy, the rate of testicular carcinoma remains higher than for those with normal testicular descent. Infection usually responds to local dressings and oral antibiotics.

General anesthetic is usually used for adults and children, but when newborn infants are circumcised, a plastic ring device (Plastibell) local anesthetic cream or no anesthesia may be used. The aim is to remove the foreskin proximally to behind the glans penis. This exposes the glans permanently. Parental or religious preference is the usual indication in the newborn. Medical reasons for circumcision include severe phimosis (foreskin stenosis), recurrent urine infections or balanitis, balanitis xerotica obliterans (BXO), and paraphimosis where the foreskin is retracted and becomes stuck behind the glans. Acute paraphimosis can be treated with emergency initial reduction with sedation or a dorsal slit through the constricting band followed by a circumcision involving a GA.

The foreskin ranges from minimal to very redundant, and physiological adhesions may join the glans penis to the foreskin in childhood which usually separate spontaneously before puberty. It is important to differentiate between the normal physiological phimosis of the young child and the pathological phimosis in older children which causes problems, such as balanitis.

See Table 7.5. Complications are generally minor and infrequent; however, some may be more significant on occasions. These include infection, cosmetic deformity, removing too much or too little skin, meatal ulceration, meatal stenosis, and bleeding. Urinary retention is uncommon and occasionally requires catheterization. Tight bandages especially with erections in the adolescent can be painful and require loosening and/or removal.

Pain may be significant and may require loosening of dressings and pain relief. Bleeding is rarely severe. Infection usually responds to local dressings and oral antibiotics, if required. Infection may increase scarring and create poor cosmesis. Meatal ulceration may lead to meatal stenosis on occasions, which may require further surgery, e.g., meatotomy. Cosmetic deformity caused by excess or too little shaft skin or from secondary phimosis may occur and may require revisional surgery.

General anesthetic is used. The aim is to explore the scrotal contents, in particular the testes. The usual indication for bilateral fixation is proven or suspected torsion of one testis. Separate transverse scrotal incisions on each side or a single (transverse or midline) incision through the layers of the scrotum can be used to expose each testis and deliver it outside the scrotum for adequate inspection. The color of the testis is noted and any evidence of torsion. If the testis is black or dark, then a period of time is spent waiting for any color change and improvement in blood supply after reduction of the torsion. Most testes will regain a pink coloration; however, if established necrosis has occurred (~ > 6 h ischemia time), then removal of the testis may be required. The objective is detorsion and fixation to prevent future torsion, achieved by several methods, which may fixate each testis to the scrotal median raphe or to the lateral scrotal tissues or both, or performing a Jaboulay procedure where the processus vaginalis is sutured behind the testis, thereby eradicating the space in which the testis can tort. Either nonabsorbable or absorbable sutures can be used.

The main cause for testicular torsion is congenital high investment of the processus vaginalis around the spermatic cord and no attachment to the posterior epididymis, allowing the testis and epididymis to rotate. The anomaly often produces the clinical “bell clapper” testis phenomenon, with a classical “horizontal lie” of the testis. Focal tenderness over the upper epididymis may signify torsion of an appendage of the testis, but surgical exploration is typically warranted to confirm this. Doppler ultrasound is not very reliable in determining blood flow in children; it may be more helpful in the adolescent and mature male. Torsion of an undescended testis may occur in the younger child.