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ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 9-12
 

Pediatric penile and glans anthropometry nomograms: An aid in hypospadias management


Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Date of Web Publication23-Nov-2016

Correspondence Address:
Archana Puri
Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.194610

Clinical trial registration not applicable

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   Abstract 

Objective: To establish pediatric penile and glans anthropometry nomograms. This may be used as a reference model for penile assessment while managing hypospadias.
Patients and Methods: Between October 2012 and September 2013, 263 boys of varying ages (0-16 years) were included in the study. Those with genetic, endocrine disorders, having genital anomaly, undescended testis, neonates, and infants with a nonretractile prepuce, with multiple congenital anomalies and refusal to take part in the study were excluded. Evaluated outcome variables were stretched penile length, glans circumference (GC) at coronal sulcus, glans diameter at coronal sulcus (Gdcl), mid glans diameter, and ventral glans length. Glans ratios were generated by dividing Gdcl by GC. Data were expressed as mean, median, and standard deviation. Correlation between age and variables was evaluated using nonparametric Spearman's rank correlation coefficient.
Results: The patients were divided in six age groups, namely 0-1 (n = 61), 1-3 (n = 37), 3-5 (n = 36), 5-7 (n = 36), 7-12 (n = 45), and >12 years (n = 48). Gdcl was the maximum transverse glans diameter and based on it small glans size varied widely from 8.9 to 35.04 mm for various age groups. Although glans anthropometry showed age-related changes, glans ratio remained relatively constant between 0.49 and 0.53 (mean: 0.5 ± 0.051, r = 0.29). All the variables except glans ratio showed a significant positive correlation with age (r = 0.954-0.98, P < 0.01).
Conclusion: Penile anthropometry nomograms provide a reference model for hypospadias. This may aid in (a) objective preoperative assessment of glans size (b) patient selection for preoperative hormonal stimulation (c) provides a yardstick for postoperative cosmesis.


Keywords: Glans size, hormonal stimulation, hypospadias, nomograms, penile anthropometry


How to cite this article:
Puri A, Sikdar S, Prakash R. Pediatric penile and glans anthropometry nomograms: An aid in hypospadias management. J Indian Assoc Pediatr Surg 2017;22:9-12

How to cite this URL:
Puri A, Sikdar S, Prakash R. Pediatric penile and glans anthropometry nomograms: An aid in hypospadias management. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2017 Jul 22];22:9-12. Available from: http://www.jiaps.com/text.asp?2017/22/1/9/194610



   Introduction Top


Penile biometrics in hypospadias is currently the focus of much research. [1] However, in the absence of comprehensive pediatric penile anthropometry nomograms, the assessments are often subjective and are prone to interobserver variations. [2] There are few studies describing penile anthropometry in children beyond neonatal age, and still few that describe penile nomograms other than penile length and diameter. [3],[4],[5],[6],[7],[8] There is scarcity of data on glans anthropometry. A study on glans anthropometry in 0-24 months, defined small glans as maximum glans width of <14 mm, and identified it as one of the determinants contributing to glans dehiscence following hypospadias repair. [8],[9] The authors, however, feel that this glans width cutoff may vary with age and may have different therapeutic implications say in 1-, 3-, and 10-year-old child with hypospadias. Hence, there is a need to develop age-related pediatric penile nomograms to define the range of normalcy so that the variations in penile biometrics can be better identified. The data thus generated shall establish age-matched controls for penile assessment to be used as reference model while managing hypospadias. This study aims to establish penile anthropometry nomograms in a wider age range from 0 to 16 years. These data may aid in better evaluation and management of hypospadias.


   Patients and Methods Top


The present study included 263 boys of varying ages (0-16 years) over a study period of 1-year (October 2012 and September 2013). Boys with genetic, endocrine disorders, having genital anomaly, undescended testis, neonates and infants with nonretractile prepuce, with multiple congenital anomalies, and parental refusal to take part in the study were excluded. Of the 263 boys, 152 were assessed during the outpatient clinic visit. The indications for surgical referral were chronic constipation (n = 62), cervical lymphadenopathy (n = 22), urinary tract infection (n = 12), abdominal pain (n = 26), and hernia (n = 30). The remaining 111 boys were assessed during hospital admission for acute intestinal obstruction (n = 42), appendectomy (n = 24), perforation peritonitis (n = 28), pancreatitis (n = 5), and neurogenic bladder (n = 12). Penile anthropometry was evaluated by measuring glans circumference (GC) at coronal sulcus, transverse glans diameter at coronal sulcus (Gdcl), mid glans diameter (Gdmgl), ventral glans length (VL), and stretched penile length (SPL). The same person (SS) under the supervision of the senior author (AP) performed all measurements in a warm room, in the supine position, in the presence of a parent or a legal guardian. Measurements were taken with calipers, measuring scale, and calibrated umbilical catheter. Three readings were taken, and the mean was recorded. GC was measured with the umbilical catheter at exposed glans with foreskin retracted. Gdmgl and Gdcl were measured with calipers as the horizontal distance between two lateral edges at mid glans and at coronal sulcus, respectively [Figure 1], as described previously. [8] Glans ratios were generated by dividing Gdcl by GC. VL was measured as the distance between the distal limit of urethral meatus to coronal sulcus on the ventral glans. [10] SPL was measured on the dorsal aspect of the penis as the distance between the tip of glans and the root of the penis as described previously. [3] Data was expressed as mean, standard deviation (SD) and median. The correlation between age and variables was determined by nonparametric Pearson's correlation analysis, with P < 0.05 defined as statistical significance.
Figure 1: Glans anthropometry measurements, glans diameter at coronal sulcus, mid glans diameter, glans circumference, and glans ratio

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   Results Top


The patients were divided in six age groups, namely 0-1 (n = 61), 1-3 (n = 37), 3-5 (n = 36), 5-7 (n = 36), 7-12 (n = 45), and > 12 years (n = 48). Penile nomograms are presented in [Table 1]. Glans anthropometry showed age-related variations, with GC, Gdcl, and Gdmgl (mean ± SD) ranging from 24 to 80 (47.9 ± 15.87), 10 to 43 (25 ± 9.02), and 8 to 39 (22.71 ± 8.70) mm, respectively [Figure 2] and [Figure 3]. Gdcl was recorded as the maximum glans transverse diameter, and based on it small glans size varied widely from 8.9 to 35.04 mm for various age groups. However, glans ratio remained relatively constant irrespective of age and varied from 0.47 to 0.53 (mean: 0.5 ± 0.051, r = 0.29). Glans ratio (mean-2SD) varied from 0.33 to 0.51. Although glans ratio in the range of mean ± 2SD may be regarded as statistical normal, small glans is defined as glans ratio < 2 SD for age. Based on our data, glans ratio < 0.3, irrespective of age, denoted small glans. All the variables except glans ratio showed a significant positive correlation with age (r = 0.954-0.98, P < 0.01). A graph depicting nomograms for SPL and VL are depicted in [Figure 4].
Figure 2: Age-related variations in glans circumference anthropometry

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Figure 3: (a) Age-related variations in glans diameter at coronal sulcus anthropometry; (b) age-related variations in mid glans diameter anthropometry

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Figure 4: (a) Age-related variations in stretched penile length; (b) age-related variations in ventral glans length

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Table 1: Age-related nomograms of SPL, GC, Gdcl, Gdmgl, glans ratio and VL

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   Discussion Top


The universally acceptable aims of hypospadias surgery are the formation of cosmetically and functionally acceptable phallus, with orthotopic slit-like meatus and conical glans. [1],[11] However, evaluation of severity of hypospadias remains a matter of dispute. [2] Thus, a need was felt to standardize the criteria to evaluate and classify hypospadias. [2] GMS score based on qualitative assessment of glans size (G), meatal position (M), and penile shaft (S) aimed to achieve uniformity in classifying the severity of hypospadias. [12] Despite the subjective nature of the G-score (glans size was graded as good, adequate, and small), this study highlighted the complexities in doing glans measurements. [12] Should the glans be measured at mid glans or at its base or should a ratio be used? [12] The present study is unique in that it presents detailed glans anthropometry nomograms including measurements of GC, Gdcl (maximum glans diameter), Gdmgl, and glans ratio in a wider age range. Thus, it provides a reference model to be used as age-matched controls while evaluating hypospadias population. Although glans anthropometry showed age-related changes, glans ratio remained relatively constant, and varied from 0.47 to 0.53 (mean: 0.5 ± 0.051; r = 0.29). Glans ratio (mean-2SD) varied from 0.33 to 0.51, implying that glans ratio of < 0.3 may denote small glans irrespective of age. The earlier study on glans anthropometry defined small glans as maximum glans width of < 14 mm. [8] The present study, however, showed that maximum glans width varies with age from 8.9 to 35.04 mm and that this definition is inappropriate for older children. Future studies are needed to evaluate glans anthropometry in hypospadias, and to study its impact on postoperative outcomes like glans dehiscence. Preoperative hormonal stimulation in hypospadias is often given empirically for "small appearing penis or small glans penis with maximum glans diameter < 14 mm." [2],[8] Patient selection based on Gdcl < mean -2 needs further investigations. Glans ratio may also be used to evaluate the cosmetic outcome following surgery.

There are many studies describing penile length variations in the neonatal age group of various ethnicities. [3],[4],[5],[6],[7] The values of SPL in this study are in accordance with those reported earlier. [3],[4],[5],[6],[7] Penile length variations in hypospadias are known to occur due to mild hypogonadism during fetal development. [1] Penile length nomograms can be used as age-matched controls while studying variations in hypospadias population. The data on VL are in congruity with earlier descriptions of the anatomy of the external urethral meatus and provide a yardstick for cosmetic outcome evaluation after hypospadias repair. [10] All the reported variables are simple and reproducible and can be measured easily in hypospadias. Although similar ethnicity of study population poses a limitation, yet to our knowledge, this is the first study to present a detailed glans anthropometry with glans ratio. Although penile length is known to have ethnic variations, whether this holds true for glans anthropometry needs to be looked into by further studies. Besides, much more can be learned from multicenter trials to study the ethnic variations, and to compare these variables in hypospadias population. These data may be used as a reference range in objective preoperative assessment, patient selection for preoperative hormonal stimulation and as a yardstick for postoperative cosmesis.


   Conclusion Top


We have established a reference range of penile anthropometry from 0 to 16 years. This may be of value to a hypospadiologist in preoperative assessment, subsequent decision making, and in the evaluation of postoperative cosmesis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
da Silva EA, Lobountch`enko T, Marun MN, Rondon A, Damião R. Role of penile biometric characteristics on surgical outcome of hypospadias repair. Pediatr Surg Int 2014;30:339-44.  Back to cited text no. 1
    
2.
Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias dilemmas: A round table. J Pediatr Urol 2011;7:145-57.  Back to cited text no. 2
    
3.
Teckchandani N, Bajpai M. Penile length nomogram for Asian Indian prepubertal boys. J Pediatr Urol 2014;10:352-4.  Back to cited text no. 3
    
4.
Cinaz P, Yesilkaya E, Onganlar YH, Boyraz M, Bideci A, Camurdan O, et al. Penile anthropometry of normal prepubertal boys in Turkey. Acta Paediatr 2012;101:e33-6.  Back to cited text no. 4
    
5.
Vasudevan G, Manivarmane, Bhat BV, Bhatia BD, Kumar S. Genital standards for South Indian male newborns. Indian J Pediatr 1995;62:593-6.  Back to cited text no. 5
    
6.
Akin Y, Ercan O, Telatar B, Tarhan F. Penile size in term newborn infants. Turk J Pediatr 2011;53:301-7.  Back to cited text no. 6
    
7.
Fievet L, Harper L, Chirpaz E, Michel JL, Sauvat F. Penile length is comparable in boys with and without hypospadias. J Pediatr Urol 2012;8:493-6.  Back to cited text no. 7
    
8.
Bush NC, DaJusta D, Snodgrass WT. Glans penis width in patients with hypospadias compared to healthy controls. J Pediatr Urol 2013;9(6 Pt B):1188-91.  Back to cited text no. 8
    
9.
Snodgrass W, Cost N, Nakonezny PA, Bush N. Analysis of risk factors for glans dehiscence after tubularized incised plate hypospadias repair. J Urol 2011;185:1845-9.  Back to cited text no. 9
    
10.
Hutton KA, Babu R. Normal anatomy of the external urethral meatus in boys: Implications for hypospadias repair. BJU Int 2007;100:161-3.  Back to cited text no. 10
    
11.
Snodgrass WT. Hypospadias. In: Wein JA, Kavoussi LR, Novick CA, editors. Campbell Urology. 10 th ed., Ch. 130. Philadelphia: WB Saunders Co.; 2012. p. 3503-36.  Back to cited text no. 11
    
12.
Merriman LS, Arlen AM, Broecker BH, Smith EA, Kirsch AJ, Elmore JM. The GMS hypospadias score: Assessment of inter-observer reliability and correlation with post-operative complications. J Pediatr Urol 2013;9(6 Pt A):707-12.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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