Phimosis & foreskin disorders (+ hypospadias, testicular tortion)

Question 1

When is surgery to correct hypospadias performed?

Answer 1

12 months of age

Question 2

Where should the urethral meatus be located in a male?

Answer 2

• Ventral urethral meatus
• Hooded prepuce
• Chordee (ventral curature of the penis) in more severe cases
• 75% of openings are distally located, may be more proximally located in severe cases

Question 3

How common is hypospadias?

Answer 3

3/1000 male infants affected

Question 4

What is a risk factor for hypospadias?

Answer 4

Family history - genetic in that 5-15% of further males will get it

Question 5

Name 2 conditions associated with hypospadias.

Answer 5

• Inguinal hernia
• Cryptochordism (present in 10%)

Question 6

Which surgery must not be performed prior to hypospadias surgery?

Answer 6

It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure

Question 7

What sign might parents notice in hypospadias?

Answer 7

Abnormal urine stream

Question 8

What is the viability in testicular torsion?

Answer 8

~6 hours

Question 9

When does normal foreskin retract in a child?

Answer 9

• Nromal foreskin does not retract in infancy
• At 1year 50% of boys still have non-retractile foreskin
• Only 1% of boys >16 years have non-retractile foreskin

Question 10

What is ammoniacal dermatitis and how is it treated in male infants?

Answer 10

This is napkin rash which can also cause reddening and soreness of the preputial opening

Reassure and advise to pay attention to routine hygiene

Question 11

How does balanoposthitis present? What is the cause and treatment in most cases?

Answer 11

Infection of the glans penis and prepuce (foreskin) = balanoposthitis

• Redness is more extensive than ammoniacal dermatitis and there is purulent discharge
• Occurs in 3% of boys and reaches peak incidence at afe 3 year
• Recurs in a third

Usually bacterial and requires antibiotics (systemic or topical)

Question 12

What is the cause of ballooning of the foreskin on urination? Is it concerning?

Answer 12

1. Results from lysis of the preputial adhesions around the glans before those at the preputial opening; self-resolves once the preputial adhesions have lysed completely
   
   • Ballooning may also occur in the shaft of the penis arising from the attachment of the shaft skin below the coronal sulcus of the glans
2. Needs no intervention - has no functional consequence and does not present obstruction. Common cause of parental concern but seldom causes any trouble

Question 13

How does sub-preputial smegma present? Is there need to intervene if there is a lump?

Answer 13

As a lump which grows briefly and is yellowish and malleable (‘cottage cheese’ appearance)- this smegma comprises of desquamated skin and secretions

It is seemingly under the non-retractile or partially retracile foreskin

No need to intervene - discharges once preputial adhesions break down

Question 14

Define phimosis.

Answer 14

Pathologically non-retractile foreskin so that the glans is ‘muzzled’ (Greek word ‘phimos’)

Question 15

What is the most common condition giving rise to true phimosis?

Answer 15

BXO - balanitis xerotica obliterans

This gives rise to progressive scarring which can extend onto the glans, into the meatus and ultimately into the urethra

Question 16

What is the aetiology of BXO? How does it present?

Answer 16

This is a chronic disease. Cause is unknown but may be due to autoimmune disease, infection, local trauma and genetics.

Presents with non-retractile foreskin which used to be retractile in earlier childhood

Question 17

What is the management of BXO?

Answer 17

Index indication for circumcision although potent topical steroids with close monitoring may cause the condition to regress.

Question 18

What are the other indications for circumcision medically?

Answer 18

• BXO causing a true phimosis
• Recurrent balanoposthitis causing refractory symptoms
• Prophylaxis of recurrent UTI esp in presence of congenital uropathy (such as posterior urethral valves or vesicoureteric reflux) or in limited renal reserve
• Access to urethra is required reliably for catheterisation e.g. spina bifida
• ?Protection from transmission of HIV and HPV

Question 19

What are non-medical reasons for circumcision?

Answer 19

Remains tradition in Jewish and Muslim religions

Question 20

What are the complications of circumcision and how common are they?

Answer 20

• Post-operative bleeding requiring return to operating theatre occurs in 1/50
• Infection of skin markin or ulceration of the exposed granular skin
• Meatal stenosis (more common after BXO circumcision) which may require another surgery
• Urethral fistula (rare)

Question 21

What is paraphimosis?

Answer 21

Condition of post-pubertal boys in which a retracted foreskin cannot be reduced easily

Question 22

What are the complications of paraphimosis?

Answer 22

Glans swells and if prepuce is not reduced can cause compromise of blood supply to the glans

Question 23

What is the management of paraphimosis in an emergency/non-emergency situation?

Answer 23

Reduction done under general anaesthesia

Has been regarded as an indication for circumcision in the past but this is no longer the case unless the foreskin is abnormal e.g. with BXO.