Objective documentation of hypospadias anatomy with three-dimensional scanning.

INTRODUCTION: The absence of a standardized classification of hypospadias hinders understanding of the anatomic differences among patients and the evaluation of outcomes following surgical repair. In working towards a standardized, objective method of recording patients' hypospadias anatomy, we describe our initial experience using a non-invasive three-dimensional scanner. MATERIAL AND METHODS: An Artec3D Space Spider scanner was used to obtain 3D scans in 29 patients undergoing hypospadias repair. Measurements of the urethral plate width, urethral plate length, glans width, penile shaft length, and penile shaft width were made by 2 pediatric urology attendings and 1 pediatric urology fellow. Measurements were compared and inter-rater reliability was calculated. RESULTS: A total of 435 measurements were made on 29 successfully generated 3D scans, ranging from distal to proximal hypospadias. The inter-rater reliability of measurements from the generated 3D models shown good inter-rater reliability of urethral plate width (ICC0.87 [95%CI:0.76,0.93]), penile shaft length (ICC0.87 [95%CI:0.70,0.94]) and glans width (ICC0.83 [95%CI:0.68,0.92]), excellent inter-rater reliability of urethral plate length (ICC0.96) and moderate inter-rater reliability of penile shaft width (ICC0.69 [95%CI:0.44,0.84]). DISCUSSION: There was a high degree of reliability of measurements made across multiple users. Calculation of the ratio of the urethral plate length/total penile shaft length objectively defined the initial position of the urethral meatus. When compared to the 3-dimensional volume of the glans, a more proximally positioned urethral meatus was associated with a lower glans volume. CONCLUSION: 3D scanning offers a rapid, reproducible, and non-invasive method of documenting hypospadias anatomy. The ability to evaluate three dimensional features (i.e. glans volume) offers an exciting opportunities for robust investigation of hypospadias outcomes and further understanding of the relationship between a patient's genotype and phenotype.

Predictive value of ultrasound in prenatal diagnosis of hypospadias: hints for accurate diagnosis.

OBJECTIVES: This study aims to assess the diagnostic accuracy of targeted ultrasound examination in prenatal diagnosis of hypospadias and to evaluate the predictive values of defined ultrasonographic findings of hypospadias. METHODS: The cases diagnosed with hypospadias in our fetal medicine center were identified on an electronic database. The ultrasound reports, images and hospital records were reviewed retrospectively. The predictive value of prenatal ultrasound diagnosis and the predictive values of each sonographic finding were assessed according to the postnatal clinical examinations. RESULTS: Thirty-nine cases were diagnosed with hypospadias on ultrasound during the 6 years. Nine fetuses with missing postnatal examination records were excluded. Twentytwo of the remaining fetuses had their prenatal diagnosis of hypospadias confirmed in postnatal examinations, indicating a 73.3 % positive predictive value. Normal external genitalia was detected in postnatal examinations of three fetuses. Five fetuses were diagnosed with other external genital abnormalities, including micropenis (n=2), clitoromegaly (n=2), and buried penis with bifid scrotum (n=1) in postnatal examinations. The positive predictive value of prenatal ultrasound for any external genital abnormality was 90 %. CONCLUSIONS: Although the positive predictive value of ultrasound for genital anomalies is satisfying, it is slightly lower for the specific diagnosis of hypospadias. This reflects overlapping ultrasound findings of different external genitalia anomalies. Standardized, systematic evaluation of the internal and external genital organs, karyotyping and genetic sex determination are essential to achieve a precise prenatal diagnosis of hypospadias.

Hipospadias: del diagnóstico ecográfico prenatal al manejo posnatal / Hypospadias: from prenatal ultrasound diagnosis to postnatal management

El hipospadias es la localización anormal del meato urinario y es la malformación de genitales externos más frecuentemente diagnosticada. El diagnóstico prenatal es posible mediante ecografía sistemática desde la semana 20 de gestación, siendo más fácil su diagnóstico en el tercer trimestre. Las formas leves suelen ser aisladas, familiares o asociadas a disfunción placentaria o restricción de crecimiento intrauterino, mientras que las formas más graves presentan hasta un 30% de asociación a defectos fetales, anomalías cromosómicas/genéticas o anomalías del desarrollo sexual. La tríada para el diagnóstico ecográfico prenatal consiste en curvatura ventral del pene, anomalía del prepucio dorsal y punta del pene roma. La valoración de la uretra durante la micción y el aspecto del chorro miccional son de gran utilidad para clasificar el defecto. Cuando se diagnostica hipospadias peneano o escrotal es aconsejable realizar una amniocentesis para estudio genético fetal y valorar otros signos de adecuada virilización, como el descenso testicular a partir de la semana 27. El seguimiento tras el parto debe ser multidisciplinario, incluyendo urólogo y endocrinólogo infantil. En hipospadias leves el pronóstico es bueno con reparación quirúrgica en el primer año de vida, pero las formas graves pueden presentar un reto mayor para su corrección funcional y estética.

Hypospadias refers to the abnormal location of the meatus; it is the most common genital malformation detected in the fetus and newborn. Prenatal diagnosis is feasible from 20 weeks onwards with routine ultrasound; however, it is easier to diagnose during the third trimester of pregnancy. Mild defects are usually isolated, familiar o related to placental disfunction or intrauterine growth restriction, while the severe hypospadias are associated to other fetal defects, genetic or chromosomal abnormalities or disorders of sex development. In about 30% of cases. The triad of ultrasound findings prenatally is ventral curvature of the penis, redundant dorsal foreskin and blunt distal penis. The identification of the urethra during the micturition and the direction of the urinary stream help in the classification of the defect. When severe hypospadias is detected, the recommendation is to perform genetic amniocentesis and search for other ultrasound findings related to poor virilization in the fetus, as testicular descent after 27 weeks of gestation. Postnatal follow up should be multidisciplinary including infantile urologist and endocrinologist. The prognosis in distal hypospadias is usually good following surgical repair, however in severe cases surgical interventions may be more challenging in order to obtain satisfactory outcome in terms of function and esthetic.

Anatomical study of hypospadias penis using magnetic resonance imaging in children.

INTRODUCTION: To assess the various anatomical patterns of the hypospadias penis, anatomical and histological study of the penile tissues, planes, and vascular patterns, and imagings such as ultrasound of penis, elastography, and Magnetic resonance imaging (MRI) of penis have been described in the literature. All these have been done to attempt the identification of anatomical variations that may influence surgical outcomes. There are very limited MRI studies of hypospadias penis to look for the pristine anatomy. OBJECTIVE: The objective was to identify anatomical variations in hypospadias penis such as the penile tissues and planes and the vascularity using MRI. MATERIAL AND METHODS: The total number of patients enrolled was 24 from January 2019 to July 2020. This included all the cases of hypospadias at any location aged ≥5 years. MRI penis was done using 3T (3 Tesla) MRI scanner (GE Healthcare signa 3T Scanner machine) with 3 mm body coil slice thickness and the surface coil of 3 inches. Non-contrast images were taken using fast spin-echo sequences in sagittal, coronal, and transverse planes. The findings analyzed were: presence and distribution of penile tissue and fascial structures, urethral plate thickness, and penile vasculature. RESULTS: The mean age was 7.62 ± 2.14 years. The types of hypospadias included were Coronal 1/24 (4.2%), Subcoronal 14/24 (58.3%), Distal penile 3/24 (12.5%), Midpenile 5/24 (20.8%) and Penoscrotal 1/24 (4.2%) (Summary Table 1). The mean urethral plate thickness was 1.33 ± 0.38 mm. The penile soft tissues were well visualized along with their fascial planes. The majority of patients (91.7%, 22/24) had Superficial Dartos vessels with both branches. Bulbourethral vessel was present in 18 (75.0%) cases but could not be visualized in the rest. Ventral and Lateral Dartos vessels were seen in 20 (83.3%) cases. Perforators distal to meatus were visualized in 21 (87.5%) cases and not visualized in 3 (1 each in Penoscrotal, Midpenile, and Coronal hypospadias). Collaterals at corona sulcus were visualized in 23 (95.8%) cases, at paraurethral spongiosum in 15 (62.5%) cases, and at dorsum in 22 (91.7%) cases. CONCLUSION: 3T MRI gives precise images in hypospadias with relation to the tissue and fascial planes of the penis. The vascular pattern visualization in these patients may be confirmed by the availability of a dedicated penile coil which will help to improve the resolution of the penile structures. Analyzing the penile vascular pattern and correlating it with surgical outcomes may aid the surgeon's knowledge of hypospadias, develop new surgical techniques and hence reduce complications.

Localization of external urethral orifice in coronary sulcus during urethroplasty in case of severe hypospadias accompanied by prostatic utricle cyst.

BACKGROUND: To explore whether opening the external urethral orifice in the coronal sulcus can reduce the incidence of epididymitis after operating on hypospadias with prostatic utricle cyst (PUC) connecting to the vas deferens. Group A consisted of 3 patients with severe hypospadias and PUC undergoing cystostomy, hypospadias correction and urethroplasty, along with the relocation of the external orifice of the urethra to the coronal sulcus. Group B consisted of 4 patients having initial hypospadias repaired with meatus in the orthotopic position in the glans, presenting with multiple epididymitis after hypospadias surgery and unsuccessful conservative treatment. MR confirmed that all the Group B patients had PUC connecting to the vas deferens. Group B patients underwent urethral dilatation along with urethral catheterization, cutting of the original corpus cavernosum that encapsulated the urethra, and extension of the position of the external urethral orifice to the coronal sulcus. RESULTS: In group A, 3 children underwent bladder fistula removal 2 weeks after the operation. The penis developed normally without any complications. Four children in group B underwent stent removal 12 weeks after operation, and one patient was still stenosed and dilated again. All patients in group B were followed without epididymitis recurrence. CONCLUSIONS: For patients with hypospadias complicating with a PUC, connecting to one side of the vas deferens, the positioning of the external urethral orifice in the coronary sulcus would be helpful to reduce the occurrence of epididymitis.

Prenatal Diagnosis and Classification of Fetal Hypospadias: The Role and Value of Magnetic Resonance Imaging.

BACKGROUND: Prenatal diagnosis and classification of hypospadias are difficult and of value for management during perinatal and neonatal periods. The conventional approach for prenatal diagnosis of hypospadias is ultrasound; however, this technique may be inconclusive in certain cases, which prompts for further exploration with magnetic resonance imaging (MRI). PURPOSE: To investigate the role of MRI in the prenatal diagnosis and classification of fetuses with hypospadias. STUDY TYPE: Retrospective. POPULATION: Thirty-five fetuses (median gestational age = 37, range 24-39 weeks) with possible hypospadias. FIELD STRENGTH/SEQUENCE: Single-shot fast spin echo T2-weighted imaging, fast imaging employing steady-state acquisition (FIESTA), and three-dimensional FIESTA acquired at 1.5 T. ASSESSMENT: Diagnosis and classification of hypospadias using MRI were performed by three experienced radiologists based on MRI features, including a short penile shaft, abnormal penile tip, penile curvature, bifid scrotum, "tulip sign," and penoscrotal transposition. The accuracy of MRI in the diagnosis and classification of hypospadias was assessed in comparison to postnatal clinical diagnosis. The interobserver agreement between radiologists was also assessed. STATISTICAL TESTS: Kendall's W test was applied to assess the interobserver agreement between radiologists. Taking postnatal clinical diagnosis as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. RESULTS: Of the 35 fetuses, 24 cases were confirmed as hypospadias through postnatal clinical diagnosis. The interobserver agreement between radiologists was substantial (Kendall's W = 0.781, P < 0.001). Of the 24 confirmed cases (13 cases of severe hypospadias and 11 cases of mild hypospadias), 22 cases were correctly diagnosed by MRI. The accuracy of MRI in the diagnosis of hypospadias, severe hypospadias, and mild hypospadias was 85.71%, 82.86%, and 80.00%, respectively. DATA CONCLUSION: MRI has good performance in the diagnosis of fetal hypospadias. In addition, MRI could help evaluate the severity of fetal hypospadias. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

Evaluation of surgical procedures of mouse urethra by visualization and the formation of fistula.

Visualization of the surgically operated tissues is vital to improve surgical model animals including mouse. Urological surgeries for urethra include series of fine manipulations to treat the increasing number of birth defects such as hypospadias. Hence visualization of the urethral status is vital. Inappropriate urethral surgical procedure often leads to the incomplete wound healing and subsequent formation of urethro-cutaneous fistula or urethral stricture. Application of indocyanine green mediated visualization of the urethra was first performed in the current study. Indocyanine green revealed the bladder but not the urethral status in mouse. Antegrade injection of contrast agent into the bladder enabled to detect the urethral status in vivo. The visualization of the leakage of contrast agent from the operated region was shown as the state of urethral fistula in the current hypospadias mouse model and urethral stricture was also revealed. A second trial for contrast agent was performed after the initial operation and a tendency of accelerated urethral stricture was observed. Thus, assessment of post-surgical conditions of urogenital tissues can be improved by the current analyses on the urethral status.

Prenatal and postnatal imaging techniques in the evaluation of disorders of sex development.

Imaging of the reproductive tract is challenging and requires a general knowledge of congenital variations in anatomy. The anatomy of the developing fetus, whether a male phenotype or female phenotype, is also a dynamic process with many changes occurring during gestation. Families may ask details about the genitalia during prenatal imaging and when variations in what is thought to be normal are present, further investigation is sometimes needed to make sense of what is seen. This overview will describe categories of disorders of sex development (DSD), whether chromosomal or structural or both, and the current state of imaging of these anomalies.

The distribution of Preputial vessels in different severity of rat congenital hypospadias model: imaging study using micro-computerized tomography.

BACKGROUND: Micro-computerized tomography (micro-CT) is considered as an innovative non-invasive and high-resolution imaging technology. The current research aims to reconstruct the distribution of preputial vessels in different severity of rat congenital hypospadias model by micro-CT, and to provide an anatomic basis for the selection of preputial vessel pedicle flaps in surgery. METHODS: Pregnant rats were exposed to finasteride from gestational day 12 to 17. Depending on the position of the urethral meatus, the pups were divided into normal, mild hypospadias and severe hypospadias groups. Six months after birth, the preputial blood vessels were observed in vascular perfusion with Microfil (a silicone-based polymer) and scanned by micro-CT. CTvox and NRecon were utilized to reconstruct 3-dimentional (3D) images. A pathological analysis of the specimen was taken in order to determine the position of Microfil. RESULTS: The normal group and the mild hypospadias group had similar preputial image characteristics. At the junction of the inner and outer prepuce, the deep layer vessels of the superficial fascia were transversely distributed and formed a vascular ring-like structure. Among the severe hypospadias group, five had sufficient blood circulation while six had insufficient blood circulation. In sufficient blood circulation type, the ring-like vessels were found at the junction of the inner and outer prepuce similar to that of the normal and mild hypospadias group. However, only a small amount of capillary supply to this area in the insufficient type. CONCLUSION: The junction of the inner and outer prepuce with abundant blood circulation was suitable to be a vascular pedicle flap. The tubularized preputial island flaps were consistent with the ring-like vessels area, and the original blood supply was retained to the greatest extent.

Prenatal diagnosis of hypospadias with 2-dimensional and 3-dimensional ultrasonography.

To compare the prenatal diagnostic performance as well as appearance of ultrasonic details between 2-dimensional ultrasonography (2DUS) combined with 3-dimensional ultrasonography (3DUS) and 2DUS alone for hypospadias. A total of 47 fetuses were enrolled and examined by 2DUS and then 3DUS. Postnatal follow-up data were obtained and 28 cases were confirmed of hypospadias. Although not statistically significant, there was a trend toward higher AUC (0.85 vs. 0.76; p = 0.08), ACC (85.1 vs. 76.6%; p = 0.22), SEN (85.7 vs. 78.6%; p = 0.63), and SPE (84.2 vs. 73.7%; p = 0.50) for 2DUS combined with 3DUS compared with 2DUS alone. The agreement between both methods was moderate [kappa = 0.592]. Both modalities showed accurately the short penis and blunt tip of the penis. 2DUS in combination with 3DUS showed more cases in other detailed features, such as "chordee", a "hooded" incomplete prepuce, and so on. Overall 2DUS combined with 3DUS showed a trend toward higher performance compared with 2DUS alone for the diagnosis of hypospadias, although the difference was not statistically significant. 3DUS is a useful complement for 2DUS in the diagnosis of fetal hypospadias and may provide more detailed information related to its diagnosis and prognosis.

Prostatic utricles without external genital anomalies in children: our experience, literature review, and pooling analysis.

BACKGROUND: It has been recognized that the incidence of prostatic utricle in boys is increasing and is closely associated with diseases such as hypospadias. However, the clinical features of prostatic utricle with normal external genitalia have received little attention. METHODS: Based on this, a series of 22 male children with prostatic utricles has been compiled by adding our 3 patients to 19 cases reported. All children enrolled had normal external genitalia. Clinical data of the case was reviewed. RESULTS: Urinary tract infection, purulent urethral discharge and pyuria were the most common presenting chief complaint (41%), irritative lower urinary tract symptoms were present in 17% of cases, obstructive lower urinary tract symptoms were noted in 14%. Urinary retention has been reported in 18% and epididymitis has been reported in 14%. Relatively rare clinical symptoms are abdominal pain, hematuria, and hematospermia. A case of calculus formation and a case of neoplasia within the prostatic utricle has been reported. A cystic mass found by digital rectal examination is the most common presenting sign. A utricular lesion posterior to the bladder was revealed by imaging examination. Unilateral renal agenesis was associated in 32% of reports. Non-surgical approach was chosen in 3 cases, transrectal ultrasonography guided aspiration has been reported in 1 case. Endoscopic techniques were used in 3 cases. Open excision was used in 11 cases. The laparoscopic excision was chosen in 3 cases and Robot-assisted laparoscopy was reported in 1 case. Symptoms and signs disappeared after treatment in all children, and no recurrence occurred during follow-up. CONCLUSIONS: Prostate utricles without external genital anomalies are rarely reported in children, and are easily missed and misdiagnosed, often accompanied by recurrent urinary tract infections, lower urinary tract symptoms, epididymitis, dysuria and other symptoms. Imaging studies can confirm the diagnosis. Symptomatic and large utricles should be actively treated. The treatment program should be based on the age, clinical symptoms, and size and location of the utricle.

Prevalence and risk factors of testicular microlithiasis in patients with hypospadias: a retrospective study.

BACKGROUND: It has been described that the incidence of testicular microlithiasis is high in several congenital disorders which may be associated with testicular impairment and infertility. Several reports have shown that a prepubertal or pubertal hormonal abnormality in the pituitary-gonadal axis was identified in some patients with hypospadias that is one of the most common disorders of sex development. However, exact prevalence or risk factors of testicular microlithiasis in patients with hypospadias have not reported so far. In the present study, to clarify the prevalence and risk factors of testicular microlithiasis in patients with hypospadias, a retrospective chart review was performed. METHODS: Children with hypospadias who underwent testicular ultrasonography between January 2010 and April 2016 were enrolled in the present study. Severity of hypospadias was divided into mild and severe. The prevalence and risk factors of testicular microlithiasis or classic testicular microlithiasis were examined. RESULTS: Of 121 children, mild and severe hypospadias were identified in 66 and 55, respectively. Sixteen children had undescended testis. Median age at ultrasonography evaluation was 1.7 years old. Testicular microlithiasis and classic testicular microlithiasis were documented in 17 children (14.0%) and 8 (6.6%), respectively. Logistic regression analysis revealed that presence of undescended testis was only a significant factor for testicular microlithiasis and classic testicular microlithiasis. The prevalence of testicular microlithiasis or classic testicular microlithiasis was significantly higher in children with undescended testis compared to those without undescended testis (testicular microlithiasis; 43.8% versus 9.5% (p = 0.002), classic testicular microlithiasis; 37.5% versus 1.9% (p < 0.001). CONCLUSIONS: The current study demonstrated that the presence of undescended testis was only a significant risk factor for testicular microlithiasis or classic testicular microlithiasis in patients with hypospadias. As co-existing undescended testis has been reported as a risk factor for testicular dysfunction among patients with hypospadias, the current findings suggest that testicular microlithiasis in children with hypospadias may be associated with impaired testicular function. Conversely, patients with isolated HS seem to have lower risks for testicular impairment. Further investigation with longer follow-up will be needed to clarify these findings.

External Genital Development, Urethra Formation, and Hypospadias Induction in Guinea Pig: A Double Zipper Model for Human Urethral Development.

OBJECTIVE: To determine whether the guinea pig phallus would be an appropriate model of human penile development, we characterized the embryology and sexual differentiation of guinea pig external genitalia and attended to induce hypospadias in males and tubular urethra formation in females pharmacologically. MATERIALS AND METHODS: The external genitalia of guinea pig were collected from genital swelling initiation to newborn stages, and scanning electronic microscopy and histology were performed to visualize the morphology and structure. Immunohistochemistry was used to determine the androgen receptor localization. Bicalutamide and methyltestosterone were given to pregnant dams to reveal the role and timing of androgen in guinea pig penile masculinization. RESULTS: Canalization and dorsal-to-ventral movement of the urethral canal develops the urethral groove in both sexes, and then the males perform distal-opening-proximal-closing to form tubular urethra. More nuclear-localized androgen receptor is found in proximal genital tubercles of males than in females at (E) 29. Antiandrogen treatment at E26-E30 can cause hypospadias, and methyltestosterone administration at E27-E31 can induce tubular urethra formation in females. CONCLUSION: Fetal development of the guinea pig phallus is homologous to that of humans. Although guinea pig has structures similar to mouse, the urethral groove and the tubular urethra formation are more similar to humans. Antiandrogen treatment causes hypospadias in males and additional androgen induces tubular urethra formation in females. Thus, guinea pig is an appropriate model for further study of cellular and molecular mechanisms involved in distal-opening-proximal-closing in tubular urethra formation and the evaluation of the pathophysiological processes of hypospadias.

Ultrasound diagnosis of fetal hypospadias: Accuracy and outcomes.

OBJECTIVES: The purpose of this study was to assess the positive predictive value of a prenatal ultrasound diagnosis of hypospadias when compared with postnatal diagnosis based on physical exam. METHODS: We retrospectively identified all pregnant women between 2004 and 2014 who were either referred to our fetal care center carrying a fetus with an ultrasound diagnosis of possible hypospadias or who had a new diagnosis of hypospadias after imaging in our center. RESULTS: A total of 32 cases of possible hypospadias were identified, with our fetal center ultrasound suggesting hypospadias in 25 of the 32 cases (78%). Of the 25 cases, 18 infants were confirmed to have hypospadias on postnatal physical exam (Table), reflecting a positive predictive value of 72%. Twenty-one of twenty-five cases with suggested hypospadias on ultrasound were found to have either hypospadias or another penile anomaly on postnatal physical exam, reflecting a positive predictive value for any genital anomaly of 84%. Infants with confirmed hypospadias often had several associated GU anomalies on postnatal clinical exam. CONCLUSIONS: Our single center experience with the fetal ultrasound diagnosis of hypospadias demonstrates a high positive predictive value for a penile anomaly (21/25, 84%), and a moderately high positive predictive value for the specific diagnosis of hypospadias (18/25, 72%) when compared with the postnatal diagnosis.

The prostatic utricle: An under-recognized condition resulting in significant morbidity in boys with both hypospadias and normal external genitalia.

INTRODUCTION: Pediatric presentations of a prostatic utricle have received only scant attention. Though recognized with increased frequency in boys with hypospadias, little is described about their incidence and potential for morbidity in boys with normal external genitalia. METHODS: We initially reviewed a cohort of 64 patients with hypospadias seen over a 3-year period to determine the frequency of investigative lower urinary tract studies and utricle identification. Children with disorders of sexual differentiation were excluded from this review. A subsequent group of 70 boys with hypospadias and 23 boys with normal external genitalia presenting with lower urinary tract symptoms (LUTS) who were found to have an unsuspected utricle were reviewed. This comparative group was investigated since symptomatology was the indication for evaluation, contrasting with those in the hypospadias group who were investigated because of hypospadias presence alone. RESULTS: In our initial review of 64 patients only 24 (37.5%) underwent an investigative study and six (9.4%) had a utricle. Three (50%) required surgical excision, allowing their hypospadias repair to proceed. Results in the subsequent group with hypospadias confirmed these findings with increased rates of investigation and identification. The boys with normal external male genitalia all required surgery since symptoms were the result of the utricle alone. Penile pain with voiding, hematuria, epididymitis, and urinary infection were the most common causes for interventions. CONCLUSIONS: The prostatic utricle should be considered as a cause of morbidity in boys with both normal external genitalia and those with hypospadias. Endoscopic or radiological evaluation (see Figure) should be undertaken in all boys with proximal hypospadias, boys with hypospadias and associated cryptorchidism, and those with hypospadias with associated urinary symptoms. Boys with normal external genitalia with lower urinary tract symptoms not explained with imaging should undergo cystoscopy, as an unidentified unsuspected utricle may be the underlying cause.