Discussion
Urethral duplication is a rare congenital anomaly that can present with varying presentations. This anomaly has been described mostly in males, few cases in females have been reported.7 Duplication usually occurs in the sagittal plane, less commonly side by side.2 A lot of hypotheses have been proposed for urethral duplication, including ischemia, abnormal lacunar fold duplication, abnormality of Mullerian duct, and urogenital sinus.3 However, the embryology is unclear as described in the literature.
In males, urethral duplication is classified into three types (Effmann’s classification):4
TYPE I- Blind incomplete urethral duplication (accessory urethra).
Distal-opens on the dorsal or ventral surface of the penis but does not communicate with the urethra or the bladder.
Proximal-opens from the urethral channel and ends blindly in the periurethral tissue.
Type II- Complete patent urethral duplication.
It is further divided into two types: A (two meatuses) and B (one meatus).
Type III- Urethral duplication as a component of partial or complete caudal duplication.
Presentations depend upon the type of anatomic variability of the anomaly. Patients may present with a double stream, urinary incontinence, outflow obstruction, recurrent urinary tract infection, sometimes with sepsis; or there may not be any symptoms.3,8 Physical examination usually reveals 2 meatuses. Other findings may include associated anatomical abnormalities, such as ambiguous genitalia, epispadias, hypospadias, and chordee.6 Investigations such as voiding cystourethrography, retrograde urography, urethrocystoscopy and intravenous urography depict a clear picture of the anatomical malformation.3,8 Patients are treated based on their presentation. Asymptomatic patients can be left untreated whereas those having bothersome symptoms should undergo surgical excision and construction as required.8 Among various surgical procedures; excision, ligation, fulguration, and sclerosis of the accessory channel have been described well.6Multistage urethral reconstruction is necessary depending upon the type of abnormality.3 Simple accessory duplicated urethras may be fulgurated with an electrode and allowed to heal and close. A single meatus can be created by dividing the septum between the two meatuses if both of the urethrae are functional and close to each other on the glans.1 A rare type IIA2 (Y type) can be treated with complete excision of the accessory urethra that opens into the scrotum from the normal urethra.9 This complex variety may need extensive urethroplasties requiring tissue transfer, such as buccal mucosa grafts.1 End-to-side urethrourethrostomy can be done in some cases of urethral duplication.10