107 Focus on cme at McGill University By J. L. Pippi Salle, md, PhD and Roman Jednak, md
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- Bu səhifədəki naviqasiya:
- CASE 1
- CASE 1 Cont. CASE 2 A five-year-old male presents com- plaining that he cannot exteriorize
- What is the suggested management
- Penile Problems 110
- CASE 2 Cont.
- Penile Problems 112
- Table 1 Indications for circumcisions Unquestionable indications for circumcision are
- Relative indications are
- Penile Problems 114
- Penile Problems
- Penile Problems 116
- Penile Problems 118
- Penile Problems 120
- For Good News See Page 122
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P enile problems are prevalent in children and adolescents. Correct identification is usually possible by careful physical examination and is essential to avoid related com- plications. The Canadian Journal of CME / September 2002 107 Focus on CME at McGill University By J.L. Pippi Salle, MD, PhD and Roman Jednak, MD Penile Problems in
Normally, the prepuce is unretractable at birth. This is because, ini- tially there is a physiologic adherence between the glans and the inner preputial skin. There is also a relatively narrow preputial ring. With age, a gradual separation of the preputial adhesions will occur. As a result of production of smegma, a whitish secretion pro- duced by the inner preputial sebaceous glands. Usually, this devel- opmental process is completed when the child reaches seven years of age, but it can continue until later in childhood. Pediatrics CASE 1 Figure 1: Fibrotic phimotic ring with associated BXO.
Penile Problems 108 The Canadian Journal of CME / September 2002 Dr. J.L. Pippi Salle MD, PhD, staff, University Health Centre, Montreal Children’s Hospital Dr. Roman Jednak MD, staff, University Health Centre, Montreal Children’s Hospital For many three-year-old boys, it is “normal” to present with physiologic phimosis which eventually resolve so that the foreskin can be retracted completely. For this reason, unless complications arise, such as recurrent balanoposthitis, urinary tract infection or paraphimosis, management should remain conser- vative. Clinicians should allow a period of observation for spontaneous resolution of the physiologic phi- mosis avoiding unnecessary surgical manipulation and possible psychological trauma. We wouldn’t encourage penile manipulation to dilate the preputial opening during the observation period. In our opinion, forceful manual dilation may be traumatic and can create microlacerations, which, upon healing, form permanent scars and produce an acquired phimosis. In this scenario, surgical inter- vention will almost certainly be necessary. Intermittent treatment with 0.1% triamcinolone cream in cases where there is a mild, non-fibrotic phimotic ring is useful and we encourage its use prior to surgical con- sultation. In about 10% of cases of phimosis there is severe scarring (whitish fibrotic ring) (figure 1) caused by balanitis xerotica obliterans (BXO), a genital variation of lichen sclerosus et atrophicus. If BXO is present, surgical correction is recommended because this is a progressive disease that can even- tually involve the urethra and cause meatal stenosis or urethral strictures. CASE 1 Cont. CASE 2 A five-year-old male presents com- plaining that he cannot exteriorize the glans. On examination there is no phimosis, but only bal- anopreputial adhesions (figure 2). What is the suggested management? The inner prepuce is initially attached to the glans and will undergo a gradual process of separation. In some cases, the production and accumulation of smegma can be significant, leading to the trapping of a significant amount. This may give the impression of a whitish “cyst” around the corona (figure 3). Completing the process of separating the prepuce from the glans can eliminate progres- sive accumulation of smegma. In some cases, these cysts can undergo a bacterial superinfec- Penile Problems 110 The Canadian Journal of CME / September 2002 What are the indications for circumcision? This remains a hotly debated subject. There are several articles in the liter- ature advocating routine neonatal circumcision on the basis of a number of specific medical benefits. These include protection against the development of urinary tract infection (UTI) and sexually transmitted disease (STD), as well as protection against the development of penile cancer. In addition, the partners of circumcised men may also benefit from a decreased incidence of cervical cancer. Opponents to circumcision claim that the procedure can lead to decreased sensation in the glans as well as to the development of psycho- logical problems. Furthermore, they feel that addressing certain lifestyle issues and stressing good hygiene are more than sufficient prevention for some of the secondary prob- lems reported in uncircumcised men. Are there contraindications to circumcision? The presence of a concealed or buried penis is an absolute contraindication for routine circumcision. The buried penis is concealed in the suprapubic fat, leaving only the foreskin and penile shaft skin visible (figure 4). When this diagnosis
tion. This can lead to an abscess-like collection between the glans and prepuce. Clinically this is characterized by penile erythema, local edema and a suppurative discharge. Treatment with warm sits baths and oral antibiotics can be effective. This complication is not an indication for circumcision unless it is recurrent and associated with phimosis. CASE 2 Cont. Figure 2: Balanopreputial adhesions. Figure 3: Smegma accumulation behind the glanular groove. An abscess can form. Figure 4: A buried penis. Only foreskin and penile skin are visible, while penis shaft is buried. Penile Problems 112 The Canadian Journal of CME / September 2002 is missed, circumcision may remove the penile skin in its entirety. This can lead to scarring and trapping of the concealed penis beneath the suprapubic skin (fig- ure 5). In some cases such scarring is intense and can cause severe urinary obstruction with the formation of a large urinoma around the penis (figure 6). Correcting the problem can be quite challenging since once the penis is released from the suprapubic fat, achieving appropriate skin coverage can be diffi- cult. It is important that recognition of this type of anatomical variant is mandatory by all professionals who perform circumcision. When severe phimosis is associated with a concealed/buried penis, circumci- sion is best performed by pediatric urologists utilizing alternative techniques. What are the complications of circumcision? The most common complication is penile trapping following the circumcision of a concealed penis. Other complications include: • Hemorrhage • Infection
• Phimosis secondary to BXO. • Paraphimosis (penile constriction caused by a prolonged retraction of the prepuce beyond the corona). • Recurrent balanitis in diabetic patients.
• Recurrent balanitis. • UTI in the first 12 months of life. • Urological malformations which predispose to UTI, such as moderate or severe vesicoureteral reflux, posterior urethral valves with significant dilatation of the upper urinary system, ureteroceles following incision, or any other malformations that cause significant urinary stasis. Figure 5: Penile trapping after circumcision on a buried penis. Penile skin was inadvertently removed. Figure 6: Obstruction to urine flow during micturition cre- ates a large collection of urine around the trapped penis.
Penile Problems 114 The Canadian Journal of CME / September 2002 • Glans amputation • Penile necrosis • Meatal stenosis • Psychological trauma Although circumcision is the most common surgical procedure per- formed, it is not complication free and on rare occasion, can result in serious morbidity. Therefore, circumcision should be reserved for patients having the aforementioned medical indications. I was instructed to perform forceful retraction of the prepuce and on one occasion the phimotic ring constricted the glans causing extreme pain and swelling. What caused this and how should the condition be treated? This is the typical description of a boy with phimosis who developed paraphimosis follow- ing forceful retraction of the prepuce (figure 7). When paraphimosis occurs, it should be reduced immediately since progressive venous congestion eventually leads to edema and pain. When prolonged , paraphimosis may even result in ischemia of the distal penis. The patient should be brought to the emergency room immediately for specialized care if reduction is not readily accomplished. A cir- cumcision should be performed two or three weeks following reduction since recurrence is very common. Why does my son have recurrent episodes of penile redness and suppuration? Infections of the foreskin (posthitis) and glans (balanitis) are usually bacte- rial, viral, or fungal in origin. Bacterial balanoposthitis is often secondary to Figure 7: Paraphimosis with intesnse progressive preputial edema after forceful retraction of a phimotic prepuce. Penile Problems The Canadian Journal of CME / September 2002 115 the accumulation of infected smegma. Often there are underlying predisposing medical conditions, such as dia- betes or an immunosuppressed state. Viral balanoposthitis is usually caused by the herpes virus and is extremely rare in children. Fungal balanoposthitis is common and usual- ly associated with the prolonged administration of wide spectrum antibiotics. Balanoposthitis is treated conserva- tively. Warm sit baths, oral antibiotics, or a topical anti- fungal cream usually resolves the problem. In cases of recurrent bacterial balanoposthitis, circumcision may be warranted. My son underwent circumcision and subsequently developed an upward devi- ation of his urinary stream when void- ing. Is this normal? How can it be treated?
This child developed meatal stenosis, the most common late complication following circumcision. A small mea- tus is often seen following circumcision, but this does not preclude a normal urinary stream. In cases where a sig- Figure 8: Classification of hypospadias. Figure 9a: Glanular hypospadias Figure 9b: Proximal hypospadias with a typical redundant dorsal foreskin. Penile Problems 116 The Canadian Journal of CME / September 2002 nificant narrowing of the meatus has occurred the stream can take on a characteristically thin appear- ance and is directed upwards. The child may take a longer time to void and can even empty the bladder incompletely. Although the diagnosis is evident on inspection, the best documentation is obtained by performing uroflowmetry and measuring post-void residual urine in the bladder. Meatotomy is indicat- ed when there is poor flow, a significant post void residual or significant deviation of the urinary stream. The meatus is enlarged surgically and post- operative meatal dilation is performed to avoid recurrence of the stenosis. My son was born with hypospadias and I was instructed to seek spe- cialized care. What is hypospadias and when should it be corrected? Hypospadias is a congenital malformation of the penis. Urethral development is incomplete and the urethral meatus opens in a ventral position. More severe hypospadias usually presents with a proxi- mal meatus (perineal/penoscrotoal) and is associat- ed with some degree of chordee (ventral curvature of the penis). The classification of hypospadias is based on the location of the meatus without taking penile curvature into account (figure 8). The majority of patients present with distal hypospadias with or without chordee (figure 9a). Proximal hypospadias (penoscrotal, perineal, proximal penile) represents the most severe end of the spectrum and is usually cor- rected utilizing preputial flaps (figure 9b). Hypospadias can be associated with other genital anomalies. Undescended testes and inguinal hernias are associated problems in up to 10% of patients. Patients with severe hypospa- dias and undescended testes should be investigated for an intersex condi- Figure 10: Penile torsion. Figure 11: Epispadias. The distal urethra is completely open dorsally.
Penile Problems 118 The Canadian Journal of CME / September 2002 tion. They require a karyotype as well as an endocrinologic evaluation. On occasion a voiding cystoureterogram is warranted to assess for the pres- ence of a large utricle (pseudovagina). There is an increase incidence of hypospadias in male siblings (~ 15%) and in offspring (~ 8%). Surgical correction aims for construction of a straight penis and normal urethra, thereby giving the penis a normal cosmetic appearance. Surgery is best performed prior to toilet- training, at around six to 18 months of age. This avoids operating during the psychologic phase of genital awareness, which usually occurs after two years of age. The surgery is usually done in one stage as an outpatient procedure. Recent advances in surgi- cal technique have significantly reduced the inci- dence of postoperative complications and improved the cosmetic outcomes. Penile Torsion Some children are born with a deviation of the penile raphe and some degree counterclockwise penile rota- tion termed penile torsion (figure 10). When the degree of torsion is mild (< 90 degrees) there is no need for surgical correction. Surgical repair is war- ranted in more severe cases and the procedure is per- formed between six to 18 months of age. Epispadias Rarely (one in 40,000 births), male babies can be born with the urethral meatus opening on the dorsal aspect of the penis; a con- dition known as epispadias (figure 11). Surgical correction focuses on the same goals as those described for hypospadias. In some cases with a proximal urethral meatus the urinary sphincter is insufficient and the patient therefore presents with total urinary incontinence. In these situations additional bladder neck surgery is required to achieve urinary continence. Paraurethral Cyst Paraurethral cysts are uncommon, but can cause significant anxiety for both parents and caregivers due to the very apparent location of the cystic lesion around the urethral meatus (figure 12). Typically the cyst is smooth, soft and Figure 13: Short frenulum causing painful erection in an adolescent. Figure 12: Paraurethral cyst
Penile Problems 120 The Canadian Journal of CME / September 2002 white in color. With time the majority diminish in size or drain spontaneously. Larger cysts may require needle aspiration or formal surgical excision. Tight Frenulum A normal frenulum should allow for erection without glanular tilt (figure 13). A short frenulum may cause pain during erection and bleeding if torn during sexual intercourse. Unless there is clear early evidence of a problem, most chil- dren should wait until puberty before being evaluated for a frenulectomy Micropenis Micropenis is a condition where the penis, though normal anatomically, is markedly small. The strict definition of micropenis is one in which the stretched penile length is more than 2.5 SD below the mean for patient age. From a term newborn to be classified as having micropenis the stretched penile length should be less than 1.9 cm. The majority of patients referred for evalu- ation of micropenis actually have a buried/concealed penis. Careful examina- tion pressing on the suprapubic fat should exteriorize the penile body and establish the diagnosis. Micropenis can be related to abnormal hormonal stim- ulation. In some cases, no hormonal abnormalities are recognized and the eti- ology is considered to be idiopathic. Once the diagnosis of micropenis is con- firmed, consultation with a pediatric endocrinologist and urologist is warrant- ed. In some cases, successful testosterone administration can significantly alle- viate the emotional distress felt by the families of boys with the condition.. Summary Penile problems are prevalent in children and adolescents. Correct identifica- tion is usually possible by careful physical examination and is essential to abbreviate related complications. Recommended Readings: 1. Campbell’s Urology, 8th ed. Edited by P.C. Walsh, A.B., Retik, E.D. Vaughan, Jr., and A.J. Wein. Philadelphia, W.B. Saunders, 2002. 2. Adult and Pediatric Urology, 4th ed. Edited by Gillenwater, J.Y., Grayhack, J.T., Howards, S.S., and Mitchell, M.E. Philadelphia, Lippincott, Williams, and Wilkins, 2002. 3. Clinical Pediatric Urology, 4th ed. Edited by Bellman, A.B., King, L.R., and Kramer, S.A. London, Martin Dunitz Ltd., 2002 For Good News See Page 122 CME Yüklə 50,96 Kb. Dostları ilə paylaş:
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