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1. What is phimosis? What causes this?
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Phimosis is gross narrowing of the preputial orifice. It occurs as a congenital lesion, but may result from scarring following the trauma of forcible retraction of the prepuce, or as a result of chronic balanitis.
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2. What are the clinical features of phimosis?
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On micturition, the prepuce is seen to balloon and the urinary stream is reduced to a dribble.
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3. How would you treat a patient with phimosis?
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Circumcision is performed. In some cases of chronic balanitis with considerable inflammation of the prepuce, a dorsal slit is an efficient, but less aesthetic, method of cure.
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4. What is paraphimosis? What causes this?
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Paraphimosis results from pulling a tight foreskin proximally over the glans. The foreskin acts as a constricting band, interfering with venous return from the glans, which therefore swells painfully. Once swelling starts, it becomes more difficult to replace the foreskin. Paraphimosis commonly occurs after an erection. It may also occur following urethral catheterization, when the foreskin is forcibly retracted over the glans to expose the meatus. Once the catheter is inserted, the thickened scarred prepuce constricts the venous return, producing paraphimosis. Hence, it is important to always ensure that the patient's prepuce is pulled forward again after the insertion of an indwelling catheter - if not, paraphimosis may result.
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5. How would you treat a patient with paraphimosis?
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Once a paraphimosis has become established it is difficult to reduce. There are two commonly used courses of action. Under a penile local anaesthetic block, the glans is squeezed for a few minutes to reduce the oedema, and enable the foreskin to be reduced. If squeezing fails, the foreskin may be slit dorsally to release the constricting band. Having once had paraphimosis, the patient should be considered for a formal circumcision to prevent recurrence.
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6. What is a non-retractile prepuce? How would you manage this problem?
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Many male infants are presented to the doctor or nurse because the parents notice that the prepuce cannot be retracted. In fact, the foreskin is normally firmly adherent to the gland until 3 years of age. In the next 3 years the congenital adhesions between the glans and the foreskin lyse, progressively separating from the glans. Forcible attempts to retract the foreskin traumatize the tissues, and the resultant scarring may lead to a true phimosis. Inability to retract the foreskin in the infant is no indication in itself for circumcision; indeed, in the ‘nappy’ stage the prepuce protects the delicate glans and the urethral orifice from the excoriation of ammoniacal dermatitis.
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7. What is circumcision? What are the indications for circumcision?
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Circumcision is the resection of the foreskin, leaving the glans exposed. Indications for circumcision include: (1) phimosis; (2) paraphimosis; (3) religious custom; (4) non-retractile prepuce over 6 years of age. Having the prepuce removed reduces the risk of carcinoma of the penis, probably because it prevents the accumulation of smegma, which is carcinogenic.
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9. Why does circumcision reduce the risk of carcinoma of the penis?
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Having the prepuce removed reduces the risk of carcinoma of the penis, probably because it prevents the accumulation of smegma, which is carcinogenic.
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10. What is ammoniacal dermatitis? What causes this?
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This is a common cause of inflammation of the penis in children and is due to the presence of ammonia liberated by urea-splitting organisms. This is especially liable to occur if the child’s nappies are infrequently changed and he is allowed to remain wet. The ammonia causes a painful, red, oedematous rash on the perineum, penis and foreskin.
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11. How would you treat a child with ammoniacal dermatitis?
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Treatment is to change the child’s nappies frequently and to cover the skin with a protective barrier cream or zinc oxide and castor oil. Secondary bacterial or candidal infections may occur and require appropriate antimicrobials. Circumcision should be avoided in the presence of ammoniacal dermatitis, as a meatal ulcer is likely to result.
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12. What is balanitis? What causes this?
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Balanitis is an acute inflammation of the foreskin and glans and it is usually due to the common pyogenic organisms, for instance coliform bacilli, staphylococci and streptococci. It may result in phimosis from scarring. It is important to test the urine for sugar to exclude diabetes, which may predispose to the inflammation, in which case Candida may be the infecting organism.
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13. How would you treat a patient with balanitis?
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Treatment consists of administering the appropriate antibiotic after the organism has been cultured and its sensitivity has been determined. Local toilet with weak disinfectant solutions may give relief symptomatically.
