⚕️ FCPS Paediatrics TOACS · Mock Test
| Observed Station | CPSP Format
⏱️ TIME REMAINING
08:00
❓ Q1. Describe the findings in the image. What is the most likely diagnosis?
✅ Model Answer:
• Findings: Downward (ventral) curvature of the penile shaft. The urethral meatus is at the tip of the glans (normal position). No hypospadias. Foreskin intact.
• Diagnosis: Congenital chordee without hypospadias (isolated chordee).
• Findings: Downward (ventral) curvature of the penile shaft. The urethral meatus is at the tip of the glans (normal position). No hypospadias. Foreskin intact.
• Diagnosis: Congenital chordee without hypospadias (isolated chordee).
❓ Q2. Define chordee. What is the difference between chordee without hypospadias and chordee associated with hypospadias?
✅ Model Answer:
• Chordee: Ventral (downward) curvature of the penis due to congenital shortening of ventral tissues (skin, dartos fascia, corpus spongiosum, or tunica albuginea).
• Chordee without hypospadias (isolated): Urethral meatus at tip (normal). Less common (~10%).
• Chordee with hypospadias: Urethral meatus located ventrally (on shaft, glans, or perineum). More common. Surgical repair must address both.
• Chordee: Ventral (downward) curvature of the penis due to congenital shortening of ventral tissues (skin, dartos fascia, corpus spongiosum, or tunica albuginea).
• Chordee without hypospadias (isolated): Urethral meatus at tip (normal). Less common (~10%).
• Chordee with hypospadias: Urethral meatus located ventrally (on shaft, glans, or perineum). More common. Surgical repair must address both.
❓ Q3. How is chordee classified based on the anatomical structures involved (Devine and Horton classification)?
✅ Model Answer:
• Type I (cutaneous): Deficient/scarred ventral skin only. Corrected by degloving.
• Type II (fascial): Fibrosis of dartos fascia. Requires excision.
• Type III (corporeal): Most common in isolated chordee – disproportion between ventral and dorsal corpora. Requires dorsal plication.
• Type IV (urethral): Associated with hypospadias – due to dysplastic corpus spongiosum.
• Type I (cutaneous): Deficient/scarred ventral skin only. Corrected by degloving.
• Type II (fascial): Fibrosis of dartos fascia. Requires excision.
• Type III (corporeal): Most common in isolated chordee – disproportion between ventral and dorsal corpora. Requires dorsal plication.
• Type IV (urethral): Associated with hypospadias – due to dysplastic corpus spongiosum.
❓ Q4. What is the artificial erection test? How is it performed intraoperatively?
✅ Model Answer:
• Purpose: To objectively assess degree and cause of penile curvature during surgery and confirm complete correction.
• Procedure (Gittes test): Tourniquet at base of penis after degloving → inject normal saline into one corpus cavernosum → observe curvature → after ventral tissue release, repeat to confirm straightening.
• Goal: Straight penis (<10-15° residual curvature).
• Purpose: To objectively assess degree and cause of penile curvature during surgery and confirm complete correction.
• Procedure (Gittes test): Tourniquet at base of penis after degloving → inject normal saline into one corpus cavernosum → observe curvature → after ventral tissue release, repeat to confirm straightening.
• Goal: Straight penis (<10-15° residual curvature).
❓ Q5. When is surgical correction of chordee indicated in a child? At what age should surgery be performed?
✅ Model Answer:
• Indications: Curvature >30 degrees, cosmetic concerns, any curvature with hypospadias, inability to pass straight stream.
• Timing: Typically 6-18 months (optimal 9-12 months). Early repair minimizes psychological impact and allows better healing.
• Indications: Curvature >30 degrees, cosmetic concerns, any curvature with hypospadias, inability to pass straight stream.
• Timing: Typically 6-18 months (optimal 9-12 months). Early repair minimizes psychological impact and allows better healing.
❓ Q6. Describe the surgical principles and techniques for correcting isolated chordee without hypospadias.
✅ Model Answer:
• Step 1: Circumcision and degloving → releases skin tethering.
• Step 2: Artificial erection test → assess residual curvature.
• Step 3: Ventral tissue excision → remove dysplastic dartos fascia.
• Step 4: Dorsal tunica albuginea plication (Nesbit or TAP) → straighten the penis.
• Step 5: Recheck artificial erection → confirm straightness.
• Step 6: Skin closure.
• Step 1: Circumcision and degloving → releases skin tethering.
• Step 2: Artificial erection test → assess residual curvature.
• Step 3: Ventral tissue excision → remove dysplastic dartos fascia.
• Step 4: Dorsal tunica albuginea plication (Nesbit or TAP) → straighten the penis.
• Step 5: Recheck artificial erection → confirm straightness.
• Step 6: Skin closure.
❓ Q7. What is the Nesbit procedure? How does it differ from tunica albuginea plication (TAP) for chordee?
✅ Model Answer:
• Nesbit: Elliptical excision of tunica albuginea from convex (dorsal) side → shortens the longer side.
• TAP: Multiple parallel plicating sutures on dorsal tunica without excision (Lue procedure) – less invasive, less erectile shortening.
• TAP preferred for mild-moderate chordee (<45°); Nesbit more durable for severe curvature.
• Nesbit: Elliptical excision of tunica albuginea from convex (dorsal) side → shortens the longer side.
• TAP: Multiple parallel plicating sutures on dorsal tunica without excision (Lue procedure) – less invasive, less erectile shortening.
• TAP preferred for mild-moderate chordee (<45°); Nesbit more durable for severe curvature.
❓ Q8. What are the potential complications after chordee repair?
✅ Model Answer:
• Early: Bleeding/hematoma, wound infection, edema, urinary retention (rare).
• Late: Recurrent chordee (5-15%), penile shortening (mild, 5-10 mm), erectile dysfunction (rare), penile numbness (rare), palpable suture knots.
• Early: Bleeding/hematoma, wound infection, edema, urinary retention (rare).
• Late: Recurrent chordee (5-15%), penile shortening (mild, 5-10 mm), erectile dysfunction (rare), penile numbness (rare), palpable suture knots.
❓ Q9. What is the long-term prognosis after successful chordee repair? Is the curvature likely to recur after puberty?
✅ Model Answer:
• Excellent prognosis – >90% straight penis.
• Recurrence risk low (5-15%), especially if not adequately corrected or with pubertal growth. Most recurrences mild (<20°) and may not need reoperation.
• Erectile function normal in vast majority. Annual follow-up until puberty.
• Excellent prognosis – >90% straight penis.
• Recurrence risk low (5-15%), especially if not adequately corrected or with pubertal growth. Most recurrences mild (<20°) and may not need reoperation.
• Erectile function normal in vast majority. Annual follow-up until puberty.
❓ Q10. Is isolated chordee associated with other genitourinary anomalies? Should any imaging be done?
✅ Model Answer:
• Isolated chordee without hypospadias rarely associated with major upper tract anomalies.
• Imaging not routinely indicated.
• If associated with hypospadias or bifid scrotum → renal ultrasound recommended.
• Isolated chordee without hypospadias rarely associated with major upper tract anomalies.
• Imaging not routinely indicated.
• If associated with hypospadias or bifid scrotum → renal ultrasound recommended.
❓ Q11. How will you counsel the parents of this infant regarding the need for surgery and the expected outcome, especially regarding circumcision which is routine practice in Pakistan?
✅ Model Answer:
• “Your baby has chordee – a downward curve of the penis. Urethra is normal at tip (not hypospadias).”
• “Surgery at 9-12 months straightens the penis (dorsal plication). Success >95%.”
• “Regarding circumcision: Delay routine circumcision until chordee repair. During surgery, we will perform circumcision as part of the procedure. If done separately, it removes necessary skin and makes repair difficult.”
• “Your son will have both procedures together under one anesthesia, without needing a second operation.”
• “Recurrence risk 5-15%. No effect on urinary control or fertility.”
• “Your baby has chordee – a downward curve of the penis. Urethra is normal at tip (not hypospadias).”
• “Surgery at 9-12 months straightens the penis (dorsal plication). Success >95%.”
• “Regarding circumcision: Delay routine circumcision until chordee repair. During surgery, we will perform circumcision as part of the procedure. If done separately, it removes necessary skin and makes repair difficult.”
• “Your son will have both procedures together under one anesthesia, without needing a second operation.”
• “Recurrence risk 5-15%. No effect on urinary control or fertility.”
❓ Q12. What are the differential diagnoses of downward penile curvature in a child?
✅ Model Answer:
• Congenital chordee without hypospadias
• Chordee with hypospadias (ventral meatus)
• Penile torsion (rotational)
• Megalourethra
• Epispadias (dorsal curvature)
• Peyronie's disease (adult, acquired)
• Penile fracture (trauma)
• Lichen sclerosus (acquired scarring)
• Congenital chordee without hypospadias
• Chordee with hypospadias (ventral meatus)
• Penile torsion (rotational)
• Megalourethra
• Epispadias (dorsal curvature)
• Peyronie's disease (adult, acquired)
• Penile fracture (trauma)
• Lichen sclerosus (acquired scarring)
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