Foreskin Problems Research Articles

1018 Emergency Urology Crash Course: Teaching Non-Urologists Pays Back

Abstract Aim To improve the knowledge, practical skills as well as professional skills of non-urologist health care professionals and bridge the gap between different specialties. Method One-day emergency urology crash course has been organised by urology team in our trust. The course is provided by 4 urology SpR under supervision of a urology consultant. Our course includes alternating sessions between lectures and practical skills. Lectures include interactive talks about common emergency urology case scenarios including obstructive uropathy, urinary infections & sepsis, andrological emergency, urologic trauma etc. Hands-on training using mannequin models includes difficult catheter, bladder wash out, 3-way catheter irrigation, flexible cystoscopy, foreskin problems, SPC insertion etc. Pretest and posttest questionnaires as well as a feed-back forms have been used to collect data used to analyse performance and the overall outcome of the course. We ran the course 3 times so far. Results Candidates included 60% A&E, 20% General surgery, 10% medical, 10% others. 70% were SpR,25% SHO and F1 or 2, 5% Nursing staff. 80% of candidates were from our trust and 20% from other trusts who got interested to attend. Candidate to faculty ratio was 5:1. Pre and post test result showed increase in knowledge by 4 points and increase in practical skills of 3 points. Conclusions One-day emergency urology course can achieve a lot on practical grounds as candidates feel more confident dealing with emergency urology cases after bridging the gaps in their knowledge and practical skills. This reflects on the overall service provided to urology patients presenting in the acute settings.

Critical Evaluation of Adler’s Challenge to the cdc’s Male Circumcision Recommendations

We evaluate Peter Adler’s challenge to the Centers for Disease Control and Prevention (cdc) draft recommendations on male circumcision (this issue, see pp. 237–262). Thecdcadvocates elective male circumcision (mc) to improve public health in theusabased on strong scientific evidence. In marked contrast to thecdc, Adler’s criticisms depend on speculative claims and obfuscation of the scientific data. Adler’s central argument that circumcision in infancy should be delayed to allow a boy to make up his own mind as an adult fails to appreciate that circumcision later in life is a more complex operation, entails higher risk, is more likely to involve general anaesthesia and presents financial, psychological and organisational barriers. These limitations are avoided by circumcision early in infancy, when it is convenient, safe, quick, low risk, usually involves local anaesthesia and provides benefits immediately. Benefits of male circumcision include: protection against: urinary tract infections that are ten times higher in uncircumcised infants; inflammatory skin conditions; other foreskin problems; sexually transmitted infections and genital cancers in the male and his female sexual partners. Circumcision during infancy is also associated with faster healing and improved cosmetic outcomes. Circumcision does not impair sexual function or pleasure. Some authorities regard the failure to offer circumcision as unethical, just as it would be unethical to fail to encourage paediatric vaccination. Since the benefits vastly outweigh the risks, each intervention is in the best interests of the child. In conclusion, Adler’s criticisms of thecdc’s evidence-based male circumcision policy are flawed scientifically, ethically and legally, and should be dismissed as endangering public health and individual well-being.

Foreskin problems in boys

AbstractThe author reviews the common clinical conditions affecting the foreskin in boys, including phimosis, paraphimosis and inflammatory penile skin conditions, and discusses their management options. Copyright © 2014 John Wiley & Sons

Role of human papillomaviruses in persistent and glucocorticoid‐resistant juvenile phimosis

In adults, human papillomaviruses (HPV), lichen sclerosus et atrophicus (LSA) and phimosis are considered to be major risk factors for penile cancer. In boys, a possible association between phimosis, LSA and HPV has been suggested. To investigate the role of HPV in the persistence of phimosis in children. Out of a cohort of 420 boys presenting with foreskin problems, we prospectively sampled the preputial tissue of 82 patients during circumcision: 46 with steroid-naïve and 36 with steroid-resistant phimosis. All foreskins were assessed clinically and histopathologically with regard to appearance, inflammation, oedema, epithelial degeneration and fibrosis. The viral status of the foreskins was determined by immunohistochemistry and highly sensitive PCR, with subsequent subtyping by DNA hybridization (HPV types 6, 11, 16, 18, 31, 33, 35, 39, 42, 44, 45, 51-54, 56, 58, 59, 61, 62, 66-68, 70, 72, 73, 81-84, 90, 91). The foreskins appeared normal in 62 boys and suggestive of LSA in one single case. Small cracks or white scars were present in seven steroid-naïve and 12 steroid-resistant foreskins. LSA was diagnosed microscopically in two of the steroid-naïve and six of the steroid-pretreated group. No evidence of HPV was found in any of the juvenile foreskins. Our prospective study has provided evidence that HPV is not usually present in the foreskin of boys with persistent phimosis after their first year of life and that topical glucocorticoid treatment failure is not associated with HPV or any specific histopathological changes.

Prepuce in boys and adolescents: What, when, and how?

The prepuce envelops the glans as a variant of a mucocutaneous tissue presenting with a lot offunctions, the most important of them being to protect the infant's glans from feces and ammonia in diapers, to protect the glans from abrasions and trauma throughout life, and to provide sufficient skin in erection. Circumcision was recognized as a method of solving foreskin problems a long time before Christ. Practicing male circumcision in history was customary several thousand years ago and has spread worldwide. Today it depends on races, and it is often an initiation ceremony near the age of puberty. In everyday practice in pediatric urology outpatient department the foreskin problems have been noticed as a phimosis in 9.91% cases and prepuce adhesions in 3.98%. Congenital anomalies are present in different numbers. Other problems, such as paraphimosis, balanoposthitis, are recorded as accidental cases. Over-all prepuce pathology can be observed in 12%-25% of patients. The article presents a review of foreskin conditions, clinical manifestation, therapy and arguments for patient's benefits. The term phimnosis describes a foreskin that is unable to retract. It is necessary to distinguish normal anatomic situation in neonate and infantile period, when prepuce has not been separated yet from true pathologic phimosis due to fibrosis and sclerosis. Up to six years of age the tip of the prepuce is elastic and might be retracted by gentle manipulations. In cases when the foreskin is trapped behind the glans penis and cannot be pulled back to normal position, paraphimosis is present and can be treated as a medical emergency by manual manipulation, or by dorsal slit (incision). Many studies have demonstrated that frequency of urinary tract infection increases in uncircumcised males and that is a reason for routine circumcision. The others are against routine circumcision. The contraindications are newborns, especially prematurely born. and congenital penile anomalies. Condition in which the frenulunm of penis is short with consequent restriction of movement of the prepuce can be easily treated by frenulotomy. Hooded prepuce is a condition of incomplete circumferential formation of foreskin with a dorsal component present and ventral component absent. In cases without any penile anomalies this is only a cosmetically unattractive appearance and could be corrected by circumcision. Infection of the foreskin due to bacterial colonization could be both prevented and treated easily However, an infection due to peno-preputial incisions in adolescent age is serious and has to be cured promptly. As a part of external genitalia, the foreskin has a lot of functions. Despite its natural role many advocates routine circumcision due to problematic condition that can develop. Routine circumcision is not generally recommended. Improved education for physicians and parents with regard to the foreskin development and management is required.

Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect?

Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect?

A Specialised Foreskin Clinic

PURPOSE 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. MATERIAL AND METHODS The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. RESULTS Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. CONCLUSIONS Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre. 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre.

A Specialised Foreskin Clinic

PURPOSE 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. MATERIAL AND METHODS The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. RESULTS Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. CONCLUSIONS Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre.

REPRODUCTIVE HORMONE LEVELS IN INFANTS WITH CRYPTORCHIDISM DURING POSTNATAL ACTIVATION OF THE PITUITARY-TESTICULAR AXIS

Testosterone and luteinizing hormone secretion is reportedly impaired in infants born with cryptorchidism. To better characterize this phenomenon, we studied a range of hormones that normally increase in boys during the first few months of life. A case-control study was conducted of boys with nonsyndromic cryptorchidism identified at birth (cases) and boys with descended testes presenting to the urology clinic without endocrine related concerns (controls). Blood was obtained at approximately 2 months of age and up to 3 urine samples were obtained at monthly intervals until age 120 days. Testosterone, estradiol, luteinizing hormone and follicle-stimulating hormone were measured in plasma and urine, and inhibin B, sex hormone-binding globulin (SHBG) and leptin were measured in plasma using standard assays. Data were analyzed using t tests with and without log transformation. Of 20 cases 15 were unilaterally cryptorchid. Although 7 testes descended spontaneously, 2 became cryptorchid again during followup and, therefore, 15 boys required orchiopexy. Diagnoses of 26 controls included foreskin problems (15), prenatal hydronephrosis (4), penile torsion (2), ectopic kidney (1) and hydrocele (1). None of the plasma or urinary hormone measurements was significantly different between boys requiring orchiopexy and controls. Plasma SHBG and testosterone, SHBG, estradiol and leptin, and body mass index positively correlated, while testosterone and body mass index negatively correlated. We failed to identify any significant differences in hormone levels between controls and boys with cryptorchidism during activation of the pituitary-testicular axis in early infancy. These data suggest that impairment of this process may be uncommon in boys with nonsyndromic cryptorchidism.

Changing trends in a decade of circumcision in Scotland

Purpose There has been a move toward conservative management of foreskin problems. The aim of this study was to examine overall trends for circumcision in Scotland to see if there has been a decrease in the number of operations performed. Methods Retrospective analysis looking at the number of circumcisions performed each year over a 10-year period (1990 to 2000), in the 0 to 13-year age group. The principal indication for circumcision in each case was ascertained as were the number of preputioplasties performed over the corresponding period. Results A total of 15,605 circumcisions were performed during the 10-year period; 10,888 (69.8%) for phimosis, 2,724 (17.5%) for nonmedical/religious reasons, and 1993 (12.8%) for all other indications. There was a 33.7% decrease in total number of circumcisions performed between the first and second halves of the study period. The fall in operations performed is almost solely attributable (94.5%) to a reduction in number of procedures carried out for phimosis. There was a corresponding increase in preputioplasties performed over the study period. Conclusions There has been a steady decrease in circumcision rates in Scotland. This is in keeping with greater appreciation of pathologic phimosis as distinguished from a healthy nonretractile foreskin, which does not require circumcision.

Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons.

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

Management of foreskin problems.

One hundred consecutive cases of boys with foreskin problems referred to local paediatric surgeons in the Edinburgh area were studied. Fifty five underwent circumcision and the remainder were managed more conservatively with or without the use of local or general anaesthetic. Although sometimes avoiding general anaesthetic, the more conservative methods involved more frequent visits to the clinic, a larger number of complications, and a longer follow up period. Despite the vogue for conservatism, circumcision still has an important part to play in the management of troublesome foreskins in children.

The Frequency of Foreskin Problems in Uncircumcised Children

We performed a retrospective survey to determine the frequency of problems of the foreskin among uncircumcised children. Among 545 boys aged 4 months to 12 years, there were 272 uncircumcised boys and 273 control patients who were circumcised at birth. The total frequency of complications was significantly higher in the uncircumcised group (14% vs 6%). Both balanitis (6% vs 3%) and irritation (4% vs 1%) were more frequent among the uncircumcised children, but the difference was not statistically significant. Problems with adhesions were uncommon (1.5%) and equal in both groups. Symptomatic phimosis was seen in eight patients. The frequency of medical visits for penile problems was significantly higher in the uncircumcised group (10% vs 5%). Although the overall frequency of complications was higher among the uncircumcised children, most of the problems were minor.

Foreskin Problems in Uncircumcised Children

Foreskin Problems in Uncircumcised Children

The Frequency of Foreskin Problems in Uncircumcised Children

The Frequency of Foreskin Problems in Uncircumcised Children

The Frequency of Foreskin Problems in Uncircumcised Children

We performed a retrospective survey to determine the frequency of problems of the foreskin among uncircumcised children. Among 545 boys aged 4 months to 12 years, there were 272 uncircumcised boys and 273 control patients who were circumcised at birth. The total frequency of complications was significantly higher in the uncircumcised group (14% vs 6%). Both balanitis (6% vs 3%) and irritation (4% vs 1%) were more frequent among the uncircumcised children, but the difference was not statistically significant. Problems with adhesions were uncommon (1.5%) and equal in both groups. Symptomatic phimosis was seen in eight patients. The frequency of medical visits for penile problems was significantly higher in the uncircumcised group (10% vs 5%). Although the overall frequency of complications was higher among the uncircumcised children, most of the problems were minor.