Epispadias

Epispadias - congenital cleft of upper wall of the urethra.
Men are distinguished: the capitate episodio - splitting in the head of the penis; the penile episodio - splitting up members-pubic corner; members-pubic episodio - splitting up of the external sphincter of the bladder; total episodio - full splitting of the urethra and anterior segment of the sphincter of the bladder.
Epispadias meets much less often hypospadias (see), light form is less common than severe; for men epispadias observed more often than in women.
In women there are 3 forms of epispadias: 1) the urethra split in its external opening, the clitoris is located below the urethra; 2) the splitting of the urethra to sphincter; 3) the urethra split up the bladder, the outer hole has the appearance of a wide funnel through which can stuff Hisself out the mucous membrane of the bubble.
The clinical picture depends on the degree of epispadias. Operative treatment, aimed at creation of the urethra and his sphincter. Children it is better to operate at the age of 5-8 years.

Epispadias (epispadia, from the Greek. epi - over and spadon - slit) - congenital cleft of upper wall of the urethra on different throughout.
In men, there are capitate epispadias (epispadia glandis) - splitting in the head; the penile epispadias (epispadia penis) - the urethra split up members-pubic corner; members-pubic (epispadia subsymphysealis) - splitting up of the external sphincter of the bladder; total epispadias (epispadia totalis) - full splitting of the urethra and anterior segment of the sphincter of the bladder.
Epispadias meets much less often hypospadias (see), light forms are less common than severe, men suffer more often women.
In all forms of epispadias distal to the external opening of the urethra has urethral furrow, covered with mucous, the foreskin is split in severe forms of the penis is underdeveloped and curved up, most of the patients there is a discrepancy pubic bone.
In women, depending on the extent of splitting the urethra disease occurs in three forms: epispadia clitoridis - channel split in its external opening, the clitoris is located below the urethra; epispadia subsymphysealis - splitting up sphincter; epispadia totalis - urethra split up the bladder, the outer hole has the appearance of a wide funnel through which can stuff Hisself out the mucous membrane of the bubble.
Epispadias often combined in men with cryptorchidism, hernias, atony sphincter, rectum, women with the weakening of the pelvic floor prolapse of the vaginal walls and cervix.
The clinical picture depends on the degree of epispadias.
In milder degrees patients complain of splashing urine, hit her on the linen and the surrounding areas of the body; sexual intercourse and fertilization is difficult, but possible. When members-pubic and total epispadias celebrated partial or full incontinence of urine, causing the maceration of the skin of the scrotum, hips, female - genitals; the constant smell of urine makes these patients intolerant society. Sexual intercourse in men is impossible in view of the dramatic curvature and rotation of the penis associated with discrepancies legs cavernous phone
Surgical treatment is aimed at the creation of the urethra and the sphincter of the bladder. It is better to operate children 5-8 years.
The most simple method to create the urethra is the following: from the urethral mucosa furrows with bordering external opening of the channel cut out longitudinal flap width of 1.5-2 cm (Fig. 1)from which the tube form the urethra (Fig. 2). The side flaps sew over the channel in the longitudinal direction (Fig. 3). As suture material is used inert filament yarn of polyester or nylon.

plastic urethra when epispadias
Fig. 1 - 4. Plastic urethra and sphincter of the bladder. Fig. 1-3. Plastic urethra when capitate, penile and members-pubic epispadias. Fig. 1, the Scheme cutting out the flap of the urethral mucosa furrows with bordering external opening of the urethra. Fig. 2. From the flap is formed of urethral tube, side flaps of skin useprivacy. Fig. 3. Above formed the urethra sew cavernous body and skin. Fig. 4-7. Plastic sphincter of the bladder and urethra. Fig. 4. The bladder and urethra opened; the pubic bone divorced; mucous membrane cut the flap; deaconate side triangular flaps for the formation of the neck of the bladder and sphincter. Fig. 5. The urethra is formed; the arrows indicate the direction of movement gemokonservanta Loskutov. Fig. 6. The scheme of creation of the bladder neck, duplicatura gemokonservanta cervical Loskutov. Fig. 7. Strengthening the bladder neck located near fabrics, convergence legs cavernous bodies over the urethra, plastic urethra and closing tissue (bottom left - scheme convergence cavernous bodies over the urethra).

plastic sphincter and bladder neck
Fig. 8 Plastic sphincter and bladder neck by Derzhavin. Bladder naked, on the area of the bladder neck imposed gavryuusha seams, convergent and strengthen the neck.

In severe forms, accompanied by incontinence, create the sphincter of the bladder, which is the preferred method of Duplet (S. Duplay), enhanced young (N. N. Young and Dis (J. E. sound way. The essence of a method consists in removing the front bezmashinnogo segment and the narrowing of the cervix bladder (Fig. 4 - 7).
Median cut cut through the soft tissue, pubic joint, and the front wall of the bladder from the internal openings of the urethra to the tip of the penis. The urethra is formed from the flap of the mucous membrane, cut to the urethral furrow from the top of the penis to mioclonia roller.
In the neck of the bladder create duplicatura by imposing on each other gemokonservanta cervical Loskutov.
Pubic bone pull together thick silk sutures, urine away by suprapubic.
C. M. Derzhavin suggested more physiological method of plasty of the sphincter using overlay on the neck of the bladder double row gavryuusha silk seams (Fig. 8).
If plastic sphincter fails, urine, assign to the large intestine.


Epispadias. If epispadias in men, the urethra is located above the corpus cavernosum, i.e. on the back surface of the penis, and deprived of the front wall on more or less over. The urethra is represented in the form of an open trench, lined with a mucous membrane.
There are three degrees of epispadias. If epispadias head split only part of the urethra that corresponds to the head of the penis. Outer hole is located either at the base of the head, either in coronal sulcus.
If epispadias of the penis (penile) the urethra split on the front wall of the whole of the penis or on a particular part. Outer hole, respectively, is located on the back surface of the penis or at its base (Fig. 67).
In total epispadias upper wall of the urethra seems splintered all over, including the area of the sphincter. All the back surface of the penis has the appearance of a wide slit, going under the pubic joint. Penis underdeveloped, curved up and attached to the skin of the abdomen. Split foreskin hang down. External and internal sphincter of the bladder and the prostate gland underdeveloped. Often there is cryptorchidism or hypoplasia of the testicles. The pubic bones are joined together at the middle line.
In women, epispadias occurs much less frequently than men, and also can be of three degrees.
When clitoral epispadias upper wall of the urethra split only in the field of the external openings so that the latter is not under the clitoris, and above it.
When subcompetency epispadias upper wall of the urethra split all the way to the sphincter, which is usually not well developed. The clitoris and his foreskin also split. The outer opening of the urethra has the form of a funnel, open at the top, leaving behind the symphysis gutters, free flowing finger.
In total epispadias the picture is the same, but the sphincter split in the upper segment. The discrepancy between the pubic bone is observed as a rule.
Penile (women subcompetency) epispadias in most cases accompanied by the relative incontinence. With the increase abdominal pressure, such as coughing, sneezing, physical stresses, urine Tacloban allocated jet in a small amount. In total epispadias, tend to have a full incontinence.
Men for diagnosis enough patient examination. Women strongholds diagnostics are: location outside zheloboobraznogo openings of the urethra over the clitoris, splitting or deformation him, absence of the upper comissary large and small lips.
Epispadias head and klitora epispadias not cause disorder and do not require treatment.
Treatment of penile (subcompetency) epispadias is to restore the front wall of the urethra by stitching her refreshed edges or direct skin flaps on the leg.
The operations that can eliminate incontinence total epispadias have to restore a split or the formation of an artificial sphincter of the bladder, or the creation of artificial obstacles to the flow of urine through the urethra. The first group includes: stapling prepared muscle fibers of the inner and outer zhomy bladder, the creation of the sphincter of the pyramid or direct muscles of the abdomen or thigh muscles; the second - the narrowing of the urethra near the bubble by suturing it, cutting out the flaps of the mucosa.
The operation is best done at the age of 10-12 years when there erections.

Fig. 67. Epispadias.