Penile Edema Research Articles

Feasibility and Safety of a Simple Non-cystoscopic Double-J Tube Removal Technique in Children.

Objective: Double-J tube placement is an important procedure during upper urinary tract surgery. A primary drawback is the requirement of a second double-J tube removal under a cystoscope. Therefore, a simple and feasible alternative is required to remove the double-J tube without cystoscopy. The present study reported the feasibility and safety of a simple non-cystoscopic double-J tube removal technique.Method: We retrospectively analysed children who underwent pyeloplasty and ureterovesical reimplantation between June 2015 and August 2021. A simple device (a catheter with a suture) was used to pull out the double-J tube. Patient characteristics, detailed surgical procedures, success and complication rates and reasons for failure were evaluated.Result: A total of 613 children were included. The mean age of patients was 6.2 months (3 months−14 years). Non-endoscopic methods were used to remove the double-J tube in all except 6 patients (0.9%). Of the 6 patients who required ureteroscopy or cystoscopy, 4 had retraction of the double-J tube into the ureter, and 2 (0.6%) had bladder stones. Of the 613 patients, 479 (76.0%) required one attempt, 127 (20.1%) required two attempts and 19 (3.0%) required several attempts. No serious postoperative complications occurred in all patients. The most common complications were gross haematuria (22.5%), pain urinating (17.9%), difficulty in urinating (3.6%), foreskin injury (1.7%), and penile oedema (1.3%). No urethral strictures developed during the follow-up period.Conclusion: The study results demonstrated that the modified and simple non-cystoscopic double-J tube removal technique is a safe and an effective alternative to cystoscopy in clinical practise.

The perils of penile enhancement: case report of a fulminant penile infection

BackgroundPenile enhancement with injectable agents is a rising trend and yet has received little scientific attention despite the potential for serious complications. These include cosmetic, functional and systemic complications that may require complex penile reconstructive surgery. We report a case of delayed severe infection following penile filler insertion leading to multi-organ failure and intensive care support.Case presentationA 31-year-old man presented with fevers and progressive pain and swelling of the penile shaft, 3 days after unprotected sexual intercourse. The patient received subcutaneous hyaluronic filler injections at a cosmetic clinic for penile enlargement two months prior to presentation. Relevant social history include polysubstance abuse and multiple sexual partners. Physical examination revealed gross penile oedema and erythema, with a ventral curvature of the penile shaft and a superficial abrasion on the distal ventral penile shaft. Within 24 h the patient developed septic shock with anuria, hypotension and fevers to 40 °C, requiring transfer to the Intensive Care Unit (ICU) for vasopressor and inotropic support. Intraoperative penile exploration revealed multiple pus stained fillers which were drained and grew Streptococcus Pyogenes on cultures. There was no abscess or evidence of necrotising fasciitis intraoperatively. The patient improved with intravenous antibiotics and was stepped down from the ICU after four days and discharged on day eight. One month post admission there was significant superficial skin loss to both ventral and lateral aspect of the penis, with healthy granulation tissue at the base. The patient opted for conservative management with regular dressings. He reported normal sexual and urinary function three months post admission.ConclusionThis is the first published case of sepsis from a penile infection in the context of hyaluronic acid penile fillers. In an era of escalating demand for penile cosmetic procedures, there is an increasing need for early recognition and appropriate management of penile filler infections. We report an unusual case of a localised penile infection rapidly progressing to sepsis with multi-organ failure requiring intensive care support. The case demonstrates early surgical intervention with targeted antimicrobials can result in successful eradication of infection, with satisfactory cosmetic and functional outcomes for patients.

Congenital webbed penis: Surgical outcomes of a simplified technique

Webbed penis is a cause of concealed penis. It reflects abnormal attachment of the scrotal skin to different ventral penile shaft levels, possibly due to abnormal scrotal dartos insertion. Different techniques are available for correction of congenital webbed penis. However, there is no single one versatile for correction of different grades. To evaluate the surgical outcome of penile degloving, excision of abnormal dartos fascia with penoscrotal fixation sutures to correct different grades of congenital webbed penis. This prospective study was conducted on boys with congenital webbed penis. Thorough clinical examination to determine the degree of webbed penis and associated anomalies were done. A technical modification of previously described technique by Frenkl etal. 2004 (22) was used. The principles include; complete penile degloving with excision of all abnormal scrotal dartos attached to the penile shaft, creation of a well-defined penoscrotal angle by penoscrotal fixation sutures and the short ventral skin was compensated from the prepuce with circumcision. Assessments of surgical outcomes and parents' satisfaction were done during follow up visits. This study included 107 boys. The median age was 9 (range, 6-40) months, and the median operative time was 55 (range, 50-65) min. Five patients (4.7%) developed self-limited postoperative penile edema, two (1.9%) developed wound infections, and two (1.9%) had a self-limited scrotal hematoma. The median follow-up period was 19 months. At the 6 months follow-up, we had two patients with persistent mild grade I webs, with a success rate of 98.13%. Parental satisfaction was obtained for all patients. Currently, there is no current single technique suitable for the correction of all grades of webbed penis. In this study, we presented a technical modification of previously described technique by Frenkl etal. 2004 (9), this modified technique is versatile for correction of different grades of congenital webbed penis without leaving a scar at the penoscrotal angle. But, absence of a comparative group is considered a limitation; however, the versatility of this technique overcomes this limitation. This described technique is simple and feasible. It could correct all types of congenital webbed penis. Short term outcome showed good cosmetic and functional results with parental satisfaction.

Male genital allergy with penile oedema and severe aseptic urethritis, due to vulvovaginal candidiasis, simulating sexually transmitted infection

Sexually transmitted diseases (STDs) are frequently encountered and more than 1 million are acquired daily. Genital allergy (GA), on the other hand, is another uncommon cause of sexually transmitted disorders that should be considered if no infection is identified or genital soreness persists or worsens with antimicrobial therapy. In this case report; we present a patient, with severe GA (type I hypersensitivity reaction) to vulvovaginal candidiasis in his sex partner. He was initially misdiagnosed as STD as he presented with severe penile and urethral oedema culminating in hematuria and bladder neck obstruction due to severe urethral oedema. Our systematic approach in diagnosis and hence treatment of the patient and his sex partner is outlined.
 Keywords: Candidiasis, genital allergy, penile oedema, STD, urethritis.

Complications and management of penile augmentation with hyaluronic acid injection.

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of 230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection. There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may affect the patient's satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.

Obstructive Urolithiasis In Dromedary Camels: Clinical, Ultrasonographic And Postmortem Findings

This article was written to evaluate camels with obstructive urolithiasis with special reference to the clinical, ultrasonographic and postmortem findings. Twenty male camels (Camelus dromedarius) with urolithiasis were examined. Of them, 18 had ruptured bladder and 2 had ruptured urethra. Main clinical findings included depression, anorexia and anuria. Ventral abdominal swelling was also detected in front of the penis with swelling of the prepuce. Exploratory laparotomy showed a massive amount of reddish uroperitoneum. In the camels with ruptured urethra, penile and ventral edema was detected in front of the penis with swelling of the prepuce. The urine penetrated the adjacent tissues that also yielded dark red urine on aspiration. The most important ultrasonographic findings included a collapsed urinary bladder in animals with ruptured bladder. Uroperitoneum was imaged easily where viscera were seen floating in the urine. Dilatation of the pelvic and penile urethra as a result of calculi was detected by ultrasonography. The urinary bladder wall was intact in cases before bladder perforation. Hydronephrosis with parenchymal pressure atrophy was also detected. The obstructing calculus was also seen within the penile urethra as a hyperechoic mass with distal acoustic shadowing. The perforated urinary bladder was also seen. In cases with ruptured urethra, the bladder wall was imaged intact and it contained hyperechoic sediment. Postmortem examination confirmed the ultrasonographic findings.

Outcome of Laser Urethrotomy in Comparison with Optical Internal Urethrotomy in Recurrent Stricture Urethra Following Perineal Anastomotic Urethroplasty for PUDD

Objective: To compare the outcome of laser urethrotomy and optical internal urethrotomy(OIU) for the treatment of recurrent stricture urethra following perineal anastomotic urethroplasty for posterior urethral distraction defect. Materials and methods: The study was conducted in Dhaka Medical College Hospital from January 2013 to December 2014.Male patients presented with obstructed voiding symptoms following perineal anastomotic urethroplasty were evaluated by their history, physical findings and investigations (urinalysis, uroflowmetry, retrograde urethrogram and micturiting cystourethrogram ) & primarily 64 patients are selected by purposive sampling. Patients are divieded again by random allocation into group A and group B and underwent for OIU and laser urethrotomy respectively. Results: Comparison was made to find out the better method between optical urethrotomy and laser urethrotomy. Overall per-operative complications (bleeding, extravasations of irrigating fluid, false passage and broken knife) in the former group were 31.3% compared to none in the latter group. Post-operative complications like bleeding, haematoma, penile oedema and erectile dysfunction were found only in Group-A (p=0.002). The mean duration of postoperative catheterization and average hospital stay were observed to be much higher in Group-A than that in Group-B (p=0.000008; p=0.0006). Comparison of final outcome (development of stricture) between groups at 1 year of evaluation in Group-A and Group-B was not significant (p= 0.320). Conclusion: Laser urethrotomy is better than optical urethrotmy in regards of peroperative and post-operative complications. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.181-187

Surgical management of post-circumcision webbed penis in children

ABSTRACT Objective To report the outcomes of surgical correction of post-circumcision webbed penis using two previously described techniques: the Heineke-Mikulicz (HM) scrotoplasty and the multiple Z-plasty. Patients and methods A prospective study of children with post-circumcision webbed penis was conducted. The patients were classified into two groups according to the degree of web and the remaining ventral penile skin as to whether adequate or short after circumcision. Group I was repaired by HM scrotoplasty and in Group II the multiple Z-plasty technique was used. Results This study included 86 patients of whom 71 maintained follow-up; 44 (62%) in Group I and 27 (38%) in Group II. The median (range) operative time was 45 (30–55) min in Group I and 75 (60–90) min in Group II. Wound infection occurred in two (4.5%) patients in Group I. In Group II postoperative mild self-limited penile oedema was present in three patients (11.1%). A self-limited scrotal haematoma developed in two (7.4%) patients. Conclusion Correction of post-circumcision webbed penis in children can be done by one of two techniques: HM scrotoplasty in Grade 1 and multiple Z-plasty in Grade 2 and Grade 3, with favourable outcomes. Abbreviations HM: Heineke-Mikulicz; IQR: interquartile range

P104 PEDIATRIC CROHN’S DISEASE PRESENTINAG AS GENITAL EDEMA

Abstract Two 12 year old boys presented to pediatric urology with chief complaints of genital swelling who were eventually diagnosed with Crohn’s disease. Patient 1 presented with swelling, erythema and discomfort of his penis. He did not respond to topical hydrocortisone or oral antibiotics. With history of short stature he was referred to pediatric GI. He had oral ulcerations and perianal skin tag, but denied abdominal pain or diarrhea. Weight was at the 3rd percentile height was at the 2nd percentile. He had Hgb of 12.2, and iron saturation of 8 with normal ESR and CRP. ASCA IgA was normal but IgG was elevated at 66 (normal <20). Endoscopy revealed erythema with linear ulcerations in the stomach and aphthous ulcerations of the colon with erythema and edema of the ileocecal valve with inability to intubate it. Pathology demonstrated mild chronic active gastritis and mild chronic active colitis with granulomas. Magnetic resonance enterography (MRE) showed mild enhancement at the ileocecal area. Budesonide improved the penile erythema but did not change the edema. He was then started on methotrexate and infliximab with no improvement of the edema. Topical tacrolimus did not resolve edema. At age 15 he had surgical resection of the indurated subcuticular penile tissues with pathology revealing fibrotic stroma with lymphoplasmacytic inflammation and rare granulomas. He has recovered well from his penile procedure with a dramatic improvement in the cosmetic appearance, with no recurrence of the penile edema. Patient 2 had scrotal edema, erythema, and discomfort. A scrotal ultrasound demonstrated moderate to severe scrotal edema without epididymitis, orchitis, or abscess. He was prescribed a dose of prednisone and diphenhydramine. Swelling improved but he presented a month later with recurrent scrotal edema and pain and was prescribed doxycycline for a presumed diagnosis of cellulitis along with recommendations for ice, compression and elevation. He returned to the ER the next day due to serous seepage from the scrotum. Upon follow up in urology, a pediatric gastroenterology referral was performed as a family history of Crohn’s disease in the mother, maternal aunt, and maternal grandmother was noted. Labs revealed a slightly elevated ESR of 17, elevated CRP of 7.3 (normal <0.5), negative ASCA, and mildly elevated fecal calprotectin of 193. Endoscopy revealed aphthous ulcerations in the duodenal bulb and patchy erythema of the terminal ileum. Pathology revealed mild reflux esophagitis, mild reactive changes in the stomach, mild chronic duodenitis, and mild active ileitis. MRE was normal. He was treated with budesonide and mesalamine with subsequent improvement in the scrotal edema. Patients presenting as genital edema as their initial Crohn’s presentation is rare and it is important for providers to be aware of this rare manifestation. Epitheliod granuloma in the bowel. Epitheliod granuloma in penile tissue.

Retained Penile Ring: Case Reports

Background: Penile constriction rings have been used to prolong erection with vacuum devices in the treatment of erectile dysfunction. Some have also employed it for recreational purposes with the attendant risks of penile edema, strangulation and necrosis. We present two cases of entrapped phallus by penile rings. Case reports: 16 years old with pain and swelling of the phallus of 12 hours duration. This started after placement of a phallic ring to purportedly prolong erection which he was later unable to remove the ring despite several attempts and developed progressive swelling and pain in the phallus. He was also unable to pass urine. Examination revealed a circumcised phallus that was detumescent but grossly edematous, tender with shiny skin. Initial simple manoeuvres in the casualty proved abortive and ring had to be cut with an orthopaedic instrument. He was subsequently able to void without difficulty or any haematuria. 47 year old Asian male with a 12 hour history of penile pain and swelling following entrapment of a penile ring he had inserted for sexual gratification about 24 hours before presentation. There was a history of haematuria. The removal of the penile ring was achieved with a combination of cold compress squeeze, corporal aspiration and lubrication under general anaesthesia. Conclusion: Successful management of retained penile ring depends on early presentation by the patient to avoid adverse outcomes. It may require instruments not normally found in the urologist armamentarium.

Urological Evidence of Tick Bites in Children.

Ticks pose a serious threat to individuals of all ages owing to numerous physical illnesses including chills, aches, and a rash. Tick-borne illnesses range from a mild fever that may be treated at home to a severe disease necessitating hospitalization. Children are at an increased risk of tick bites owing to to their exposure to tick-infested areas during the summer. We report 2 cases of boys aged 3 and 8 years who sustained tick bites to the hemiscrotum and penis. Overnight hospitalization and a course of antibiotics were mandatory. In the first case, the child experienced significant scrotal cellulitis with erythema and edema extending to the suprapubic area with induration of the right anterior scrotum at the site of the tick bite. A scrotal ultrasound demonstrated swelling of the scrotal wall. In the second case, considerable swelling and induration of the distal penis and glans, pruritis of the left groin and penis, and an erythematous rash over the entire anterior pelvis were observed. A high index of suspicion is warranted because a tick bite may present as penile edema. Pediatric emergency physicians should be aware of the risks associated with tick bites and accurately diagnose and initiate treatment to prevent morbidity and mortality.

The impact of sex hormones on genital wound healing in mice: a comparative study

The effects estrogen and testosterone have on penile wound healing are still uncertain. This study evaluated the effects of these hormones on the wound healing process of penile and non-penile skin in wild-type (Mus musculusspecies) 4-5-week-old mice. Seventy wild-type Mus musculusspecies were randomly assigned to four groupscontrol (n=17), 1-week post-operative topical estrogen (n=18), 1-week pre-operative testosterone (n=17), and immediate post-operative testosterone (n=18). Incisions were made on the ventrum of the penis and dorsal neck skin. On post-operative day 3, 7, and 14, incision sites were harvested. Evaluation was performed grossly for postsurgical penile edema and histologically for inflammatory cell concentration, presence of fibrinopurulent materials and distribution of collagen-fibroblastic cells. Each treatment group was compared at the three post-operative time points using the Fisher-Freeman--Halton exact test. CD34 and androgen receptor immunohistostaining was performed for between-group differences to assess microvascular density or vasodilatation and androgen receptor upregulation. In this study, the experiment noted significant penile edema on post-operative day 7 in the testosterone groups, whereas less edema in the estrogen group (P=0.010; Figure). On histologic evaluation of the penile wounds, a significantly increased inflammatory cell concentration was noted for both pre-operative and post-operative testosterone groups on post-operative day 14 (P=0.023). The estrogen group revealed significantly increased fibrinopurulent material on the 3rd and 7th post-operative days (P=0.045 and P=0.005, respectively). No significant between-group differences in the collagen-fibroblastic distribution were noted over the three-time phases. On histologic evaluation of the skin wounds, no significant differences were noted between the groups for inflammatory cell concentration and presence of fibrinopurulent materials. However, compared with the testosterone treatment groups, a significant higher collagen-fibroblast distribution was noted in the estrogen groups on post-operative day 3 and 14 (P=0.001 and P=0.044,respectively). Sex hormones, when given peri-operatively, may affect the wound healing process in mice. Testosterone appears to stimulate a prolonged inflammatory effect on penile wounds. Conversely, estrogen induces a fibrinopurulent congregation early in the penile wound healing process. For general skin healing, estrogen induces earlier collagen and fibroblast distribution, whereas testosterone has a delayed effect. The findings of this study should be further investigated in larger animal model with longer follow-up period.

Experience in circumcision of children aged 3-6 years under the intervention of modern holistic medical model

Objective Under the intervention of modern holistic medical model, the subjective feelings and objective effects of parents and children in circumcision were studied in children aged 3-6 years. Methods A prospective study was conducted to select 2012 children aged 3 to 6 years who underwent circumcision at the First Affiliated Hospital of Kunming Medical University from August 2013 to May 2017. The patients were divided into control group and experimental group by completely randomized grouping, there were 1 006 cases in each group. The children in the control group were treated with a single biomedical model, which was completed according to the conventional flow-type operation. The children in the experimental group adopted the modern holistic medical model, and the full modern holistic medical model intervention was performed before, during and after the operation. The medical treatment process highlighted the overall humanistic care for the children. The age of the control group was (4.19±1.75) years old, and the age of the children in the experimental group was (4.26±1.68) years old. The operation time, the degree of surgical pain [with the pain visual analogue scale (VAS)], the postoperative complications (including postoperative hemorrhage, penile edema, infection, wound rupture), wound healing time, surgery satisfaction rate and fear level of children were compared between the two groups. Measurement data were expressed as mean±standard deviation (Mean±SD), t-test was used for comparison between groups; Chi-square test was used to compare the count data. Results In the control group, the operation time was (9.26±1.87) min, the surgical pain VAS was (2.59±0.72), postoperative bleeding was 38 (3.8%), severe penile edema was 78 (7.8%), and infection was 12 (1.2%), wound rupture was 32 cases (3.2%), the wound healing time was (20.4±2.56) d, and the surgical satisfaction rate was 67.4%. In the experimental group, the operation time of was (6.15±1.23) min, the surgical pain VAS was (1.71±0.54), postoperative bleeding was 6 cases (0.6%), severe penile edema was 12 cases (1.2%), and infection was 8 cases (0.8%), wound rupture was 2 cases (0.2%), the healing time was (15.2±3.16) d, and the operation satisfaction rate was 98.8%. The operation time, surgical pain VAS, postoperative bleeding, severe penile edema, wound splitting rate, healing time and surgical satisfaction rate were statistically significant (P 0.05). The fear level of children in the experimental group was superior to the control group at levels 0, 1, 2 and 3, the difference was statistically significant (P<0.05). Conclusions Under the intervention of modern holistic medical model, the child′s operation process is smooth, the children and parents have good subjective feelings, no obvious fear, good compliance, high satisfaction, good objective clinical effect, and positively improve the relationship between doctors and patients. The society has won a good reputation and deserves to be promoted clinically. Key words: Child, preschool; Circumcision, male; Modern holistic medical model

Managing complications of collagenase Clostridium histolyticum (CCH) injection.

The introduction of collagenase Clostridium histolyticum (CCH) has revolutionized the treatment of Peyronie's disease. The efficacy of this therapy has been well demonstrated and the safety profile is favorable. However, post-injection complications are poorly characterized and management of these complications lacks standardization. This review includes literature published in English and indexed in the PubMed®, Embase® or Google Scholar™ databases. What follows is a synopsis of relevant articles, including original research studies, in an attempt to better define CCH complications and their respective management strategies. Adverse effects of therapy are common but generally self-limiting. Penile pain and edema are expected events, and most patients experience hematologic sequelae (bleeding, hematoma, ecchymosis, etc.). The intervention rate for penile hematoma is low. Penile fracture is a morbid complication of therapy that is rare and may be challenging to diagnose given the frequency with which pronounced bruising and swelling are encountered. Imaging is a useful adjunct in situations of diagnostic uncertainty. Alternative injection protocols have been evaluated to limit the cost and morbidity of CCH therapy. Clinical efficacy of these protocols is promising, but prospective evaluation is lacking. No standardized protocols exist for management of post-injection complications of CCH therapy. The majority of these complications are managed conservatively, but suspected penile fracture should be carefully evaluated and imaging employed when needed. Future prospective studies of alternative injection protocols are warranted to decrease morbidity while maintaining efficacy.

Penile hair strangulation: A prodigious cause of pediatric agitation.

Penile hair strangulation is secondary to a hair tourniquet effect. Albeit a rare presentation in pediatric emergency units, penile hair strangulation must be cautiously noted in any penile pain and edema, to avoid inevitable damage to external genitalia, including penile necrosis, urethrocutaneous fistula, and even amputation.

Evaluation of Male Circumcision: Retrospective Analysis of One Hundred and Ninety-eight Patients.

IntroductionCircumcision is the oldest and most frequently used surgical procedure. It dates back to at least 10,000 years from today. The debate on the benefits and necessity of circumcision is ongoing. In this study, we aimed to determine the complications and complication rate of circumcisions occurring in our circumcision clinic and to compare these with the complication rates in the world.MethodsA total of 198 male patients circumcised between 2011 at 2019 at Bursa State Hospital was enrolled in the presented retrospective study. Demographic data of the patients were assessed and the height and weight of the patients were evaluated according to the child growth standards and weight for age percentile charts for boys of the World Health Organization (WHO). All early or late complications were noted after circumcision.ResultsThe mean age of the patients was 93.57±40.12 (2-248) months. The mean follow-up time was 16.32±9.24 (2-35) months. Sixteen patients had bleeding, four patients had a penile hematoma, and 108 patients had penile edema. There is no statistically significant difference in the penile edema occurrence according to the weight of the patients (p=0.58). ConclusionCircumcision is a frequently applied procedure. Like any other surgery, perioperative and postoperative complications can be observed. More importantly, a significant number of these complications can be prevented by careful surgery and postoperative care.

A controlled trial of Gomco versus Plastibell for neonatal circumcisions in Saudi Arabia.

BackgroundGomco or Plastibell devices are the most widely used method for circumcision. The present work was aimed to assess the incidence of complications in infants of ages up to six months in two used methods.MethodsIt was a prospective randomized study conducted at a pediatric surgery clinic in 3 hospitals in Jeddah, Saudi Arabia. Eight hundred and five children, their ages were less than 6 months were enrolled for the present work. Children were randomized into two groups: Groups P and G using Plastibell and Gomco Circumcision methods, respectively. Statistical analysis of data was performed by using SPSS Version 17. Chi-square test and independent sample t-test was applied to compare both qualitative and quantitative variables, respectively. P-value was considered as significant difference at <0.05.ResultsSeven hundred eighty three children were were enrolled in this investigation. Plastibell method was concomitant with low volume of bleeding in comparison with Gomco method (P < 0.001). Incidence of complications including infection, penile edema, proximal migration and redundant skin was higher in Plastibell device method (P<0.05).ConclusionGomco circumcision is the safer method and is accompanied with lowest rate of complication.

Penile Edema and Lichenoid Plaques on Scrotum: An Unusual Presentation of Secondary Syphilis.

Sir, A previously healthy 35-year-old male presented with complaints of swelling of penis with inability to retract foreskin and dark-colored lesions on scrotum for 20 days. There was a history of unprotected sexual exposure with a female commercial sex worker 3 months back. One month later, he developed a solitary, painless ulcer on the penis. The patient opted for over-the-counter topical and systemic antibiotics following which the ulcer healed in the next 4–5 weeks. However, 2 weeks later, he developed swelling of the penis with inability to retract the foreskin, dark-colored asymptomatic lesions on scrotum and dark-colored scaly rash on palms and soles. There was no history of any urethral discharge, burning micturition or any constitutional symptoms. On examination, the patient had edema of the prepuce with secondary phimosis [Figure 1a]. There were multiple, violaceous, scaly plaques on scrotum [Figure 1b]. Palms [Figure 2a] and soles [Figure 2b] had multiple hyperpigmented macules with few keratotic papules. The mucosae, scalp and nails were unremarkable. He had multiple, discrete, non-tender, shotty lymph nodes (1–2 cm in diameter) in both inguinal regions. The hematological and biochemical investigations were normal. The venereal disease research laboratory (VDRL) test was reactive in a titer of 1:128 and Treponema pallidum hemagglutination assay (TPHA) was positive. ELISA (enzyme-linked immunosorbent assay) for HIV was negative. Our patient denied consent for skin biopsy. In the setting of corroborative history, examination and reactive serological tests, a final diagnosis of secondary syphilis was made. The patient was treated with a single dose of benzathine penicillin 2.4 million units (1.2 million units given in each buttock) after sensitivity testing. He was counseled about safe sexual practices and was asked to get his wife evaluated too.Figure 1: (a) Edema of the prepuce with secondary phimosis; (b) violaceous, scaly plaques on the scrotumFigure 2: (a) Hyperpigmented macules on both palms; (b) hyperpigmented, keratotic papules on both solesWhen the patient was reviewed 6 weeks later, the penile edema and the scrotal lesions had resolved and a healed atrophic scar was appreciable on the undersurface of the prepuce [Figure 3]. A repeat VDRL titer 3 months post treatment was 1:32, indicating adequate response to the treatment.Figure 3: Healed atrophic scar on the undersurface of the prepuce (solid black arrow)Discussion Secondary syphilis is often called “the great mimicker” because of its protean clinical presentations.[1] Skin rash is seen in more than 80%–95% of cases with over 95% of the eruptions being macular, maculo-papular or papular lesions. Rare variants include nodular, pustular, lichenoid and erythema multiforme like lesions. Penile edema is usually a feature of syphilitic balanitis seen in primary syphilis. Our patient had unusual lichenoid lesion on scrotum associated with penile edema resulting in secondary phimosis. He did not have any systemic involvement or generalized rash on body. Only because he had typical lesions on palms and soles did we consider the possibility that the scrotal lesions and penile edema were possible manifestations of secondary syphilis, which was later confirmed by serological tests. Lichenoid lesions on scrotum as a manifestation of secondary syphilis was previously reported by Narang et al. in two cases who also had generalized lymphadenopathy, fever and malaise.[2] Also, scrotal eczema-like presentation in syphilis has been rarely mentioned in literature.[3] Therefore, one must keep a high index of suspicion of syphilis in a patient presenting with a temporal history of high risk sexual behavior and cutaneous manifestations that can easily be confused with common dermatoses like lichen planus, psoriasis, tinea, eczema, etc. Penile edema is usually seen as a manifestation of syphilitic or Follmann's balanitis[4] in the primary stage and usually resolves with the resolution of the chancre. In our patient, the penile edema may have been a manifestation of chancre redux which went unnoticed due to secondary phimosis or could have been a rare manifestation of secondary syphilis itself as has been described by Korta et al.[5] To conclude, clinical presentations of secondary syphilis are protean and might be misleading. It is important that a high index of suspicion is maintained when evaluating lesions in patients at epidemiologic risk for syphilis and any suspicion should be dealt accordingly with appropriate investigations. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgements We are thankful to the family of our patient for their support and cooperation.

A comparative study between tubularized incised plate urethroplasty with and without fibrin glue

Objective To compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate (TIP) repair with and without fibrin glue as regards fistula formation, penile edema, wound infection, and cosmetic outcome. Background One of the most important factors in reducing the incidence of fistula and other complications is incorporation of an intermediate layer between the neourethra and the skin layer. It may be dartos fascia, tunica vaginalis, and others. The key step is using fibrin sealants as a protective covering layer. Patients and methods Between December 2014 and December 2016, we enrolled 32 male patients into our study at Menoufia University Hospital. The patients will be divided into two groups. The first group included about 18 patients where fibrin glue was applied after construction of a neourethra before closure of the skin. The second group consisted of about 14 patients who were treated by a construction of a neourethra but without the use of fibrin glue. Results The results of group I which underwent TIP urethroplasty with fibrin glue showed an 11% incidence of fistulation. Group II which underwent TIP urethroplasty without fibrin glue showed a 43% incidence of fistulation. Conclusion Applying a clot of fibrin glue between the layers of hypospadias repair will decrease the incidence of the complications after the repair. The fibrin glue results are poorer because of the increase in the rate of infection which will be the cause of fistula and wound dehiscence.

Effectiveness of modified Brisson surgery in treatment of severe concealed penis

To discuss the effectiveness of modified Brisson surgery in treatment of the severe and obviously obese concealed penis. A clinical data of 96 boys with severe concealed penis, of 53 cases combined with obviously obese, who were treated by modified Brisson surgery between January 2014 and August 2016, was retrospectively analysed. The children ranged in age from 1 year to 11 years and 9 months, with an average of 5 years and 3 months. The median longitudinal incision of the penis scrotum was used instead of the wedge-shaped skin incision at the junction of the penis and scrotum, which could completely expose the surgical field; fully release and removal of the abnormal meat membrane and fascia around the penis were performed; the propulsion and rotating flaps match the inner sheath of the foreskin was used to completely remove skin stenosis. Postoperative effectiveness was evaluated by Boemers standard. All the incisions healed by first intention and no infection or necrosis of the foreskin flap occurred. Ninety-three cases were discharged from hospital after operation and followed up 1 year to 3 years and 6 months, with an average of 2 years and 4 months. Scrotal hematoma occurred in 2 cases within 48 hours, penile skin edema occurred in 5 cases, and scar hyperplasia in the penis scrotal corner incision occurred in 1 case at 1 month after operation. Postoperative exposure of the penis was good in 90 cases; there was no retraction of the penis in the upright position and sitting position; the family members were satisfied with the appearance of the penis. The penis were partially retracted in 3 cases, that affected the appearance of the penis during the sitting position. The modified Brisson surgery is one of the most effective methods to treat the severe and obviously obese concealed penis, with satisfactory effectiveness and less complication.