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