Concealed congenital anterior urethral diverticulum in a child

DK Gupta; M Srinivas

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CASE REPORT

Year : 2000 \| Volume : 16 \| Issue : 2 \| Page : 160-161

Concealed congenital anterior urethral diverticulum in a child

DK Gupta, M Srinivas
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
D K Gupta
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

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Keywords: Diverticulum; Urethra.

How to cite this article:
Gupta D K, Srinivas M. Concealed congenital anterior urethral diverticulum in a child. Indian J Urol 2000;16:160-1

How to cite this URL:
Gupta D K, Srinivas M. Concealed congenital anterior urethral diverticulum in a child. Indian J Urol [serial online] 2000 [cited 2023 Mar 28];16:160-1. Available from: https://www.indianjurol.com/text.asp?2000/16/2/160/22221

Introduction

Congenital anterior urethral diverticulum (CAUD) is an uncommon condition in children. CAUD is classified into saccular variety and globular variety. The saccular type is more common than the globular type. The cause and effect relationship between anterior urethral diverticulum (AUD) and anterior urethral valves (AUV) is still debated. AUD may lead to a flap valve as the diverticulum burrows.^[1] AUV may possibly lead to the proximal diverticulum mimicking AUD.^[2] As each one of the two leads to the other some authors do not distinguish between AUD and AUV. Some authors believe that AUV is a distinct entity and suggest it be distinguished from AUD. AUV does produce proximal dilatation of urethra but the dilatation is generally mild without an acute angle between the proximal part of the dilated portion of the urethra and the ventral floor. It is suggested not to label this as true diverticulum and distinguish this from the CAUD that forms an acute angle between the proximal part of the dilated portion of the urethra and the ventral floor.^[3] Based on this suggestion we have separated CAUD from the other anterior urethral abnormalities. CAUD generally presents as a ventral penile swelling. However, this condition may present with lower urinary tract obstruction and its sequelae. When CAUD presents with urinary tract infection or poor stream but not as a ventral penile swelling, a high degree of suspicion is necessary to pick up this condition. This child presented with a poor urinary stream and urinary tract infection and the swelling apparently concealed within the preputial sac. CAUD may even be asymptomatic.^[4]

Case Report

A 1-year-old male child presented with poor urinary stream and recurrent urinary tract infection. The general physical and local examination performed at the outpatient department did not pick up the condition. Routine urine examination showed presence of pus cells and the culture was positive. MCU showed bilateral grade II VUR. Urethrography phase revealed the CAUD [Figure 1]. Detailed examination later performed showed a fluctuant swelling of the distal anterior urethra and the swelling was being masked by the prepuce. At surgery, the diverticulum was well delineated when sterile saline was delivered through the meatus while obstructing the urethra proximally. Endoscopy revealed the diverticulum of the anterior urethra. The child underwent excision of the diverticulum and repair of the urethra. Postoperatively the MCU showed normal urethra and the severity of reflux had decreased and presently the child is asymptomatic.

Comments

The embryology of CAUD is still not clear. Dilation of periurethral glands, incomplete urethral duplication, defective fusion of ventral folds over urethral groove or faulty development of corpus spongiosum.^[5],[6] Because of the lack of periurethral erctile tissue support, urethral dilation in this region may develop into a diverticulum. Suter^[7] proposed the theory that diverticulum of urethra is because of epidermal pockets communicating with ventral wall of the urethra. As the anterior urethral tube forms, urethral gutter may leave behind epithelial cells that form a congenital cyst. Cysts in this region developing a communication with urethra could also lead to diverticulum as a result of spontaneous rupture of cyst into the lumen of the urethra.^[8]

In children, most patients present with difficulty in micturition, dribbling of urine, poor urinary stream or UTI. A palpable compressible swelling at the ventral aspect of penis is diagnostic of CAUD. AUD may be overlooked at a cursory examination unless kept in mind. Patients may present with lower urinary tract obstruction, vesico ureteric reflux and rarely with signs and symptoms suggestive of uremia. This condition may present later in adult age with similar symptoms and signs or even with a stone in the diverticulum^[9] or hydrocele.^[10] In the absence of a swelling, diagnosis depends on urethrography that is the sheet anchor for the diagnosis. Urethroscopy is both diagnostic and therapeutic as well. Ultrasonography is complementary to the contrast studies to diagnose this condition. We could delineate very well the diverticulum of the anterior urethra^[11] and this offers an additional advantage of evaluating the upper tracts. In this child the fluctuant swelling was missed initially as the swelling was being concealed by the prepuce and the diagnosis was confirmed by the contrast study. Open diverticulectomy and the repair of the anterior urethra has given excellent results. We believe that open diverticulectomy and repair is better as the complete exposure of the diverticulum is possible and surgical repair offers treatment in a single stage.

References

1.	Watts SH. Urethral diverticula in the male with report of a case. John Hopkins Hospital Reports 1906: 13: 48-89.
2.	Gingell JC, Mitchell JP, Roberts M. Concealed anterior urethral diverticulum causing urinary obstruction in the male child. Br J Urol 1972: 44:602-606.
3.	Karnak I. Senocak ME, Buyukpamukcu N, Hicsonmez A. Rare congenital abnormalities of the anterior urethra. Pediatr. Surg Int 1997; 12:407-409.
4.	Ortlip SA. Gonzalez R, Williams RD. Diverticula of the male urethra. J Urol 1980: 124: 350-355.
5.	Dorairajan T. Defects of spongy tissue and congenital diverticula of the penile urethra. Aust NZ Surg 1963; 32: 209-214.
6.	Kirks DR, Grossman H. Congenital saccular anterior urethral diverticulum. Radiology 1981; 140: 367-372. [PUBMED] [FULLTEXT]
7.	Suter F. Ein Beitrag zur histologic and genese der congenitalen divertikel der mannlichen hornrorhe. Archiv Fur Kilische Chir 1908; 87: 225-242.
8.	Johnson F P. Diverticula and cysts of the urethra. J Urol 1923; 10: 295-310.
9.	Sreedhar K, Singh SK. Mandal AK, Sharma SK. Giant calculus in anterior urethral diverticulum. Urol Int 1992: 48: 117-119.
10.	Lima SVC, Pereira CS. Giant diverticulum of the anterior urethra. BR J Urol 1980: 52: 335-336.
11.	Goyal M, Sharma R. Gupta DK, Sharma A. Berry M. Congenital anterior urethral diverticulum: sonographic diagnosis. J Clin Ultrasound 1996: 24: 543-544.