Introduction
The bifid scrotum is a congenital anomaly. It is a rare finding in the population. In this anomaly, the midline of the scrotum is affected. The bifid scrotum level of abnormality varies in a different spectrum and can be minor, partial, and severe. In minor form, the scrotal raphe (a tissue running from the anus to the root of the penis) becomes wide, or it can be split. In partial bifid scrotum cases, appearance may be at the proximal scrotal end or maybe at the base of the scrotum. In the severe form, there is the wild separation of scrotal sacs with a record of proximal hypospadias (a condition where the opening of the penis is not on the tip but is present underside) with the laid opened urethra. In some cases, appearance is like only scrotal dimples, considered a normal finding in some animals.
What Is a Bifid Scrotum?
It is a developmental defect where the scrotum is separated into two parts by an aperture or deep groove. Often, the bifid scrotum is associated with an anomaly known as hypospadias. In hypospadias, the urethral opening is not precisely present at the tip of the penis but elsewhere on the head of the penis. It is sometimes displaced to be present anywhere from the scrotum to the shaft. The bifid scrotum is sometimes found as an isolated genital anomaly. Sometimes It may be associated with conditions like hypogonadism and sometimes androgen insensitivity syndrome (a disease that affects genital development). It could be found in some rarely occurring syndromes. The occurrence of the bifid scrotum may be at the time of embryo and could be a developmental defect.
In general, the cases of the bifid scrotum are very few. However, in some cases, people are born with it. Treatment modality mainly depends on the severity of the condition. Earlier, no treatment options were available for bifid scrotum. Still, modern and advanced treatment modalities can repair and fix it, so the condition has become even more uncommon.
What Are the Types of Hypospadias?
There are types of hypospadias depending upon the location of the urethral opening:
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Glandular: In this type, the opening is present near the head of the penis. It is the most common type of hypospadias.
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Midshaft: In this type, the opening presents the middle to the lower shaft of the penis.
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Penoscrotal: In this type, an opening is at the joining point of the penis and scrotum.
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Perineal: In this type, an opening is behind the scrotal sac. This form is the least common among all and, if present, then considered the most severe form also.
How Common Is the Condition?
The condition is a rare anomaly. Sometimes it is genetic. However, the incidence of the disease is seen in one out of every 150 to 300 boys.
What Are the Causes?
The condition can be associated with genetic factors and sometimes due to environmental factors or may be due to hormonal factors of the body.
During the embryo period, the bifid scrotum occurs because caudal mesenchyme (the type of connective tissue present in the embryo) fails in ventral growth. Hence, the urogenital fold (structure in the embryo that gives rise to genitalia) closes over and covers the cloacal membrane (the membrane that covers the anus end in the embryo) in the ventral midline, causing a bifid scrotum.
What Are the Conditions Associated With Bifid Scrotum?
The syndrome associated with the bifid scrotum:
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Elsahy waters syndrome (distinct syndrome there is a short, broad nose, asymmetry).
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Hand-foot genital syndrome (abnormally short thumbs and first toes).
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Methemoglobinemia (abnormal amount of methemoglobin is produced).
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SCARF syndrome (a rare syndrome characterized by abnormalities in the skeletal system, cutix laxa (loose skin), craniostenosis (defect in the bone where the bony skull joins too early), ambiguous genitalia, psychomotor retardation, and facial abnormalities.
What Are the Signs and Symptoms?
Boys who have only mild form will not show significant signs and symptoms or no symptoms at all. However, in moderate or severe cases, patients may have signs and symptoms that, if not corrected on time, can create issues when a child grows old.
Signs and symptoms also depend upon the severity of the condition:
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The urine of the patient may be hard to control.
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The condition can produce sexual dysfunction later in life.
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The patient may have a lack of confidence.
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If the urethral opening shifts behind or near the scrotum, fertility problems may also happen in routine life.
What Is the Diagnosis of the Condition?
In most cases, conditions are noticed at birth usually. For example, misplaced opening, abnormal anatomy, or division appearance is visible at the time of delivery, sometimes foreskin is incomplete, and hood formation occurs, called the dorsal hood. Both hypospadias and bifid scrotum may be signs of undervirilization. Sometimes, the genetic evaluation will not usually happen when patients have these conditions. In most cases, prior genetic diagnosis helps improve clinical care, and according to it, proper guidance and instruction can be given to the patient and his family. Prenatal (before birth) diagnoses are complex. For prenatal diagnosis, the conventional approach that we follow is ultrasound. In some cases, ultrasound is unable to make a proper diagnosis, so the results of the ultrasound are inconclusive in such cases. Then further exploration with magnetic resonance imaging (MRI) to make the diagnosis more conclusive and appropriate.
What Is the Treatment?
No medicine can correct the situation. Treatment modality mainly depends upon the severity of the condition. In mild cases, if patients do not have any particular problem, then no or very little treatment is required. Depending on the severity, the condition is generally treated with surgery in infancy. The bifid scrotum is usually present in any form of hypospadias. In situations where the urethra is present over the scrotum. In such cases, hypospadias treatment is done along with testicular separation. For proper repair and treatment, determining the suitable type is necessary. In conventional surgical repair of defects, first, the rotation of two scrotal flaps is done, then joining them in the midline, and vertical skin closure is done. Dimpling in the skin can occur. Sometimes due to dimpling, esthetic results are not so accurate. In a technique, the bifid scrotum was rebuilt and countered using single or multiple Z-plastics (a type of plastic surgery). Due to this tension, midline closure is elongated and relaxed. Contracture and scar formation can be avoided using multiple Z-plastics.
Surgery is the only modality that can correct the situation of a patient. A team of surgeons does the correction. Surgery can locate the opening of the urethra at the tip of the penis, allowing a steady stream of urine while standing.
A pediatric urologist may use the foreskin in the process of surgical repair. Circumcision (surgical meaning of the tip of the penis) at birth is not recommended in these children. At the age of four to six months, surgical repair can usually be attempted. But it is not necessary; it can also be done later in life. The surgery is generally done on an outpatient basis while the patient is asleep under general anesthesia. In severe forms, surgical repair can also be attempted in multiple stages.
What Are the Possible Complications of Surgery?
Surgery will be very successful in many cases, but in some cases, there can be some potential complications that can also be encountered. In some cases, holes or fistula (abnormal openings or passages in body organs or parts) may develop, and urine may leak through that hole. In such cases, additional surgery is also required to correct defects. Urethra narrowing occurs due to scarring within the urethra. Due to this passage, urine flow is also affected, requiring additional surgery to fix it. For check-ups, patients may need to return until or after puberty.
Conclusion
The bifid scrotum is a defect of the midline in the scrotum area. It occurs at the time of development. It can be genetic. No medicine can cure it. Surgical treatment helps patients to live with a routine.
