Pathological Phimosis Research Articles

102 An Audit of Phimosis Management at Primary Care Level

Abstract Aim To audit the appropriateness of phimosis management and adherence to paediatric surgical referral guidelines at the primary care level against the Royal College of Surgeons (RCS) recommendations. Method A search of paediatric patients with diagnoses of phimosis, paraphimosis and Balanitis Xerotica Obliterans from January 2016 to October 2021 was performed at one General Practice (GP) surgery with a population size of 14,315 patients. Data on the frequency of urological symptoms reported, the medical treatment initiated, the number of paediatric surgical referrals and waiting times, and outcomes were recorded. Results A total of 35 patients with ages ranging from 1-17 years old were included. The most common symptom reported was dysuria (n = 21, 60%). Twenty-five (71.4%) paediatric patients with phimosis were referred. The paediatric surgical referral waiting times ranged from 3–232 days (mean = 111.4). Fourteen of the referred patients (73.7%) who had been reviewed by the surgical team were diagnosed with physiological phimosis and discharged back to the GP. Thirty-two per cent of the referrals (n = 8) were done without trialling on topical steroids. In terms of potency, 53.5% of the steroids (n = 15) prescribed by the GP were weaker than is recommended by the RCS. Conclusions Variation in practice was seen in phimosis management, including the types of steroids initiated and decisions on surgical referrals. Only pathological phimosis generally requires a referral. Therefore, a clear management and referral pathway and additional training on phimosis management within primary care providers can help optimise the patient management and appropriateness of secondary care referrals.

Termokoterle yapılan sünnet sonrası gelişen fimozisin tedavisinde topikal steroid kremlerin etkinliği var mı?

OBJECTIVE: Thermocautery device is commonly used in circumcisions implemented under local an anaesthesia for a quick and safe circumcision. One of the complications that might evolve after circumcision implemented with thermocautery is pathological phimosis. Treatment of this complication is generally surgical revision. There are very few studies in the literature about it’s medical treatment. In this study, we aimed to search the efficiency of topical corticosteroid application in the the treatment of pathological phimosis evolving after circumcision implemented with thermocautery. MATERIAL and METHODS: Datas of 54 patients aged 1–9 who evolved pathological phimosis complication after circumcision in our hospital between 2011–2021 were examined retrospectively. Efficiency of topical corticosteroid application in the treatment of pathological phimosis evolving after circumcision implemented with thermocautery was evaluated. RESULTS: In 38 cases which grade 5 phimosis evolved after surgery there was no response to steroid treatment. In 6 of the 8 patients who evolved grade 4 phimosis there was no response to steroid treatment. Although there was partial response and regression to grade 3 in two patients, full recovery was not achieved and grade 4 phimosis reevolved in 2–3 weeks. 0.05% clobetasol propionate a highly strong steroid (Dermovate 0.05% 50 gr, Turkey) for 6–8 weeks morning and evening was implemented to all of the patients and circumcision revision was made in all 46 patients with no response. In 8 cases patient’s relatives did not accept topical corticosteroid and circumcision revision was made. CONCLUSION: As a result, topical steroid is not found to be effective in the treatment of phimosis evolving after circumcision implemented with thermocautery. Keywords: thermocautery, phimosis, circumcision, topical steorid, inflammation

Effectiveness of Topical Steroid in Phimosis: A longitudinal Observational Study

Introduction: Most non-retractile foreskins have been diagnosed with phimosis and referred for circumcision. However, many patients can be managed with corticosteroid cream. This study evaluates the effectiveness of the topical application of corticosteroid cream and manual prepucial stretching in the treatment of phimosis. Methods: This was a longitudinal observational study carried out among children aged six months to 10 years with the diagnosis of phimosis between 1st September 2019 to 31st August 2020. The patients were advised to apply 1% Hydrocortisone cream together with manual prepucial stretching twice daily for four weeks. Patients were assessed at four weeks and six months at the outpatient clinic using Kirkos grading for retractability. Results: A total of 110 patients were diagnosed with phimosis during the study period. Fourteen patients had pathological phimosis out of which four had balanitis xerotica obliterans and were excluded from the analysis. Ninetysix patients with physiological phimosis were treated conservatively with 1% hydrocortisone and manual prepucial stretching. Among them, 87 cases were successfully treated whereas five patients had a partial response with treatment failure in four cases. Those five cases with partial response underwent adhesiolysis while circumcision was performed in the remaining four patients with treatment failure. Prepucial retraction was possible in four weeks in most of the patients with physiological phimosis with successful results in 90.6% of cases. Conclusions: All non-retractile prepuce are not pathological phimosis and doesn’t need circumcision. Local application of a potent corticoid cream and foreskin stretching is a safe, simple, and effective long-term treatment for physiological unretractable foreskin in children.

Retrospective analyses on preputioplasties in boys with pathological phimosis performed over the last nine years

AbstractIn our clinic, more patients wish to treat pathological phimosis with a preputioplasty to preserve their foreskin. This study aims to analyze the long-term effects of preputioplasty. Additionally, we have produced an instructional video for those who want to master this surgical technique. A retrospective cohort study was performed in boys aged ≤ 18 years old suffering from pathological phimosis. All patients underwent preputioplasty between January 2011–2020. The outcome of the preputioplasty is considered positive when the foreskin was retractable months post-operative.In total, 176 patients were included. The mean age operating was 8.9 years. A positive result after preputioplasty was observed in 163/176 patients (93%). Patients with a negative outcome most often chose a re-operation: circumcision in seven cases and a redo-preputioplasty in three. Four patients showed complications (minor infection (1), wound dehiscence (2), and excess amount of skin (1)). Thus, a preputioplasty is shown to be a feasible operative treatment option.

Referrals from primary care with foreskin symptoms: Room for improvement

AimsReferrals to secondary care for boys with foreskin symptoms require face-to-face review, resulting in time out of school / work and costs to the family. This study aimed to review outcomes of referrals to ascertain if there was scope to reduce referrals. MethodsNew patients referred to a UK regional paediatric surgery clinic during 2019 were identified and screened retrospectively. Medical records for boys over one year of age referred due to foreskin symptoms were reviewed. ResultsOf 2598 referrals, 1939 (75%) were boys & 1094 were > 1 yr; 398 (21%) were referred with foreskin symptoms at median age 7.2 yrs (IQR 4–10). 307 (77%) were diagnosed with physiological phimosis, 67 (18%) with pathological phimosis, 9 (2%) with balanitis (the remainder had ‘smegma’ retention cysts, preputial adhesions, tight frenulum or anatomical abnormalities). 211 (53%) were discharged at the initial appointment, this was significantly more likely for younger boys, and those with physiological phimosis (p<0.001). 62 (16%) were prescribed topical steroids (more likely in older boys, p<0.001). 70 (18%) were offered surgery: circumcisions (n = 51), preputioplasties (n = 13), other (n = 4). The circumcision rate was therefore 12%. Age at referral was positively correlated with GP trial of steroid (older more likely), diagnosis (physiological phimosis more likely if younger) and outcome (topical steroids or surgery more likely if older): Spearman's rank correlation p<0.001. ConclusionsOver 75% of boys referred had a normal foreskin, over half were discharged at their first review. Improved knowledge amongst parents and primary care providers could reduce referrals and save money and resources. Level of evidenceLevel IV - Case series with no comparison group.

Lichen sclerosus in pediatric age: A new disease or unknown pathology? Experience of single centre and state of art in literature.

Lichen Sclerosus (LS) is a chronic inflammatory skin disease with unknown etiology. In pediatric age the main disease "lichenlinked" is the phimosis in male. This is a retrospective study that reports the experience of our clinic and review of the literature. We included all patients affected by pathological phimosis, treated by circumcision between January 2015 and May 2020, older than 6 years old and with an histopathological diagnosis of lichen sclerosus. The aim was to identify prognostic factors based on histological report to plan the clinical management of patients. Statistical analysis was done. We included 207 patients. The mean age of children was 9,78 years (5-18 years, DS±3.29). Based on the histological features we divided patients in 2 groups: early lesions (70/207, 34%) and advanced (137/207, 66%). In term of complications lichen linked we considered meatal stenosis that needed of urethral dilatations. We included 7 patients (7/207, 3,4%). We report P value Statistical Significance in many aspects. An early diagnosis of LS and surgical treatment of foreskin are essential to prevent early and late complications in children. The size of sample is a limit of the study but results encourage our management.

676 Paediatric Circumcisions- Compliance with RCS Standards

Abstract Introduction Variation in regional paediatric circumcision rates suggested some circumcisions were being performed unnecessarily. In 2016, the Royal College of Surgeons (RCS) released a clinical commissioning guide on foreskin conditions to standardise the indications for circumcision. We retrospectively audited the foreskin procedure practice at our urology department and its adherence to RCS clinical commissioning guidance. Method We assessed electronic health records for all paediatric patients (&amp;lt;17 years) having undergone a foreskin procedure from 1st Jan 2018 to 1st Jan 2019. Records were assessed for referral source, trial of medical treatment (steroid cream), indication, operative management carried out, daycase or inpatient cases, and histological analysis. Results 198 patients (mean age 8.7, range 2-16) underwent foreskin procedures in the set time frame. 98.9% were referred from GP surgery, and the remainder directly from A&amp;E. 29.8% had documented trials of steroid creams prior to surgery. 51.5% of procedures were performed for ‘non-retractile foreskin’ and 11.6% for pathological phimosis. 87.4% of patients underwent circumcision and 11.1% had freeing of adhesions. All of procedures were performed as day-case. Histology was sent for 17.3% of circumcisions, with non-specific inflammation being the most common finding (46.7%), followed by lichen sclerosus (40%). Conclusions In our series large number of foreskin procedures were carried out over a 12-month period with a minority for the only absolute indication of pathological phimosis We have introduced stringent guidelines in the department since this audit, which will prevent circumcision in children who may otherwise avoid surgery.

Comparative Study of Patient Satisfaction Between Traditional and Modified Plastibell Method for Circumcision in a Tertiary Care Centre

Introduction: Phimosis is Inability to retract prepuce. At birth the foreskin is normally adherent to the glans penis. Incidence of pathological phimosis is 0.6%. Circumcision is a very old procedure. Any technique for surgery can be applied but rate of morbidity should be low. Materials and Methods: Study conducted in Department of surgery of a tertiary care hospital. Data collection of selected patients with relevant history, clinical examination, appropriate investigation and surgical intervention were included. Results: Study was conducted with 116 subjects with mean age of 3.1 years with surgery done by the dorsal slit method and mean age of 3.7 years by plastibell method. The average duration for dorsal slit procedure to complete is 15.7 minutes and for plastibell is 12.2 minutes. Mean blood loss occurred in dorsal slit method is 9.0 while that in plastibell is 6.0. Frequency of surgical site infection in dorsal slit method is 5.2% while that in plastibell method is 6.9%. Post-operative heamorrhage seen in dorsal slit method is 5.2% while that in plastibell is 1.7%. 89.7% of parents satisfied with dorsal slit method while 96.6% parents were satisfied with modified plastibell method. Conclusion: Study showed that plastibell has advantage of shorter time for surgery and relatively lower risk of post-operative bleeding when compared with dorsal slit method of circumcision. The cosmetic outcome as judged by parental satisfaction was also better with plastibell technique.

A survey of adult men who underwent circumcision in childhood for pathological phimosis

Purpose: Pathological phimosis in childhood typically results in circumcision. Long-term follow-up data for men circumcised in childhood are lacking. This study sought long-term data regarding satisfaction with circumcision and voiding symptoms from men who had childhood circumcision between 1989 and 2010. Methods: Following ethical approval, a postal survey was sent to males &gt; 17 years who underwent circumcision at an age &lt; 16 years for pathological phimosis. Results: The survey was sent to 177 men, 23 completed surveys were returned [19 histology proven Lichen Sclerosus [LS, BXO], 4 chronic balanitis]. Mean age at circumcision was 9.7 years [range 3-15], at survey 23.5 years [18-37]. Seven [all &gt; 9 years] remembered the decision for circumcision. Four warranted urologist review as adults, three required surgery for voiding symptoms and one still performs structure therapy; all had LS. When asked which treatment option[s] they would have considered; ten of them chose circumcision, nine of them chose preputioplasty, eight of them chose topical creams [two of them chose all three options, one man chose both foreskin preserving options]. Eight agreed with the statement ''Having a circumcision in childhood or adolescence had an impact on my adult life''; this was positive in two men but negative in five men-they wouldn't have chosen circumcision. Conclusions: The response rate to the survey was low, making it difficult to draw firm conclusions. However, even in this limited sample, not all men would choose childhood circumcision for pathological phimosis, data supporting the need for larger studies of alternative treatment options. In addition, some men circumcised for childhood LS had significant voiding difficulties in adulthood.

Termokoterle Yapılan Sünnet Sonrası Gelişen Fimozisin Tedavisinde Topikal Steroid Kremin Etkinliği

Objective : In our country, thermocautery device is used extensively for circumcision performed under local anesthesia for fast and safe circumcision. One of the complications that may occur after circumcision with thermocautery is pathological phimosis. However, there aren’t studies in the literature regarding the medical treatment of pathological phimosis after circumcision with thermocautery. We aimed to investigate the effectiveness of topical corticosteroid application in the treatment of pathological phimosis developed after circumcision with thermocautery. Material&Methods: Data of 68 patients (aged: 1-8 years) who developed phimosis secondary to circumcisions performed by one surgeon between the years 2009 and 2018 were analysed retrospectively from a computerised database. Cases of phimosis developed after circumcisions performed using thermocautery and scalpel were analysed in two separate groups, and the effectiveness of topical steroid treatment was evaluated. Results : In the thermocautery group, 32 patients who developed Grade 5 phimosis didn’t respond to steroid therapy, while only three of 16 (18.75%) cases with Grade 4 phimosis responded partially to topical steroid treatment. All these 48 cases were treated with surgery. In the scalpel group, no therapeutic response was elicited in four cases who developed Grade 5 phimosis. However, four out of eight (50%) patients with Grade 4 and six out of eight (75%) patients with Grade 3 phimosis responded to steroid therapy, and full retraction of the foreskin was achieved. In the scalpel group, ten cases underwent surgical revision. Conclusion : Topical steroid creams may be partially beneficial in cases of pathological phimosis after circumcision. However, they do not show efficacy in cases of high-grade phimosis after thermocautery use.

Save the foreskin: Outcomes of preputioplasty in the treatment of childhood phimosis

BackgroundSymptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods like preputioplasty. We sought to examine outcomes of preputioplasty for the treatment of non-scarred pathological phimosis in two UK paediatric surgery tertiary centres. MethodsRetrospective case series selecting cases performed in both departments over a 4 year period (January 2012–December 2015). Inclusion criteria: non-scarred pathological phimosis treated with preputioplasty. Exclusion criteria: diffuse scarring of foreskin or presence of balanitis xerotica obliterans (BXO), preputioplasty performed as part of hypospadias repair. Outcome measure was treatment success as evidenced by fully retractile prepuce at follow up. Follow up occurred between 3 and 24 months. ResultsWe identified 126 patients, 6 were excluded due to the above criteria. Median age was 13.4 years (range 10 months–18 years). Median follow up was 13 months (range 3–24 months). 115 patients (96%) had successful treatment as evidenced by satisfactory post-operative cosmesis and complete resolution of phimosis at follow up. Recurrence of phimosis occurred in 5 patients (4%). Mean time of recurrence was 6 months, with a median age of recurrence of 15.3 years (range 10.7–16.7 years). All patients with recurrence were successfully treated with circumcision. ConclusionForeskin conserving methods like preputioplasty are a valid option in the treatment of non-scarred pathological phimosis.

Ultrasound evidence of bladder outlet obstruction secondary to lichen sclerosus et atrophicus in boys (balanitis xerotica obliterans)

BackgroundLichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on examination so ultrasound scans (USS) of the urinary tract are not routinely indicated. We review a series of abnormal USS in boys with LS. MethodsRetrospective note review for boys undergoing surgical treatment for LS between 2000 and 2017. Seventy-eight boys had a USS prior to surgery, those with abnormal USS form the study population. Boys with neuropathic bladder or congenital urinary tract abnormalities were excluded. ResultsNineteen of 78 boys (24%), mean age 9 years, were included. Seventeen had obstructive symptoms, 13 had culture proven UTIs, 12 had new onset incontinence. On USS 3 (17%) had acute retention, 8 (78%) had an isolated post-void residual volume (PVR) >10% of estimated bladder capacity (EBC); 3 had bladder wall thickening +/− PVR >10%, 5 had upper tract changes. Symptoms resolved with successful treatment of LS. Six boys had post treatment USS, abnormalities resolved in 5. ConclusionsClinicians should consider LS in boys presenting with UTIs, new onset incontinence and obstructive urinary tract symptoms. Routine USS are not indicated though should be considered in those with an atypical history or examination. Type of StudyCase Series. Level of EvidenceLevel 4.

Childhood Phimosis Secondary to Lichen Sclerosus: Is There a Spatial Pattern of Histopathological Changes?

The accurate histopathological diagnosis of the phimotic prepuce is indispensable because early diagnosis, treatment, and close follow-up are crucial in genital dermatosis such as lichen sclerosus (LS). This study analyzes the histopathological spectrum of childhood phimosis with special emphasis on LS. We also highlight a peculiar pattern of histopathological evolution in LS, prepuce. The histopathology slides of all the pediatric preputial circumcision specimens performed for the indication of pathological phimosis (n = 43) during the study period (2012-2017) were analyzed. Eight histopathological features viz. hyperkeratosis, hypergranulosis, epidermal atrophy, acanthosis, dermoepidermal cleft, upper dermal edema and homogenization, mid dermal lymphocytic band, and interface dermatitis were studied in each case, separately in inner preputial surface, tip, and outer preputial surface. On the basis of evolution of the disease and histopathological features, the lesions of LS were classified into early, established, and advanced. LS was found in 32 cases, whereas 11 cases showed nonspecific inflammation and fibrosis. The upper dermal homogenization (n = 29), dermoepidermal cleft (n = 28), and mid dermal band (n = 27) were the commonest histopathological changes. The established and advanced changes were confined to the inner preputial surface (n = 31), and the outer preputial skin surface was unaffected in all the cases. A peculiar histopathological evolution pattern was seen with established or advanced lesions, early lesion, and normal histology on the inner preputial surface, mucocutaneous junction, and outer preputial skin, respectively. LS is a common cause of childhood phimosis. It shows a peculiar histopathological evolution that mandates the thorough analysis of inner mucosal surface.

Modified partial circumcision for phimosis

Objectives: In the last years, many surgical techniques of preputioplasty have aimed to preserve the foreskin in case of phimosis. These techniques are not reliable for patients affected by phimosis linked to balanitis xerotica obliterans (BXO) and scarred foreskin. We tried an original technique of resection of the pathological foreskin, removing the mucosal internal layer followed by reconstruction of the foreskin. The aim was to evaluate the outcome of paediatric patients who underwent modified partial circumcision for pathological phimosis. Patients and methods: In all, 360 patients with phimosis underwent modified partial circumcision at our institution. The mean age of the boys was 8.9 years, range 5–15 years. In 145 (40.3%) cases, indication for surgery was clinical suspicion of BXO, in 215 (59.7%) cases it was chronic inflammation of the foreskin. Results: In all cases, the postoperative period was uneventful. Cosmesis was considered by parents as excellent in 95.2% of patients. In these patients, the glans was almost completely covered by soft foreskin. Histopathological examination of the removed foreskin documented BXO in 162 (45%). Twelve (3.3%) patients complained of recurrences and five (1.4%) patients of smegmatic cysts. Conclusion: The described surgical technique of modified partial circumcision for the correction of pathological phimosis appears cosmetically well accepted, safe, and simple with low rate of late postoperative complications. Keywords: balanitis xerotica obliterans, circumcision, partial circumcision, phimosis

Outcome of Topical Steroid Application in Children with Non-retractile Prepuce

True phimosis is overdiagnosed due to the failure to distinguish it from physiological phimosis, which is a normal developmental non retractability of the foreskin. The non-retractile prepuce in children is a cause of parental anxiety and concern. This leads to the majority of the children undergoing surgical procedures. Pathological phimosis needs to be differentiated from physiologic phimosis to avoid unnecessary circumcision. In recent years, topical steroid application use in cases of non-retractile prepuce has shown a good success rate and is well accepted by the parents. It has low risks, is cost effective and avoids anaesthetic and surgical complications.This is an observational study of 100 children with non-retractile foreskin who were managed by local application of topical steroid cream (0.1% Mometasone) over a period of 6 weeks. The non-retractibility was classified according to Kikiro’s classification. These patients were analyzed on the basis of age at presentation, complaints at the first presentation, grade of phimosis at first presentation (as per Kikiro’s classification), results of the topical steroid application as assessed at 6 weeks after starting application and after stopping of the steroid administered for 6 weeks. The results were analyzed on the basis of the resolution of symptoms and the decrease in Kikiro’s grade. Those patients in whom there was no response to treatment or who developed recurrence after stopping steroid treatment underwent circumcision. A total of 19 patients required surgical intervention in the form of circumcision. The use of topical steroids yields satisfactory results in patients with a non-retractile prepuce. It could be a first-line treatment for management in such cases and is an effective alternative designed to avoid unnecessary circumcision.

Preputialplasty: can be considered an alternative to circumcision? When, how, why? Experience of Italian centre.

Phimosis is a condition in which the foreskin cannot be portrayed on the glans. It is a physiological and common condition in the pediatric age. The pathological form derives from an inflammatory or traumatic lesion. Circumcision is the most common surgical treatment of phimosis but it is a controversial practice, especially in occidental world. We enrolled 61 patients with pathological phimosis (22/balanoposthitis, 18/painful erection, 21/urinary discomfort) between 2015-2017. All patients underwent preputialplasty. Various alternatives to circumcision have been described, as manual retraction therapy, topical steroid therapy, and many types of preputialplasty. We report our technique.

A Holistic Approach to Phimosis in Children

Phimosis is described as condition in which prepuce or foreskin of glans penis is not retracted backwards resulting in poor narrowed stream of urine during micturition causing ballooning of prepuce along with recurrent attacks of balanoposthitis and Urinary Tract Infections (UTIs). Majority of new born boys do have non-retractile foreskin called as Physiological Phimosis. In Ayurveda phimosis is described as Nirudhaprakasha. Physiological phimosis usually does not require any kind of treatment as it resolve spontaneously within first couple of years mostly taking 3 to 6 years after which measures are considered to correct it surgically. Pathological phimosis is condition in which prepuce get adhered to glans secondary to adhesions or scarring made because of infection, inflammation or trauma. Pathological phimosis and physiological phimosis with recurrent attack of balanoposthitis and UTIs do require treatment. There are several treatment modalities are available according to severity of adhesions such as local application of steroid cream or oil, manual retraction, dilatation and Circumcision. In this review article we assess the various treatment modalities available in Ayurveda and contemporary medical science for better management of Phimosis.

Dorsal slit preputioplasty for phimosis: a prepuce conserving surgery

Background: Phimosis is narrowing of prepuce leading to non-retraction behind glans penis. Phimosis is physiological in majority of patients. Pathological phimosis gives rise to symptoms of urinary tract infection and balanoposthitis. Most of patients with phimosis are subjected to circumcision. Instead of circumcision, a conservative surgical approach preputioplasty can be done as a prepuce salvage procedure. Methods: Patients suffering from urinary tract symptoms and persistent narrowing of phimotic ring and recurrent balanoposthitis were subjected to this prepuce salvage surgery. The dorsal slit preputioplasty was performed in these patients. Results: All patients were operated under local anaesthesia in outpatient department. The mean operative time was 10 minutes. No major complication was seen in any of these patients. Oedema of prepuce, haematoma and mild inflammation was noticed in a small number of patients. But wound infection and disruption occurred in none of the patients. The wound healing was good in all the patients on two weeks follow up. On one month follow up the cosmetic results were very good as per patient satisfaction. Conclusions: Dorsal slit preputioplasty is a simple procedure to perform without special equipment, less cost and less morbidity as day surgery procedure. This technique produces salvage of prepuce thereby conserving the sensations and functions inherent to prepuce.

Outcome of a standardized technique of preputial preservation surgery for phimosis: A single institutional experience

Introduction: Pathological phimosis or preputial stenosis is a distressing problem in children leading to recurrent balanoposthitis, ballooning of prepuce, and rarely back pressure changes in the urinary tract. Circumcision has been the standard of care for such situations, although recently, various alternatives to circumcision have been reported in the literature. Most of these techniques are often complex and are met with poor acceptance. Moreover, besides personal preferences (in Hindus), advantages of preputial preservation is increasingly being realized recently. Materials and Methods: A prospective study was carried out in which a simple standardized technique of preputioplasty (dorsal slit) was used in 40 pediatric preputial stenosis cases. The outcome of this procedure including cosmesis and parental satisfaction was evaluated. Results: The average duration of this procedure was from 10 to 25 min with no intraoperative complications. The cosmetic outcome was good in 62.5%, satisfactory in 30%, and poor in 7.5% of cases. All of the boys had retractable prepuce with no functional problems. There was 100% parental satisfaction. None of the patients required a redo procedure or circumcision. Conclusion: A dorsal slit of adequate length i.e.; 1/3 rd the length from the corona to the tip leads to a satisfactory cosmetic outcome in more than 92% of cases. Preputioplasty is a safe and simple alternative to more radical procedure of circumcision.

Prepuce: Phimosis, Paraphimosis, and Circumcision

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis. Actually, physiologic phimosis is common in male patients up to 3 years of age, but often extends into older age groups. Balanoposthitisis a common inflammation occurring in 4–11% of uncircumcised boys. Circumcision is generally undertaken for three reasons: first, as an item of religious practice, typically neonatally although occasionally transpubertally, as a rite of passage; second, as a prophylactic measure against future ailments for the reduction in the risk of penile cancer, urinary tract infection, and sexually transmitted infection; and third, for immediate medical indication. Balanitisxeroticaobliterans is an infiltrative skin condition that causes a pathological phimosis and has been considered to be the only absolute indication for circumcision. Various kinds of effective alternatives to circumcision have been described, including manual retraction therapy, topical steroid therapy, and several variations of preputioplasty. All of these treatments have the ability to retract the foreskin as their goal and do not involve the removal of the entire foreskin. Paraphimosis is a condition in which the foreskin is left retracted. When manipulation is not effective, a dorsal slit should be done, which is usually followed by circumcision.