PHIMOSIS, CIRCUMCISION AND OTHER FORESKIN DISORDERS

PHIMOSIS, CIRCUMCISION AND OTHER FORESKIN DISORDERS

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The foreskin, or prepuce, protects the glans (head of the penis) against urine, feces and other types of irritation agents. It also protects against infection and scarring of the urinary opening (meatus) and protects the sensitivity of the glans.
At birth, it is unusual for the foreskin to be retractable because of the incomplete separation between the skin layers and also the conical shape of the foreskin. Only about a 4% of the newborns have a fully retractable foreskin and in 54% the tip of the glans may be revealed by very gentle traction.

Normally, after the age of 3 years the prepuce can be normally retracted to uncover the glans of the penis in 90% of the boys.
The word phimosis is used to describe the narrow, nonretractable foreskin of childhood.

Phimosis can be:

Primary, referred also as physiologic, where the foreskin is narrow since birth and in most cases will cease (90%).
Secondary, a pathologic process resulting from scarring after forceful retraction of the foreskin or as a result of a scarring process called balanitis xerotica obliterans (BXO).

In the first years of life, keratin is produced between the foreskin and the gland, and because the space is very narrow, balls or “pearls” of keratin (also called smegma) can accumulate and be visible under the foreskin. This is a normal process and sometimes parents get worried when watching these keratin pearls. This situation ends when occurs the complete separation between the glans and the foreskin around 3-4 years of age.

Phimosis, note the very small opening on the tip of the prepuce and impossibility to uncover the glans

Phimosis: This is a condition in which the foreskin is tightly covering the head of the penis and it cannot be retracted (pushed down exposing head of penis). Phimosis is uncommon and an attempt can be made to treat with a topical medication.   In general, true pathologic phimosis is resolved through surgery. These cases that require surgery usually have a very narrow foreskin with a small opening, or scarring after forced retractions.   Sometimes the skin is possible to retract with difficulty and it’s observed a compressive ring of skin, which can result in an episode of paraphimosis if the foreskin is not put back to its original position.

In some cases of phimosis the opening of the foreskin is so narrow that the parents notice that when the child is urinating the foreskin inflates like a balloon and after finishing keeps dripping for the time this “balloon” needs to deflate. These anatomical conditions rarely resolve without surgery so they always should be evaluated by a pediatric surgeon to decide whether or not the patient needs a circumcision (Complete or partial resection of the foreskin).

Paraphimosis

Paraphimosis

Paraphimosis: Occurs when the narrow tip of the foreskin (prepuce) is withdrawn behind the glans and constricts the penile shaft, leading to swelling of the glans. Complications of this include urinary retention, ulceration of the glans and even ischemia and necrosis of the skin of the glans.

Phimotic ring, a cause of paraphimosis

This condition is very painful and is an emergency, the foreskin must be repositioned by a pediatric surgeon as soon as possible and sometimes is necessary to resolve this with surgery and then the patient is programmed for a circumcision once the swelling disappeared after a couple of days (Doing a circumcision in the same moment is difficult and often leads to unaesthetic results).

Balanoposthitis: This is the term to describe the inflammation of the glans and foreskin seen in small boys. This occurs in around 4% of uncircumcised boys, mostly between 2 and 5 years of age. The cause can be an infection, irritation due to long exposure to urine and allergy to some component of the diaper. Symptoms are pain, dysuria (pain when urinating, bleeding from the foreskin and others). The treatment is an antibiotic cream, warm baths and proper local hygiene. In the case of associated narrow foreskin the pediatric surgeon will recommend a circumcision in some patients with repetitive balanoposthitis without other associated causes but phimosis.

Buried penis

Webbed Penis (Buried penis): This is the condition where the scrotum, instead of being attached in the base of the penis, is attached closer to the prepuce, giving the impression of a small or “buried” penis. Careful examination by the specialist will reveal the presence of a normal sized penis for the age of the boy and the anatomic characteristics particular to this pathology. Normal circumcision does not give good results and a more complex procedure is performed with the objective of giving a more normal appearance and functionality.

Balanitis xerotica obliterans

Balanitis Xerotica Obliterans (BXO): BXO is the cause of a secondary or true phimosis, and a recognizable lesion at the tip of the prepuce can be observed, usually in children from 5 years until adolescence. The resulting phimosis is severe and often is not possible to visualize any part of the glan. In some cases the scarring process can involve the glans and the meatus as well (external opening of the urethra in the glans, where the urine goes out). The cause of BXO is unknown and the treatment is essentially surgical with a circumcision that resects all the fibrotic tissue involved, though the healing process can be longer and a higher rate of complications are seen.

Circumcision is the surgical technique for the removal of the prepuce. There are different techniques and they differ according to the patient and also the opinion of the parents, some of them can save more skin and give the appearance of a more covered glans when possible, while others leave the glans completely uncovered.
Some pathologies require more complex techniques to resolve the pathology but this is discussed with all the parents and also the child when appropriate.
This is an ambulatory procedure, meaning that the patient goes home the same day of the surgery.

Indications for circumcision:

• Phimosis in children older than 3-4 years, especially when scars in the tip of the prepuce are seen because this has a very low chance of resolving with medical treatment or waiting more time.
• Episode of paraphimosis.
• Repetitive episodes of balanoposthitis in spite of effective treatments and proper local hygiene.
• Urinary infections in boys in the absence of any urinary malformation, vesico-ureteral reflux or immune disorder in children that already underwent all the indicated studies. In this case, circumcision can help to diminish the amount of bacteria located between the glans and the prepuce and the colonization of upper parts of the urinary tract.
• Religious reasons: Circumcision is a fundamental part of the Jewish and Muslim faiths.

Contraindications for circumcision:

• Presence of unresolved hypospadias (This is a pathology where the opening of the urethra is located before than the usual place in the glans), the skin of the prepuce might be needed for the surgical correction.

Benefits of Circumcision

• Decrease the risk of urinary tract infections. The risk of urinary tract infections in boys during the first year of life is low. However, these infections are more common in uncircumcised boys.
• Prevent a new episode of paraphimosis, which is an emergency.
• Prevent new episodes of balanoposthitis.
• Prevent painful erections (they are normally present in boys from early childhood and during the rest of the life).
• Lowers the risk of penile cancer in older men. Even though this cancer is very rare, it is less common in circumcised men. It tends to occur in males who do not practice good hygiene.

Parents that need evaluation by a pediatric surgeon can appoint a consultation with Dr. Jose Varas in Arcadia Clinic. The clinical history of the child is taken, as well as physical examination. In the case of needing a surgical procedure to resolve the problem all alternatives are discussed with the parents and also the child if appropriate, as well as the care after the surgery, recovery time and controls.

Preparation for the Surgery

According to the patient age and medical antecedents different tests can be taken in our clinic such as hemogram (blood analysis), coagulation tests, metabolic and urine tests, electrocardiogram. If the child is healthy only the necessary tests are taken to avoid discomfort and stress.

Medication such as analgesics and antipyretics (like ibuprofen, diclofenac, ketoprofen) must be avoided 10 days before the surgery because this can interfere with coagulation and facilitate bleeding after the surgery. If the child is taking any medication or is allergic to any medication, material or food please notice it to the pediatric surgeon and staff people when arriving to our clinic.

Admittance to Arcadia Clinic should be arranged in advance by phone or e-mail. The patient can arrive early the same day of the surgery without having breakfast in the morning and without drinking fluids or milk that day. After accommodating in the room with his parents, vital signs are taken and once again the child is examined by the treating pediatric surgeon.

When entering operating room the mother or the father can accompany the child until the anesthesiologist asks he/her to wait in the room, where they will be noticed at the end of the surgery. We usually ask the parents to wait few minutes outside the room to accommodate the child in his bed and then the parents can join him for the rest of the recovery until the time of going home.

Finished “complete” circumcision in operating room (With retracted skin to show the stitches that will fall in 2-3 weeks)

The surgery is normally performed in children under general anesthesia (He sleeps during the procedure) with the participation of an anesthesiologist with experience in children. To minimize pain after the surgery a local anesthetic will be given also in the moment of the surgery.

Circumcision 3 months after surgery

The procedure lasts between 45-60 minutes and after this the child is returned to his room where is monitorized for few hours until the patient is able to urinate and then can go home. There is no problem that the child uses his car seat for the return to home. The pediatric surgeon will give you his contact number in case of need.

For pain control we recommend to use for a day or two an analgesic in the form of syrup.
After the circumcision, the tip of the penis may look raw. Also, it will be discolored and swollen for a few weeks. Frequently, there will be a yellowish mucus or crust covering the head of the penis. This will slough off with time. Do not attempt to wash or scrape it away as it is a natural part of the healing process.

We ask to the parents to put a cream on the penis 2 times a day for a week to minimize dryness of the glans newly exposed to air. The stitches are self-dissolvable and will fall in 2-3 weeks.  For bathing we indicate a daily short shower from the third day, avoiding long exposure to moisture until the stitches fall in the next days.

The rest at home includes 2 days in bed to avoid any trauma to the operated area and complete a week at home. After this, he can return to school or kindergarten but avoid sports for the next 3 weeks.

The first control will be at 5-7 days after the surgery in Arcadia Clinic or in the office in Zagreb, mostly to check how is going the hygiene process, as the glans is very sensitive in the first days sometimes parents are a bit scared of cleaning well the area. The next control will be in 3-4 weeks to check the healing process, the absence of new adherences or small granulomas that are a reaction to the suture material.

After surgery call the doctor for the following situations:

• Temperature of 38,5°C or higher
• A green or yellowish discharge from the suture lines along with increased redness, swelling and pain.
• Vomiting more than 3 times.
• Important pain, not relieved by pain medication.
• Bleeding not controlled by continuous pressure: If you notice slow oozing of blood, this is normal. If it is a continuous drip, hold firm pressure for 15 minutes without peeking and without letting up on the pressure. If the bleeding continues, call to Arcadia Clinic to contact the pediatric surgeon. This is uncommon but might be necessary to check the bleeding point. Unnoticed trauma or manipulation by the child may cause local bleeding.
• In rare cases, months after the surgery the opening of the urethra can narrow (meatal stenosis), this is a reaction to the friction of the glans with the underwear. In some cases will be necessary a small surgery to widen the opening.