Phimosis & foreskin disorders Flashcards
Define phimosis and foreskin disorders.
Unretractile foreskin secondary to either a physiological or pathological process.
Explain the aetiology of phimosis and foreskin disorders.
Physiological phimosis: The foreskin is not fully developed at birth; preputial adhesions cause the glans to adhere to the foreskin. It is rare for the neonate’s foreskin to be completely retractile (4%). Unretractile foreskin may be normal until adolescence. Ballooning of the foreskin is a normal process that aids the breakdown of adhesions. Foreskin protects the glands whilst the neonate is incontinent of urine (ammoniacal).
Pathological phimosis: Most likely to be secondary to balanitis xerotica obliterans (BXO) which is a progressive fibrotic condition of unknown aetiology (may also affect the urethral meatus).
What are risk factors for phimosis and foreskin disorders?
Preputial pearls (retained smegma)
Lichen sclerosus et atrophicus (LSA)
What is the pathophysiology of phimosis and foreskin disorders?
Balanitis xerotica obliterans (BXO): Oedema and homogenisation of collagen in the upper dermis, inflammatory infiltration of lymphocytes and histiocytes in the mid-dermis, atrophy of the stratum malphighi and hydropic degeneration of the basal cells.
HIV: Possible protective role of circumcision in HIV transmission; HIV binds to the Langerhans cells on the inner surface of the foreskin. Decrease incidence of cervical carcinoma secondary to decreased HPV transmission. Nil evidence of UTI/penile carcinoma prevention.
Summarise the epidemiology of phimosis and foreskin disorders.
Physiological: 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17.
Pathological: BXO: 0.6% (<15 years).
What are the signs and symptoms of phimosis and foreskin disorders?
General: Forceful retraction should not be attempted. Often the child will self-retract, allowing inspection.
Physiological: May have a history of ballooning and spraying of urine. Distal erythema (secondary to urine ammonia irritation). Should have a spout of mucosa as the foreskin is retracted.
Pathological: There is white fibrotic ring at the distal foreskin. Absence of normal mucosal spout. Associated with pain +/- haemorrhage.
Balanitis: Often misdiagnosed. True balanitis involves oedema, erythema and generation of purulent material from the distal phimotic foreskin.
What are appropriate investigations for phimosis and foreskin disorders?
Normally none required.
What is the management for phimosis and foreskin disorders?
Conservative: No attempts should be made to retract a foreskin. Variable results for the use of topical steroids for physiological phimosis. Gentle retraction with tissue dying in older boys may aid retraction and prevent ammonia irritation.
Preputial plasty: Small non-traumatic dorsal slit procedure to widen the meatus.
Circumcision: Only treatment for BXO. Usually performed under GA with the sleeve dissection method. In neonatal ritual procedures, devices such the Plastibell may be used.
What are complications associated with phimosis and foreskin disorders?
Pathological: May lead to progressive phimosis and possible urinary retention.
Circumcision: Haemorrhage, infection, meatal stenosis, glans injury, urethrocutaneous fistula, anesthetic risks.
What is the prognosis of phimosis and foreskin disorders?
Physiological: Majority will retract with time.
Pathological: Advanced BXO may affect the urethral meatus and extend proximally which may require extensive reconstructive surgery.
