Penile Pathology Flashcards
What is paraphimosis?
Paraphimosis is the retraction of a too-narrow foreskin behind the glanular sulcus, causing a constrictive ring. This results in oedema of the glans and foreskin, impairing blood circulation. It is relatively common in young boys.
What are the key symptoms of paraphimosis?
The key symptoms of paraphimosis include swelling of the glans and foreskin, a tight and painful constriction around the penis, and impaired blood circulation, which can lead to tissue damage if left untreated.
How is paraphimosis treated?
Paraphimosis requires urgent medical intervention. Treatment typically involves manually reducing the constriction by gently pulling the foreskin back over the glans. In severe cases, surgical intervention may be necessary.
How common is paraphimosis in young boys?
Paraphimosis is reasonably common in young boys, especially if they have a tight foreskin or improper handling during activities like bathing or cleaning.
What are the primary concerns associated with paraphimosis?
The primary concerns are the potential for permanent damage to the glans due to impaired blood circulation, as well as the risk of infection if not treated promptly.
What should practitioners be aware of regarding penile pathology in children?
Practitioners should know which penile problems they can manage at the primary level and which require referral for specialist review. They should also understand the laws surrounding elective circumcision and medical indications for circumcision.
What is the role of reassurance in managing penile problems in children?
Most penile problems in paediatric practice require reassurance and follow-up only. Many conditions, such as mild phimosis or non-serious anatomical variants, resolve naturally over time
When should a child with a penile problem be referred to a specialist?
A child should be referred to a specialist if the problem is severe, does not resolve with conservative treatment, or involves complications such as infection, phimosis causing urinary issues, or the need for surgical intervention.
What are the medical indications for circumcision in children?
Medical indications for circumcision may include recurrent urinary tract infections, phimosis that is causing functional problems, or other conditions that affect the health of the penis or urinary tract.
What laws must practitioners consider when dealing with elective circumcision?
Practitioners must be aware of the legal and ethical guidelines surrounding elective circumcision, including the age of consent, the reasons for circumcision, and the requirement for informed consent from the parents or guardians.
Why is paraphimosis considered a surgical emergency?
Paraphimosis is a surgical emergency because if not reduced, there is a risk of necrosis due to impaired blood circulation to the glans and foreskin.
What is the risk if paraphimosis is not treated promptly?
If paraphimosis is not treated promptly, there is a risk of necrosis (tissue death) due to restricted blood flow, which can cause permanent damage to the penis.
How is paraphimosis reduced?
Paraphimosis can be reduced under sedation and analgesia with appropriate monitoring, assistance, and emergency equipment, or under general anaesthetic. Various techniques, including osmotic agents, ice, and compression bandages, are used to reduce oedema.
What is the goal of the techniques used to treat paraphimosis?
The goal of these techniques is to reduce the oedema (swelling) of the glans and foreskin to allow the foreskin to be returned to its normal position over the glans.
How is manual pressure applied in the reduction of paraphimosis?
Manual pressure is applied to the oedematous tissue in a sustained fashion to reduce the swelling. Once the oedema is reduced, the foreskin can usually be slipped back over the glans.
What is a dorsal slit, and when is it used in paraphimosis treatment?
A dorsal slit is a surgical incision made on the foreskin. It is used in difficult cases of paraphimosis to help facilitate the reduction and allow the foreskin to be repositioned over the glans.
Is circumcision always required after an episode of paraphimosis?
No, circumcision is not routinely indicated after a single episode of paraphimosis. It is only considered if there are repeated episodes or other medical reasons that necessitate it.
What are some methods for reducing oedema in paraphimosis treatment?
Methods for reducing oedema include the application of osmotic agents, ice, and compression bandages. These techniques aim to decrease swelling and facilitate the reduction of the foreskin.
When is general anaesthesia required in paraphimosis treatment?
General anaesthesia may be required for reduction of paraphimosis if the procedure is expected to be more complicated or if sedation and analgesia are not sufficient.
What is the definitive surgical management of paraphimosis?
Circumcision is the definitive surgical management for recurrent or severe paraphimosis, though it is not indicated after a single episode unless there are additional factors involved.
What is phimosis?
Phimosis is the inability to retract the foreskin behind the glanular sulcus, preventing exposure of the glans.
What is the difference between primary and secondary phimosis?
Primary phimosis is usually physiological and resolves with age without evidence of scarring or inflammation. Secondary phimosis occurs due to pathological processes, such as balanitis xerotica obliterans, and may require treatment
What causes primary phimosis?
Primary phimosis is generally physiological, often seen in infants and young children. It typically resolves on its own as the child ages and the foreskin becomes more retractable.
What are the main causes of secondary phimosis?
Secondary phimosis can occur due to pathological processes such as balanitis xerotica obliterans, recurrent balanoposthitis, or other conditions that cause scarring or inflammation of the foreskin.
What are the indications for therapy in cases of phimosis?
Therapy is indicated in cases of secondary phimosis caused by balanitis xerotica obliterans, recurrent urinary tract infections (especially in patients with urological abnormalities), and recurrent balanoposthitis.
What are the therapeutic options for secondary phimosis?
The therapeutic options for secondary phimosis include the use of topical corticosteroid cream or circumcision, depending on the severity and underlying cause.
How does topical corticosteroid cream help with phimosis?
Topical corticosteroid cream can help by reducing inflammation and promoting the stretching of the foreskin, making it easier to retract. This is often used as a conservative treatment before considering surgery.
When is circumcision considered for phimosis?
Circumcision is considered when conservative treatments, like topical corticosteroids, are ineffective or when the phimosis causes recurrent infections or significant medical problems.
What is balanitis xerotica obliterans, and how is it related to secondary phimosis?
Balanitis xerotica obliterans is a condition involving chronic inflammation and scarring of the foreskin, which can lead to secondary phimosis. It often requires medical treatment, including corticosteroids or circumcision.
What other conditions are linked to secondary phimosis besides balanitis xerotica obliterans?
Secondary phimosis can also be caused by recurrent balanoposthitis (inflammation of the glans and foreskin) and repeated urinary tract infections, particularly in children with urological abnormalities.
What is balanoposthitis?
Balanoposthitis refers to the inflammation of both the glans of the penis and the foreskin.
What is the cornerstone of management for balanoposthitis?
The cornerstone of management is good perineal hygiene, but this does not involve vigorous retraction of the foreskin, as that can cause small tears and chronic inflammation.
Why should the foreskin not be retracted vigorously during cleaning?
Vigorous retraction can cause small tears, leading to chronic inflammation and further irritation.
What is the role of antibiotic therapy in managing balanoposthitis?
Antibiotic therapy is used to treat urogenital organisms responsible for the infection, aiming to reduce inflammation and clear the infection.
What are the indications for referral in cases of balanoposthitis?
Indications for referral include acute urinary retention, infections requiring debridement, infections not responding to antibiotics, genital ulcers, or suspicion of non-accidental injury. Also, abnormal findings on imaging of the upper tracts should prompt referral.
What should be included in the mandatory urinary tract infection (UTI) work-up for patients with balanoposthitis?
The mandatory UTI work-up includes urine dipstick tests for nitrites and leucocytes, urine microscopy, culture and sensitivity, and an ultrasound of the kidneys, urethra, and bladder.
When might a micturating cysto-urethrogram be indicated in balanoposthitis?
A micturating cysto-urethrogram may be indicated if there are abnormal findings on imaging or concerns about the urinary tract, to evaluate for any anatomical or functional issues.
What are some complications or severe signs that require urgent referral in balanoposthitis?
Complications requiring urgent referral include acute urinary retention, infections that need surgical intervention like debridement, persistent infections despite antibiotic therapy, or concerns about non-accidental injury.
What is Balanitis Xerotica Obliterans (Lichen Sclerosus)?
Balanitis Xerotica Obliterans, also known as Lichen Sclerosus, is a chronic inflammatory condition of the male genitalia. The exact aetiology is unknown.
What are the key symptoms of Balanitis Xerotica Obliterans?
Key symptoms include:
Dryness of the skin (xerotica)
Dysuria (painful urination)
Ballooning of the prepuce (foreskin) due to phimosis
What is the possible consequence of ongoing inflammation in Balanitis Xerotica Obliterans?
Ongoing inflammation may cause secondary phimosis, which is the inability to retract the foreskin.
When should a patient with Balanitis Xerotica Obliterans be referred?
Referral to a paediatric urology or surgical service is indicated for proper management and evaluation.
What is the primary treatment for Balanitis Xerotica Obliterans?
The primary treatment is circumcision, as it removes the affected foreskin and resolves the condition
Can topical treatments be used for Balanitis Xerotica Obliterans?
Yes, topical steroids may be used to reduce inflammation, particularly in less severe cases or as an adjunct to circumcision.
What are the potential complications of Balanitis Xerotica Obliterans?
Potential complications include meatal and urethral strictures, which can lead to urinary obstruction or difficulty.
Why is circumcision typically indicated in Balanitis Xerotica Obliterans?
Circumcision is indicated because it removes the affected tissue, alleviates the symptoms, and reduces the risk of complications such as phimosis and strictures.
What should be the approach to managing penile trauma?
Penile injuries, except for very superficial ones, should be referred to a paediatric urological service for further evaluation and management.
What is a warning sign of potential urethral injury in penile trauma?
Blood at the urethral meatus is a warning sign of possible urethral injury and requires further investigation, often with retrograde urethrography.
How are simple lacerations of the penis managed?
Simple lacerations can be sutured using absorbable sutures to promote healing.
What type of penile injuries require referral to an experienced paediatric urologist?
Complex degloving injuries, injuries involving the meatus, and injuries to the corpora cavernosum should be referred to an experienced paediatric urologist for proper management.
What is the management for zipper entrapment or constricting bands in paediatric penile trauma?
Zipper entrapment or constricting bands (often hair in paediatric patients) may require general anaesthesia to safely release the penis and perform a thorough evaluation.
Why is retrograde urethrography important in cases of penile trauma?
Retrograde urethrography is important in cases where there is blood at the urethral meatus, as it helps assess the extent of urethral injury and guide appropriate treatment.
What are the key considerations when managing penile trauma in children?
Key considerations include early referral to paediatric urology for complex injuries, ensuring thorough evaluation (e.g., retrograde urethrography for urethral injuries), and addressing simple injuries with appropriate suturing.
What is a surgical circumcision?
Surgical circumcision is the removal of the entire foreskin. Modified procedures may be performed in selected cases.
What are the common complications of surgical circumcision?
Common complications include:
Bleeding and haematoma formation
Wound sepsis
Urinary retention
What is the role of local anaesthetic in circumcision?
Circumcisions are frequently performed with local anaesthetic cover only, which numbs the area to minimize pain during the procedure
What are some complications associated with commercial circumcision devices?
Complications of commercial circumcision devices include:
Premature detachment
Failure to detach (should occur within 10 days, on average)
Bleeding
Excessive swelling
Wound sepsis
Glanular necrosis due to incorrect sizing of the device
What can cause premature detachment in commercial circumcision devices?
Premature detachment can occur if the device is not properly applied or if there is excessive tension or pressure during the procedure.
What should happen if the circumcision device fails to detach within 10 days?
If the circumcision device fails to detach within 10 days, it may indicate a complication that requires medical attention.
What is glanular necrosis, and how can it occur in circumcision?
Glanular necrosis is the death of tissue on the glans of the penis, and it can occur if the circumcision device is incorrectly sized, leading to excessive pressure or restriction of blood flow.
How can complications like bleeding and haematoma formation be managed after circumcision?
Bleeding and haematoma formation can be managed by applying pressure to control bleeding, and in some cases, suturing may be required to stop persistent bleeding.
What are the signs of wound sepsis after circumcision?
Signs of wound sepsis include increased redness, swelling, discharge, fever, or tenderness at the surgical site. Prompt antibiotic treatment is necessary.
Indications for referral of patients with complications of circumcision
• Urinary retention
• Bleeding that does not respond to conservative measures such as
compression
• Infection that does not rapidly respond to proper wound cleaning and oral
antibiotics
• Any suspicion of necrotizing fasciitis or glanular necrosis
• Failure of the ring to detach after 14 days
What is hypospadias?
Hypospadias is a congenital condition that involves:
An abnormal opening of the urethral meatus on the ventral side of the penis, scrotum, or perineum.
An abnormal foreskin, often referred to as a dorsal hood, which may be circumcised while awaiting repair.
Abnormal angulation of the penis, known as chordee.
How is the severity of hypospadias classified?
Hypospadias is classified into three types based on the location of the urethral opening:
Anterior (near the tip of the penis)
Middle (along the shaft)
Posterior (closer to the scrotum/perineum)
As the meatus becomes more proximal, the corrective surgery becomes more complex.
What are some associated conditions with hypospadias?
Hypospadias can occur as an isolated condition or in combination with:
Bifid scrotum
Penoscrotal transposition
Undescended testis
When should a child with hypospadias be referred to a specialist?
All patients with hypospadias require a non-urgent referral to a paediatric urologist for further evaluation and management.
At what age is repair of hypospadias typically performed?
The repair of hypospadias usually takes place between 6 and 12 months of age.
Why should the child with hypospadias not be circumcised before repair?
The child should not be circumcised because the hooded foreskin is used in most hypospadias repairs. Circumcision before surgery could complicate the repair process.
What is chordee in the context of hypospadias?
Chordee refers to the abnormal angulation or curvature of the penis, which can vary in severity and may require correction during surgical repair.
What is epispadias?
Epispadias is a congenital condition where the urethral meatus opens on the dorsal (upper) side of the penis, rather than on the ventral side.
Is epispadias a common condition?
No, epispadias is a rare defect. It may occur in isolation or in association with bladder exstrophy, forming the exstrophy-epispadias complex.
What is the exstrophy-epispadias complex?
The exstrophy-epispadias complex occurs when the anterior bladder wall fails to fuse, leading to an open bladder plate on the abdominal wall. It is associated with epispadias.
How should isolated epispadias be managed?
Isolated epispadias should be referred non-urgently to a paediatric urologist for further evaluation and management.
How should a newborn with exstrophy-epispadias complex be managed?
Newborns with exstrophy-epispadias complex should be referred urgently to a paediatric urologist, as closing the bladder is considered a urological emergency.
When should bladder closure be attempted in cases of exstrophy-epispadias complex?
Bladder closure is typically attempted within 48 hours of birth in cases of exstrophy-epispadias complex.
What is a buried penis or congenital megaprepuce?
A buried penis or congenital megaprepuce is a normally developed penis that appears hidden due to excess pre-preputial tissue. This condition can be either congenital or acquired.
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What are the congenital causes of a buried penis?
Congenital causes include:
Inelasticity of the dartos fascia
Congenital megaprepuce
What are the acquired causes of a buried penis?
Acquired causes include:
Cicatrix ring secondary to neonatal circumcision
Large supra-pubic fat pad in a chubby baby that hides the penis
What is the typical presentation of a child with a buried penis?
The child may present with ballooning of the preputial tissue during urination, followed by constant dribbling of urine as the preputial sac empties.
How can parents manage a child with a buried penis?
Parents can manage the condition by expressing urine from the preputial space to prevent complications like dribbling urine.
What are the risks for children with a buried penis or congenital megaprepuce?
Children with this condition are at risk for recurrent infections and dysuria due to improper urination and preputial tissue retention.
What treatment options are available for a buried penis?
There are various surgical techniques available to correct the anomaly, though cosmetic outcomes may vary depending on the method used.
What are ambiguous genitalia?
Ambiguous genitalia are an external manifestation of a possible disorder of sexual development (DSD), where the external genitalia do not clearly appear male or female.
What are the signs of ambiguous genitalia in a phenotypic male?
A phenotypic male may appear under-virilised with:
Severe peno-scrotal or perineal hypospadias
Bifid scrotum
Undescended testes
What are the signs of ambiguous genitalia in a phenotypic female?
A phenotypic female may appear virilised with:
- Large clitorophallus
- Rugae and pigmentation of the labia majora
- Urogenital sinus (single opening for the vagina and urethra)
-Palpable gonads
What should be done if phenotypic gender is unclear in a patient with ambiguous genitalia?
In some cases, the phenotypic gender may not be possible to identify immediately. This requires further investigation and referral to a specialist team.
Why is Congenital Adrenal Hyperplasia (CAH) considered a true emergency in patients with ambiguous genitalia?
CAH is a true emergency because:
- Females with CAH appear over-virilised.
- They have salt-wasting syndrome, which must be urgently treated.
- Life-threatening issues such as dehydration, hyponatraemia, and hyperkalaemia may occur.
How should patients with CAH be managed?
Patients with CAH should be managed urgently by paediatric endocrinology and neonatal specialists to address the life-threatening symptoms
How should patients with ambiguous genitalia be referred for further management?
Patients with ambiguous genitalia should be referred to a paediatric endocrinology team with experience in managing DSDs. This team will conduct necessary evaluations and refer the patient to paediatric surgical or urological services if needed.
What is physiological phimosis?
Physiological phimosis is the inability to retract the foreskin beyond the glans of the penis. It is a common condition in male infants and young boys and usually resolves spontaneously by puberty. There is no need for medical or surgical intervention unless there is evidence of inflammation.
How is physiological phimosis managed?
In most cases, physiological phimosis resolves on its own by puberty. No medical or surgical treatment is needed unless there is evidence of inflammation or other complications.
What causes an itchy penis, and how should it be managed?
The itchy penis can be caused by normal urogenital commensals, which may cause a rash or itching. Management typically involves perineal hygiene measures and reassurance, as it is not usually a serious condition.
What is micropenis?
Micropenis is defined as a penile length smaller than -2.5 SD for age in a 46XY male with normal external and internal male genitalia. It is usually associated with underdeveloped external genitalia, a hypoplastic scrotum, and undescended or small testis. Micropenis can occur in isolation or as part of a syndrome or association.
How should micropenis be measured?
Micropenis should be measured using the correct technique from the symphysis pubis to get an accurate length.
What is smegma and are smegma balls pathological?
Smegma is a whitish, chalk-like substance that can accumulate around the foreskin and form small pearls or balls. It consists of desquamated epithelial cells and body fluids and acts as a natural lubricant. It is not pathological and does not indicate infection.
How should smegma be managed?
Smegma is not a cause for concern and does not require medical treatment. Regular perineal hygiene helps to clear it naturally. Smegma balls are not a sign of infection.
What does the Children’s Act 38 of 2005, Section 12 state about circumcision of male children?
The act prohibits circumcision of male children under the age of 16 except for:
Religious circumcision, performed according to religious practices and manner.
Medical circumcision, performed on the recommendation of a medical practitioner
Under what conditions can circumcision be performed on male children older than 16?
Circumcision on male children older than 16 can only be performed if:
The child has given consent after proper counselling and in the prescribed manner.
The child has the right to refuse circumcision, considering their age, maturity, and stage of development.
Is elective circumcision legal for children under 16 years old?
Elective circumcision, unless performed for religious purposes, is illegal for male children under the age of 16.
What are some relative medical indications for circumcision?
Medical indications for circumcision include:
- Recurrent documented urinary tract infections
- Pathological phimosis
- Recurrent paraphimosis
- Patients requiring clean intermittent catheterization where the foreskin causes difficulties
- Congenital megaprepuce requiring surgical correction
