Other genital conditions

Question 1

Paraphimosis vs phimosis.

Answer 1

• Paraphimosis occurs when a tight foreskin is forcibly retracted, this foreskin forms aconstricting ring around the coronal groove of the glans, causing venous engorgement and painful swelling of the glans.
• Phimosis = inability to retract the foreskin (prepuce)

Question 2

When does paraphimosis usually occur, and why?

Answer 2

Just after the foreskin has separated from the glans, so usually in toddlers or early primary years.

Question 3

Main complication of paraphimosis

Answer 3

Urinary retention -> renal failure

Question 4

Mx of paraphimosis

Answer 4

MEDICAL EMERGENCY: External compression of the glans is applied to reduce the swelling it is then pushed back through the constriction. This may require GA.

Question 5

How does normal separation of the foreskin occur?

Answer 5

• Separation of the foreskin from the glans penis occurs by desquamation and begins late in gestation, but remains incomplete in most
• After birth, penile growth and physiologic erection aid in the desquamation process and the formation of keratinised pearls (smegma) between the layers, which loosens the adhesions and allows retraction of the preputial skin.

Question 6

What are some causes of phimosis?

Answer 6

• Secondary to poor circumcision
• Usually by trauma (inappropriate retraction in a baby where the foreskin is still adherent to the glans)
• After recurrent infection under the foreskin (E.coli) contaminating space under foreskin during phase of separation.

Question 7

What is physiological vs pathological phimosis?

Answer 7

• Physiologic phimosis
  
  • due to the normal development of congenital adhesions between the foreskin and glans
  • Physical examination reveals a pliant unscarred preputial orifice.

• Pathologic phimosis (“true” phimosis):
foreskin that is truly non-retractable secondary to distal scarring of the prepuce, such as occurs with the preputial fibrosis due to infection and inflammation (e.g. after forcible retraction)

Question 8

Signs of pathological phimosis

Answer 8

○ Foreskin not retractile by the time of established puberty.
○ Previously retractile foreskin becomes non-retractile.
○ Obvious ring of scar tissue visible at foreskin opening
○ Inability to visualise urethral meatus when foreskin opening is lifted away from glans.
○ Ballooning of foreskin on micturition, with pinhole foreskin opening, and very narrow urinary stream

Question 9

Possible omplications of phimosis

Answer 9

• Foreskin ballooning during voiding, may lead to urinary Sx, urinary retention and recurrent UTIs
• Painful erections
• Irritation or bleeding from the preputial orifice
• Paraphimosis
• Recurrent balanitis
• Increased risk of penile cancer

Question 10

Prevention of phimosis

Answer 10

Good perineal hygiene in babies and toddlers by washing regularly in salt water or antiseptic (to displace E.coli from under foreskin).

Question 11

What are conservative interventions for phimosis

Answer 11

• Gentle stretch exercises
• May consider a 4-8 week course of topical betamethasone cream applied directly to the preputial outlet to speed up the natural process of foreskin retractability

Question 12

What is smegma?

Answer 12

• peeling skin and secretions accumulating between the foreskin and glans
• Appears like white cheesy material - often mistaken for infection
• Normal for age

Question 13

What is the purpose of smegma?

Answer 13

• Spontaneous separation of preputial adhesions
  • Prepuce (foreskin) is lightly adherent to the glans in the first few days of life but becomes more tightly adherent during the first year
  • Separates from the coronal groove forwards - not from the tip

Question 14

When does smegma occur?

Answer 14

Occurs between 1-3+/5 years - around toddler i.e. if you see it, you know what the age of the child is