swedish pediatrics pediatric urology team devon snow-lisy...
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Swedish Pediatrics Pediatric urology team Beth Andersen, MD Devon Snow-Lisy MD
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Penis
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Physiologic phimosis
• At birth prepuce can be retracted completely in 4% of newborns
• 54% the external meatus can only just be seen • 42% the tip of the glans cannot be seen
– (Gairdner 1949)
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Likely there are regional differences in phimosis
• Zheijiang China: high prevalence of physiologic phimosis in kindergarten children, up to 44% at age 6
• Swaziland (preputial adhesions-39% + phimosis-78% + hypospadias-3%:
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Inner preputial adhesions in the uncircumcised penis
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Abnormal raphe
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Abnormal raphe
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Penile torsion
• Common 12% of men • Most commonly
counterclockwise • Can be associated
with chordee and identified before circumcision by deviated penile raphe
• More likely to be bothered with increasing severity >45 degrees
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Penile Chordee
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Penile chordee • Seen in 4-10% of males • Results from disproportionate development of the tunica
albuginea of the corporal bodies. • Untreated patients may have worse penile perception
scores, mentally unhealthy days and increased difficulty with intercourse (> 20 degrees curvature)
• Plication is used almost exclusively with satisfactory curve correction rates in 67-97%.
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Inconspicuous penis variants
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Penile webbing
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Buried penis
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Buried penis
After penoplasty
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Normal skin fixation in a obese infant
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Inconspicuous penis
• When does it “need” to be fixed • UTIs, urine trapping (megaprepuce variant),
recurrent balanitis, continuing phimosis
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Open/cleft foreskin
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Megameatus variant of hypospadias OK for newborn circumcision if intact prepuce • 93 had an aborted newborn circumcision
– 28 underwent hypospadias repair – 47 underwent circumcision completion under general
anesthesia – 18 either deferred surgery or underwent in-
office circumcision. • 10 had completed circumcision with hypospadias with
intact prepuce – No complications
• 151 control group patients – 5.3% complication rate
• Performing circumcision in newborns with hypospadias and an intact prepuce did not affect repair or the risk of complications.
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Proximal shaft hypospadias
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Micropenis
(2.5 SD smaller than mean) ie in newborn < 1.9 cm (0.75 inches) Normal stretched penile length length of newborn penis 2.8-4.2 cm
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Epispadias
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Epispadias
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Chronic Complications after Circumcision
• Incomplete circumcision and skin tags • Skin Bridges • Meatitis and meatal stenosis • Secondary phimosis and concealed (buried)
penis • Fistulas and megalourethras • Inclusion cysts
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Buried Penis after Newborn Circumcision
• 88 patients with buried penis AFTER newborn circumcision
Patient age (years)
# of Patients
% with Buried penis (#)
Younger than 1
14 100% (1)
1-3 59 32.2% (19) >3 15 6.7% (1)
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Trapped Penis after Newborn Circumcision
• Retrospective review • 14 infants with trapped penis • Within 4 weeks of the newborn circumcision • 0.05% Betamethasone cream 3 times daily
for 3 weeks + manual retraction • 78% with improvement/able to retract
behind head of the penis • 21% required formal reconstruction
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Incomplete Circumcisions
Insufficient skin and insufficient inner prepuce is removed
Skin did not necrose or was left
Chronic Complications
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Adhesions
Pathologic
Chronic Complications
0%
10%
20%
30%
40%
50%
60%
70%
80%
Fine adhesions to thecorona
Adhesions coveringless than 50% of glans
Adhesions covering>50% of glans
Total Adhesions
less than 1 year old 1 to 5 years 5 to 9 years over 9 years
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Chronic Complications-Skin Bridging
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Chronic Complications-Skin Bridging
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Chronic Complications-Unusual Skin Bridging
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Presumably develops secondary to diaper dermatitis with subsequent scarring
Chronic Complications-Meatal Stenosis
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Questions?