A review of pediatric glans malformations: a handy clinical reference

Acquired Penile Epidermoid Cysts in Children

Background

In this study, we aim to present the experience of a tertiary center regarding penile epidermoid cysts over 15 years.

Methodology

Patient files of those who underwent surgical excision for penile epidermoid cysts between 2005 and 2019 were reviewed retrospectively. The demographics, clinical characteristics, etiological factors, cyst features, surgical techniques, complications, and follow-up data were analyzed.

Results

In total, 24 penile epidermoid cysts were excised in 21 boys. The median age at the time of surgery was 52 (15-204) months. The median duration between previous surgery and cyst excision was 40 (1-180) months. In total, 11 cases had a history of circumcision, and 10 had undergone hypospadias surgery. There was no significant difference between these two etiologic groups (p > 0.05). The main symptom was an asymptomatic penile mass. The average cyst size was 9.4 ± 6.7 mm. All cysts were completely excised with incisions made over old scars, except one. No complications were observed during a median follow-up period of 50 (12-120) months, and only one recurrence was noted.

Conclusions

Acquired penile epidermoid cysts may present as an early or late complication after penile surgery. Complete excision with an incision along the existing scars seems to be an effective solution for preventing new scars.

Do Parameatal Urethral Cysts in Children Need Surgical Excision?

OBJECTIVE

To examine pathophysiology of parameatal urethral cyst (PUC) with comparison between the surgical excision group and the spontaneous resolution group.

METHODS

We retrospectively reviewed all patients diagnosed with PUC and aged ≤15 years. Initially, all the patients received observation without any treatment. The indication of surgical excision was family preference. The patients were analyzed according to their sex, age, symptoms, clinical course, and pathological examination findings.

RESULTS

Among the 54 boys visited our hospital for PUC. The median age at presentation was 35 (IQR: 12-50) months, including 7 (13.0%) neonates cases. In total, 38 (70.4%) patients were underwent surgical excision, 12 (22.2%) had spontaneous resolution during observation, 1 (1.9%) had observation without resolution, and 3 (5.6%) were lost to follow-up. The median size of PUC at the first visit was significantly larger in the surgical excision group (5 mm median, IQR 3-5) than in the spontaneous resolution group (1.5 mm median, IQR 1-2.5) (P <.0001). In this study, PUC ≥5 mm in diameter did not have spontaneous resolution.

CONCLUSION

This is the largest study of PUC conducted at a single institute. This study indicated that 22% of PUCs had spontaneous resolution, and PUCs <5 mm had potential for spontaneous resolution. The results recommend an observation of at least 5.5 months for patients with asymptomatic PUC <5 mm. By contrast, we recommend the surgical excision for symptomatic PUC ≥5 mm according to the family preference.

Zebras in Foreskin Dermatopathology: A Review

OBJECTIVES

The aim of the study was to review uncommon foreskin dermatopathology conditions clinically and pathologically.

METHODS

A database search of PubMed and Google Scholar were extracted between March 1, 2009, and March 1, 2019, using the search terms "foreskin," "prepuce," "penis," "pathology," "dermatology," and "rare." The search was limited to "humans" and "dermatopathology." Full article texts were reviewed. Reference lists were screened for additional articles. Patient details (diagnosis, dermatopathology, treatment, and follow-up if available) were extracted. We excluded articles written in the non-English language, unusual variants of common conditions, and cases of common dermatologic conditions.

RESULTS

A list of 369 articles was identified and another screening identified 30 articles for rare foreskin pathologies. Those are divided into categories based on the following etiologies: (a) benign, including congenital (e.g., aposthia), infectious (graft versus host disease and histoplasma), autoimmune (Crohn's disease and pyoderma gangrenosum), and benign neoplasms (neurofibroma, apocrine hidrocystoma, verruciform xanthoma, porokeratosis, penile cutaneous horn, localized amyloidosis) and (b) malignancies, including primary (myeloid sarcoma, basal cell carcinoma, Kaposi's sarcoma, mucosal-associated lymphoid tissue lymphoma), and metastasis.

CONCLUSIONS

We reviewed and discussed unusual benign and malignant dermatopathology conditions that can affect the foreskin.

Median raphe cyst of the penis: a case report and review of the literature

BACKGROUND

A defect in embryological development or closure of median raphe may lead to formation of cyst(s) anywhere in the midline from glans to anus. These cysts are referred to as median raphe cysts, an uncommonly encountered clinical condition. The cyst is generally solitary, with the penile shaft being the most common location, with average size of around 1 cm. The diagnosis is mostly clinical and confirmed histologically. We report a case of a patient with a rare histological variant of median raphe cyst and provide a focused review on presentation, histopathology, and management.

CASE PRESENTATION

A 29-year-old unmarried Nepali man presented to our clinic with an asymptomatic, solitary, soft, translucent, nontender cystic lesion of about 1-cm diameter at the ventral aspect of glans penis, close to the meatus, that had been noticed at the age of 3 and was nonprogressive for the past 15 years. Ultrasonography demonstrated an isoechoic cystic lesion at the tip of the penis, separated from the urethra, and lying entirely within the mucosa without any evidence of solid component, septation, or vascularity. On the basis of clinical and ultrasonographic findings, a diagnosis of median raphe cyst of the penis was made. The cyst was excised with the patient under local anesthesia, and there was no evidence of recurrence in 2 years of follow-up. The histopathological examination with Hematoxylin and eosin staining showed the cyst wall was lined partly by ciliated pseudostratified columnar epithelium and partly by columnar epithelium with apical mucin.

CONCLUSIONS

Median raphe cyst is an uncommon, mostly asymptomatic condition in young patients. The cyst may occur anywhere along the midline from glans to anus. The diagnosis is clinical with histological confirmation. Excision is the treatment of choice with minimal chance of recurrence.

Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder

Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring. In our opinion, surgery for small glanular venous malformations is indicated within puberty to prevent traumatic bleeding and psychological impact.

Glans duplication: In-depth review and proposal of a new classification

BACKGROUND

Diphallia is a very uncommon malformation, and glans duplication (GD) is its rarest form. In this last group, patients normally present with esthetic/sexual complaints or obstructed voiding late in life after pubertal genital development. Associated malformations are uncommon and relatively mild in those cases.

METHODS

After a case presented, we present herein an extensive review of GD, as the disease is rare, and there is very little about its treatment and there are diverse approaches to address the condition.

RESULTS

After an extensive review of the available literature, we carefully analyzed each published case to describe specific aspects of their clinical presentation (age, main complaint, voiding/urethral problems, and individual anatomy) and treatment.

CONCLUSION

This review allowed us to propose a new classification for diphallia into four groups (true diphallia, hemiphallus, pseudodiphallia, and partial duplication), considering embryological, anatomical, clinical, and therapeutic implications (see Fig. 1). Glans duplications present as esthetic/sexual cases or show abnormal voiding patterns caused by urethral associated abnormalities. Reconstructive techniques may be simple (resection of a hypoplastic accessory glans + urethra) or relatively complex (glans and/or urethral reconstruction).

Long-term Follow-up of Median Raphe Cysts and Parameatal Urethral Cysts in Male Children

OBJECTIVE

To clarify the long-term outcome of median raphe cysts (MRCs) and parameatal urethral cysts (PUCs) in males, the clinical, anatomical, and histological findings of these cysts are described, along with treatment and follow-up.

MATERIALS AND METHODS

Forty-six children diagnosed with PUCs and 23 children with MRCs at our institute during the past 14 years were retrospectively reviewed. The indications for surgery were symptoms or family preference. Telephone interviews of the parents or patients were conducted to ascertain the current condition of the cyst at a median age of 12.2 years. Fifty-nine children (85.5%) agreed to the telephone interview.

RESULTS

Median age at first presentation was 41 months; 81% of children were asymptomatic. The main symptoms were voiding symptoms with PUCs and pain of the ruptured cyst in MRCs. A total of 41 (59%) children underwent complete excision at a median age of 58 months. No recurrences were encountered with surgery in all children. Of 28 children managed nonoperatively, 22 agreed to an interview. All children (95.5%), except for 1, remained free of symptoms. Six cysts showed spontaneous resolution at a median age of 24 months, and 15 improved or stabilized. No one was concerned about the genital appearance and opted for surgical intervention.

CONCLUSION

Complete excision of the cyst is a durable procedure without recurrences in childhood. In the nonoperative management, several cysts may continue to be free of symptoms during childhood, and some cysts may resolve spontaneously during the first 2 years.

Benign penile skin anomalies in children: a primer for pediatricians

BACKGROUND

Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern.

DATA SOURCES

The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions.

RESULTS

Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age.

CONCLUSION

This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

Comparative gene expression analysis of genital tubercle development reveals a putative appendicular Wnt7 network for the epidermal differentiation

Here we describe the first detailed catalog of gene expression in the developing lower urinary tract (LUT), including epithelial and mesenchymal portions of the developing bladder, urogenital sinus, urethra, and genital tubercle (GT) at E13 and E14. Top compartment-specific genes implicated by the microarray data were validated using whole-mount in situ hybridization (ISH) over the entire LUT. To demonstrate the potential of this resource to implicate developmentally critical features, we focused on gene expression patterns and pathways in the sexually indeterminate, androgen-independent GT. GT expression patterns reinforced the proposed similarities between development of GT, limb, and craniofacial prominences. Comparison of spatial expression patterns predicted a network of Wnt7a-associated GT-enriched epithelial genes, including Gjb2, Dsc3, Krt5, and Sostdc1. Known from other contexts, these genes are associated with normal epidermal differentiation, with disruptions in Dsc3 and Gjb2 showing palmo-plantar keratoderma in the limb. We propose that this gene network contributes to normal foreskin, scrotum, and labial development. As several of these genes are known to be regulated by, or contain cis elements responsive to retinoic acid, estrogen, or androgen, this implicates this pathway in the later androgen-dependent development of the GT.