Case No. :	70
Month :	October
Year :	2004
Contributor :	Dr. Ansu Abraham

Other Cases

An 18-year-old male came with complains of double urinary stream since birth . He had no difficulty in micturation . On examination, the patient had a double meatus with chordee.

RADIOLOGICAL Examination:

Voiding csytourethrography showed a double membranous urethra. ( Fig 1)

Fig. 1

Distal urethrography showed a complete duplication of the penile and bulbous urethra.

Fig. 2

Sonourethrogram : An Infant feeding tube was passed through the ventral urethra , and adaptor attached to dorsal urethra and saline flushed through both simultaneously under real time ultrasound. This showed saline entering the urinary bladder through two seperate channels. No plaques or calcifications were detected. ( Figs 3-6).

Fig. 3	Fig. 4
Fig. 5	Fig. 6

 

MRI : Infant feeding tubes were passed through both urethras and both were seen entering the bladder through two completely different channels. (Figs. 7-9).

Fig. 7	Fig. 8
Fig. 9

DISCUSSION:

Urethral duplication is a rare congenital anomaly with approximately 190 cases described in literature. Most of the reported cases are of incomplete duplications, with complete duplication being rare. This anomaly is most common in males with a few cases having been reported in females.

The embryology of this condition is unclear.

There have been various attempts to classify urethral duplication .

1) True Duplication : ( very rare) Complete duplication of bladder necks, two seperate urethral channels, two external orifices and a double penis are present

2) Complete double urethra : Same as true duplication but with a single penis.

3 ) Incomplete duplication and accessory channels .

The most accepted classification is the Effman's classification.

Type 1 : Incomplete Duplication

Type 1A : Distal	Type 1B : Proximal

Type 2 : Complete Urethral Duplication

Type 2A : Two meati	Type 2B : One meatus.

Type 3 :Urethral duplication as a component of partial or complete caudal duplication



According to this classification our case belonged to type 2A -1

Clinical features : Most patients are asymptomatic except for a double stream , though some of them can present with urinary tract infections, incontinence, bladder outflow tract obstruction . Genitourinary anomalies and lumbar spine anomalies have been reported.

Differential diagnosis : Fistulous tract resulting from instrumentation, operative procedures, infections.

Knowledge of urethral duplication is important in respect to surgical procedures. Surgery should be considered in patients with annoying symptoms such as double stream, for cosmetic deformity such as epispadiac meatus.

Sonourethrogram : Is a real time study and has its own advantages - no radiation hazard, no use of iodinated contrast media, and can help to detect any plaques and calcifications.

MRI : helps in delineating urethral and periurethral soft tissues non invasively. In congenital anomalies it is mainly reserved for intersex anomalies and complex genitourinary anomalies.Its multiplanar capability and excellent tissue contrast being a definite advantage.

USG and MRI are thus now being used as adjuncts to voiding cystography and retrograde urethrography in urethral imaging.

In this case, the patient underwent surgical correction - the duplicated urethra was completely excised and the chordee corrected.

 

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