Physiological Phimosis Research Articles

Balanoposthitis in children: Analysis of treatment diversity and development of a treatment proposal

Balanoposthitis in boys with physiological phimosis is common. Publications on the topic are rare and literature provides no evidence-based guidelines on treatment efficacy. With this study, we aim to analyze treatments currently used, physicians' experience regarding the success and thus derive a treatment proposal. An online questionnaire was created to evaluate practice patterns and experience. A case scenario, open questions and multiple-choice questions were used to allow multilayered answers. Pediatricians, pediatric surgeons, pediatric urologists, and family practitioners were invited to participate. Demographic data and answers to multiple choice questions were analyzed descriptively. Free text comments were analyzed quantitively by coding the text entries and identifying relevant themes. The themes were then grouped into categories. Three-hundred-and-one data sets were analyzed. Predominantly, participants were from Germany and Switzerland, and most were specialized in either pediatrics or pediatric surgery. The analysis revealed a wide variability of treatments. Three main treatment forms were identified: baths, topical antiseptic treatment (wraps, gels), and topical antibiotics. Many participants use combinations of the above. Altogether, 53 treatment varieties and 27 categories were identified, including oral antibiotics and local irrigation. Treatment success was reported to be good for all treatment forms, baths were reported to be the best perceived treatment by the majority of participants. The online questionnaire generated valuable data on the wide variety of treatment used for posthitis. The fact that all treatments are reported to be highly effective suggests that little is necessary to treat the condition or that it might even be self-limiting. Further studies will be needed to prove this conclusion. Until those are available, three main concepts should be considered when choosing a treatment: avoid (traumatizing) manipulation, apply antibiotic stewardship and adhere to families' preferences and feasibility. We propose baths or local antiseptics, depending on the practitioner's and family's choice as the least invasive alternative. A prospective study to back our recommendation is scheduled.

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.

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.

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.

Primary care of preputial adhesions in children - a retrospective cohort study.

Aside from religious circumcisions, the indications for circumcision are few. However, in the cultural context, many patients are unnecessarily referred for circumcision for physiological phimosis (adhesions). Due to parental concerns and misperceptions by general practitioners, non-retractile prepuce is one of the most common indications for referral to a paediatric surgeon in many countries. This study aimed to determine whether preputial adhesiolysis successfully managed symptomatic non-retractile foreskin and therefore prevented the need for circumcision. A retrospective review was performed of the health records of children who presented with preputial adhesion. We included 65 symptomatic patients (ballooning of the prepuce in all cases and additional dysuria in three cases) who underwent preputial adhesiolysis. All cases were followed up for 2 years. Circumcision was subsequently carried out for patients who developed fibrous scarring resulting in difficult retraction due to the development of thick adhesions or skin fissuring with persistence of symptoms. Of the 65 boys, 58 (89.2%) achieved complete retraction of the prepuce. The remaining 7 boys (10.8%) presented with recurring symptoms and thick fibrosed prepuce, and they underwent circumcision due to the dense adhesions. Histopathological examination of the circumcised prepuces revealed balanitis xerotica obliterans in two cases. Preputial adhesiolysis is a safe and effective treatment for symptomatic preputial adhesions in boys younger than 5 years old. The procedure avoids circumcision and its associated risks. Preputial adhesiolysis should be offered as a primary treatment instead of circumcision.

Physiological Phimosis and The Use of Topical Steroid

Background: Aim of this study is to see the efficiency of topical 1% hydrocortisone in the treatment of physiological phimosis.&#x0D; Materials and Methods: Retrospective study was conducted in the Kaski Model Hospital, Pokhara, Gandaki, Nepal from January 2016 to June 2019. Forty-nine patients treated in outpatient basis have been selected for this study. Selection was made according to Kikiros and Woodward retractability grading.&#x0D; Results: Out of 49(100%) patients 40(81.63%) achieved complete response to steroid, which is Kikiros and Woodward retractability grade 0. 2(4.08%) patients showed satisfactory response (symptom free) which is Kikiros and Woodward retractability grade 1. And 7(14.28%) patients showed no response after six weeks course of treatment and underwent circumcision.&#x0D; Conclusion: This study demonstrates the use of 1% topical hydrocortisone is safe, simple and cost effective. And it could be the initial choice of treatment.

Circumcision requirement in children with phimosis: immediately or elective?

Objective: Phimosis is define as unretractable prepuce and has two different clinical presentation; pathological (PaP) and physiological. Physiological phimosis (PhP) is a common condition in children that does not require treatment. In our study, we aimed to determine the actual requirement for circumcision in patients with phimosis who were recommended circumcision.&#x0D; Material and Methods: Children who were offered circumcision due to phimosis between July 2019 and January 2020 and applied to the pediatric surgery and pediatric urology outpatient clinic were included in the study. They were evaluated in terms of referring physicians, genital examination findings and requirement for circumcision.&#x0D; Results: Between the study dates, 199 patients applied for circumcision due to phimosis. 126 patients are under one year old, 73 patients are over one year old. PhP was present in 194 of the patients and PaP in 5 of them. While PaP is not detected in patients under one year of age, there are 5 patients with PaP over one year of age (2%). There was no requirement for urgent circumcision in any of the patients. Genital examination revealed incidentally undescended testicle in 3 patients and hydrocele in 12 children.&#x0D; Conclusion: Male genital system examination and pathological findings are not well known by physicians. We think that there is a need for detailed training for physicians regarding PhP and childhood testicle pathologies.

Effectiveness of topical steroid treatment in physiological phimosis

Introduction: Phimosis is a condition in which the foreskin cannot be retracted on the glans. Physiological phimosis affects up to 96% of newborns, persisting until three or four years of age. It is a common reason for consultation in primary medical care, with the main treatment being circumcision. Several studies have evaluated the use of topical steroids in the release of the foreskin. Objective: To determine the effectiveness of topical steroid treatment for the liberation of the prepuce in infants with physiological phimosis in the Naval Hospital of Specialties of Veracruz (HOSNAVESVER). Material and methods: Randomized controlled clinical trial in infants between 30 and 60 days of age with physiological phimosis. Three groups were randomized: A (hydrocortisone 1%/physiotherapy), B (petrolatum/physiotherapy) and C (only hydrocortisone 1%), comparing their effectiveness using the Kayaba scale before and after treatment. A statistical análisis was made with ?2 and Kruskal-Wallis tests. Results: 61 infants were included. At the beginning, 17 (85.0%) of group A, 14 (70.0%) of B and 17 (81.0%) of C were in category I of Kayaba; at the end of the treatment, 19 (95.0%) of group A were in category III and IV, 18 (90.0%) of group B, and 19 (90.5%) of group C were in category II and III (p &lt; 0.05). Hydrocortisone/physiotherapy had RR of -93.8%, 95% CI (-99.1% to -57.2%) and NNT of 1, 95% CI (1 to 2). Conclusion: Hydrocortisone 1% with physiotherapy showed greater effectiveness for the treatment of physiological phimosis in infants between 30 and 60 days of age.

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.

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.

Inappropriate Circumcision: Referrals by General Practitioners

A large proportion of general practitioners have difficulty in discriminating between a true phimosis and a developmentally non-retractile foreskin. This diagnostic inaccuracy was greatest when the referring doctor did not examine the patient and inappropriately refer the patient to a pediatric surgeon for circumcision due to fear of obstructed voiding. From July 2005 to April 2007 total 33 boys with physiological phimosis were assessed in BSMMU. Among them 20 cases were without ballooning and 13 cases with ballooning. All the boys had upper tract and bladder USG followed by uroflowmetry and USG to determine post-void residual urine volume. Data were compared between boys with and without ballooning of foreskin. In all 33 boys with physiological phimosis completed uroflowmetry and USG. Ballooning of the foreskin was present in 13 boys (mean age-22.08 months range from 18 to 25 months) and non ballooning were 20 (mean age-22.7 months range from 18 to 28 months). Upper tract USG and bladder wall thickness were normal in all boys. The mean Maximum flow rate (Q max) was not significantly different in boys with ballooning and those with non ballooning (mean 8.4ml/s maxi-10.3 mini-6.7-) vs (8.5 ml/ s, maxi-10.7,mini -6.7). In addition all Qmax values were within normal range. The two groups had comparable mean PVR (0 .92 ml SD-0.9, range -0 to7) vs (.85 ml SD-0.8 range 0 to 8). The non-invasive assessment of voiding efficiency in boys with physiological phimosis with or without ballooning of foreskin showed no evidence of obstructed voiding). In conclusion physicians should be educated on the conservative management and care of thel foreskin and be able to distinguish between physiological phimosis and balanitis xerotica obliterans in order to decrease inappropriate circumcision referrals.2, 3J. Paediatr. Surg. Bangladesh 4(1): 19-23, 2013 (January)

Study of Voiding Obstruction in Physiological Phimosis

Background: There are many circumcisions done by the surgeons due to physiological phimosis which need no intervention. General practitioners inappropriately refer those cases due to fear of obstructed voiding.Materials &amp; Methods: From July 2005 to April 2007 total 33 boys with physiological phimosis were assessed in BSMMU.Among them 20 cases were without ballooning and 13 cases with ballooning. All the boys had upper tract and bladder USG followed by uroflowmetry and USG determined postvoid residual urine volume. Data were compared between boys with and without ballooning of foreskin.Results: In all 33 boys with physiological phimosis completed uroflowmetry and USG. Ballooning of the foreskin was present in 13 boys (mean age 22.08 months range from 18 to 25 months) and non ballooning were 20 (mean age- 22.7 months range from 18 to 28 months). Upper tract USG and bladder wall thickness were normal in all boys. The mean Maximum flow rate (Q max) was not significantly different in boys with ballooning and those with non ballooning (mean 8.4ml/s maxi-10.3 mini-6.7-) vs (8.5 ml/s, maxi-10.7,mini -6.7). In addition all Qmax values were within normal range. The two groups had comparable mean PVR (0 .92 ml SD-0.9, range -0 to7) vs (.85 ml SD-0.8 range 0 to 8). Conclusions: The non-invasive assessment of voiding efficiency in boys with physiological phimosis with or without ballooning of foreskin showed no evidence of obstructed voiding.DOI: http://dx.doi.org/10.3329/jpsb.v1i2.19530

Not a typical urinary tract infection: A case of urethritis due to an exogenous oil instillation in penile urethra of an infant

However, there are no reports of the exogenous oil instillation in penile urethra in infants or children. We report the first case of sterile urethritis caused as a result of cultural practicing of blowing oil into urethra of an infant.An 11-month-old male child was taken to the outpatient department of a tertiary care center of Central India with the complaints of increased frequency and excessive crying during micturition. There was no history of passing of loose stools, fever, and previous history of urinary tract infection or edema. There was no external gross deformity of the penis. Investigations revealed total leucocyte count of 5600/cumm (polymorphs 38%, lymphocytes 54%, monocytes 6%, and eosinophils 2%). Serum urea, creatinine, and electrolytes were within the normal limits. Urinalysis was also within normal limits except for the 40-50 white blood cells/high power field. Ultrasonogarphy of the abdomen was within normal limits. On detailed history taking from the parents it was admitted that mustard oil was instilled in the urethra of the infant. It was further admitted by the mother that this a common practice in their tribe to instill oil in urethra and blow it with mouth to relieve physiological phimosis in children. A diagnosis of sterile urethritis was made, and the parents were counseled to avoid such harmful customs. Patient was given a short course of paracetamol and prednisolone (1 mg/kg/day) for 5 days. A repeat urinalysis was done after a week which revealed no abnormality.Thus, in the present case, the urethritis was caused by the exogenous instillation of mustard oil and presented as sterile pyuria that is a common sign of intraurethral foreign body induced disorder.

Influence of maternal diet on the development of malformation of the external genitalia – Are we ready to make some recommendations?

The influence of our environment on the development of malformation is well known and, again and again, discussed with great enthusiasm. For example, the supplementation of the diet with folic acid has been proven to prevent neural tube defects already in 1991 [1, 6]. However, despite this well–known fact, only 10.6% of women take folic acid at least four weeks before getting pregnant; although 60% know the increased risk. It was interesting to see, that there were no big differences between the social groups [7]. Some epidemiological studies suggest an increasing risk of disorders / malformation of the external genitalia in males. The influence of the hormonal environment, especially of androgens, has been discussed. A recently published review demonstrated, that with the possible exception of testicular cancer there is no strong epidemiological evidence to indicate that prenatal exposure to estrogen are linked to disturbed development of the external genitalia [8]. Skakkebaek and co–workers suggested that hypospadias, undescended testis, testicular cancer and poor semen quality are symptoms of the testicular dysgenesis syndrome, which may be due to adverse environmental influences [9]. If there really is an increasing incidence of hypospadias, as stated in the article of Kowal and Co–Worker [5], is questionable. For example, in New York State there were no statistically significant changes in hypospadias rates between 1992 and 2005 [4]. Also, in Europe there was no increase in the incidence of hypospadias observed [3]. In a Danish study, birth prevalence of hypospadias was significantly higher than in a parallel Finnish study (1.03 vs. 0.27%; P = 0.012). However, at three years of age the prevalence increased to 4.64% because additional mild cases were detected when physiological phimosis dissolved [2]. Therefore, the so–called increase of hypospadias may be only related to higher awareness of small variants of hypospadias. The presented study by Kowal and co–worker is quite interesting. They looked for some signs of vitamin B12 deficiencies in mothers of babies born with hypospadias. High levels of propionylcarnitine (C3) seem to be a sensitive indicator of vitamin B12 deficiency as stated in the literature mentioned in their article. The authors found that in 41 newborns with hypospadias, the mean concentration of propionylcarnitine was higher compared to 90 newborns without congenital anomalies [3.52 (1.50) micromol/L vs. 2.91 (1.13) micromol/L (p = 0.026)]. The mean methionine level in these cases was insignificantly lower than in controls [5]. This seems to suggest the influence of the environment on the development of congenital anomalies. However, like in many other congenital malformations, the cause is multifactorial and to this day we still do not know which factors are important and which are not. It would be interesting if the authors could also determine the vitamin B12 levels in the mothers, ask them for a description of their diet, and compare it to the levels propionylcarnitine in the newborns. Before recommendation about some vitamin supplementation can be made, we need much stronger evidence that vitamin B12 plays a role in the development of hypospadias.

Differences in preputial-colonizing bacteria between balanoposthitis and physiological phimosis

ObjectiveRedundant prepuce and phimosis are known risk factors for balanoposthitis. It is usually caused by retrograde infection and is related to the preputial bacterial flora. We investigated differences in the preputial bacterial flora between patients with balanoposthitis and physiological phimosis. Materials and MethodsFifty-six male children were included in the study. Fifteen patients presented to the emergency room or outpatient department with balanoposthitis. Forty-one patients with physiological phimosis received a circumcision. Preputial swab cultures were done. Differences in age, body weight, and preputial flora between these two groups of patients were compared. ResultsPatients with balanoposthitis in this study were significantly younger. Common uropathogens were predominant in patients with balanoposthitis, whereas in patients with physiological phimosis, the main isolates were enteric flora other than common uropathogens. Patients with a body weight higher than the 50th percentile of the normal growth curve had a lower risk of balanoposthitis (odds ratio = 0.212). ConclusionsThe preputial bacterial flora in patients with physiological phimosis may change from enteric flora to common uropathogens which are predominant in patients with balanoposthitis. Furthermore, patients at a younger age and with a lighter body weight also had increased susceptibility to balanoposthitis.

Phimose

Phimosis is a common condition in which the foreskin cannot be retracted over the glans penis. First appearing at 8 weeks gestation as a ridge of thickened epithelium, the prepuce grows forward over the developing glans. Physiological phimosis is common in male patients up to 3 years of age. Balanoposthitis is an inflammation of the foreskin and glans and occurs in 4-11% of uncircumcised boys. Lack of circumcision has been identified as a risk factor for urinary tract infection in infants as well as several sexually transmitted diseases and penile cancer in adults. Local steroid application showed satisfactory success rates of more than 80% and is recommended as first choice therapy. Male circumcision carried out under the age of 14 years without medical indications is unlawful and classified as bodily harm under German law.

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.

Common paediatric problems

Many paediatric problems can present to medical professionals. This article covers some of the common ones including phimosis, undescended testis, retractile testis, vesicoureteric junction reflex, hypospadias, neonatal hydronephrosis, obstruction of...

Foreskin development before adolescence in 2149 schoolboys

We examined the external genitalia of 2149 elementary schoolboys in the suburban area of Taichung in Taiwan for an understanding of foreskin development before adolescence. The study's subjects comprised 692 first-grade boys, 725 fourth-grade boys, and 732 seventh-grade boys. The foreskin's condition was classified as: type I (normal prepuce), type II (adhesion of prepuce), type III (partial phimosis), type IV (phimosis) and type V (circumcised foreskin). Other abnormalities of the genitalia also were recorded. All of the examinations were performed by the same urologist. The incidence of type I foreskin was 8.2% in first-grade boys, 21.0% in fourth-grade boys, and 58.1% in seventh-grade boys. The incidence of type IV foreskin was 17.1% in first-grade boys, 9.7% in fourth-grade boys, and 1.2% in seventh-grade boys. Only one boy had balanoposthitis. Other abnormalities included inguinal hernia (n = 2), hydrocele (n = 12), cryptorchitism (n = 8), varicocele (n = 22), and subcoronal-type hypospadia (n = 1). Physiological phimosis declines with age. Most boys with phimosis in this study did not require treatment.