Basics
Description
Penile problems:
- Buried penis
- Hidden or concealed penis, poor skin fixation at the penoscrotal/penopubic junction resulting in buried or hidden appearance
- Buried penis may be normal in obese children with large suprapubic fat pad.
- Penile curvature (chordee)
- Bending of the penis with erection, can be lateral, ventral (most common), or dorsal curve
- Chordee is usually associated with abnormal foreskin
- Webbed penis
- Penoscrotal webbing or poor separation of penile skin from scrotum, obscuring penoscrotal angle
- Balanitis
- Inflammation of the glans
- Probably overdiagnosed owing to physiologic drainage of smegma or urea dermatitis from failure to retract foreskin during voiding in toilet-trained boys
- When infections present, there can be significant cellulitis of the penis, edema, and fever.
- Most commonly caused by gram-positive organisms. Yeast is another causative organism.
Foreskin problems:
- Balanoposthitis
- Inflammation of glans and prepuce
- Seen in 4% of uncircumcised boys age 2 " 5 years
- See balanitis.
- Phimosis/penile adhesions
- Physiologic attachment of prepuce to glans, which it protects and gradually separates to allow retraction of the foreskin
- Ring of fibrotic scar tissue that prevents the foreskin from being retracted
- Paraphimosis
- When narrow prepuce is retracted behind the glans, constricting penile shaft causing glanular and foreskin edema and preventing replacement of prepuce over glans
Postcircumcision problems:
- Penile adhesions
- Attachments of the foreskin back to the glans after circumcision
- Penile skin bridges are dense scar adhesions that cannot be separated.
- Meatal stenosis
- Urethral meatus narrowing
- Significant meatal narrowing will produce an upwardly deflected urine stream, which is narrow and strong. In severe cases, straining, and prolonged voiding
- Epidermal inclusion cysts
- Small, enlarging white lesions growing subcutaneously along the scar from circumcision
Risk Factors
Genetics
Epidermal inclusion cysts may occur from congenital rests of skin cells buried during development, but these are rare and occur along the median raphe of the penis or scrotum.
General Prevention
Some penile and foreskin problems may be prevented with proper hygiene and education of the caretakers.
Etiology
- Buried/webbed penis
- Scrotal attachments attending along ventral penile surface to varying degrees
- Penis tethered by abnormal attachments of dartos tissue
- Penile curvature (chordee)
- Asymmetry in tunica albuginea of corporal bodies and compliance of corpora cavernosa
- Balanoposthitis/balanitis
- Unclear etiology: possible infection, mechanical trauma, contact irritation, and contact allergies
- Phimosis
- Probably results from recurrent bouts of irritation of the foreskin from improper hygiene habits such as voiding through the foreskin or repetitive forceful retraction
- Penile adhesions
- Physiologic adhesions: The prepuce has adhered down to the glans after circumcision.
- Surgical adhesions (skin bridges): Adherence between the scar of the circumcision and the glans due to healing of the crushed tissue where the foreskin was removed and the glans
- Meatal stenosis
- Narrowing of the urethral meatus secondary to recurrent irritation of the meatus, likely from rubbing against moist diapers. Occurs almost exclusively in circumcised boys
- Epidermal inclusion cysts
- Caused by small islands of epithelium buried beneath the skin surface that progressively accumulate desquamated skin cells
Diagnosis
History
- Issues with newborn circumcision
- Ability to retract foreskin
- Retraction of foreskin in uncircumcised males during voiding
- Penis straight with erection
- Character of urinary stream
- Ballooning of the foreskin with voiding
- Straining to void
- Presence of fever
- Penile discharge
- In older boys, inquire about sexual activity.
Physical Exam
- Circumcised males
- Size and position of meatus
- Redundancy of preputial skin
- Presence of adhesions to the glans and whether they involve the scar line between the shaft skin and the inner preputial skin
- Lesions or erythema of glans or shaft
- Watch patient void if meatal stenosis is suspected, usually upward deviated stream.
- Uncircumcised males
- Ability to retract foreskin with gentle retraction
- Presence of phimotic ring
- Lesions or erythema of prepuce
Alert
- Do not try to forcefully retract the foreskin in an infant or young child. It can take 3 " 5 years before the foreskin can be retracted.
- Do not circumcise infants with a buried or webbed penis, asymmetric foreskin, or those with a significantly deviated penile raphe.
- Never circumcise an infant with an abnormally located meatus (hypospadias, epispadias).
- Always replace the foreskin back over the glans after retraction (for cleaning, voiding, or examination) to prevent paraphimosis.
- Paraphimosis is an emergency. The sooner it is diagnosed, the easier it is to treat and reduce without surgery.
Diagnostic Tests & Interpretation
Lab
- In cases of balanitis with drainage, cultures may be taken by spreading foreskin (with hemostat) and sending drainage for culture.
- If urethral discharge is present, culture for gonorrhea and chlamydia in an adolescent male.
Treatment
Medication
Balanitis/balanoposthitis
- If child is afebrile, oral antibiotics such as a 1st-generation cephalosporin would be the 1st line of treatment.
- If the child develops fever or there is progression of cellulitis, then treatment with IV antibiotics (cefazolin, clindamycin)
Additional Treatment
General Measures
- Phimosis
- Physiologic: no need for intervention
- Good hygiene practices should be encouraged such as pulling the foreskin back to expose the meatus when voiding and not voiding through the foreskin. The foreskin should always be placed back over the glans after voiding (or any retraction) to prevent paraphimosis.
- Pamphlets or Web sites that explain the care of the penis for uncircumcised males are helpful to give to the parents.
- If there is a fibrotic ring of scar tissue preventing the retraction of the foreskin, a trial of betamethasone cream 0.05 " 0.01% applied to the foreskin t.i.d. for 4 " 6 weeks with daily gentle retraction may soften the scar tissue enough to resolve the phimosis. According to Orsola et al, use small amounts of cream only in the constrictive ring and do not use occlusive dressings.
- In cases where conservative measures fail, a circumcision may be indicated.
- Penile adhesions
- Physiologic: Practices in the past have included separation using anesthetic cream (EMLA). If there is redundancy of the foreskin or a prominent suprapubic fat pad that can tend to hide the penis in infants, adhesions often recur or require constant application of barrier creams or ointments to the penis and manual retraction of the redundant foreskin by the parents to prevent recurrence:
- In many cases, no treatment is necessary, as the adhesions will break down over a period of years.
- If there are extensive adhesions with significant redundancy of foreskin, consideration should be given to revision of the circumcision if the adhesions are to be treated.
- Surgical (skin bridges)
- These are due to scar tissue formation between the raw cut edge where the foreskin was removed and the glans.
- As this represents true scarring and not two epithelial surfaces stuck together, the surfaces cannot be simply pulled apart like physiologic adhesions. They will not resolve with time, and if left in place, with growth, penile skin will be transferred to the glans, resulting in discoloration, especially in patients with darker skin tones.
- These adhesions need sharp division either in the office with EMLA cream anesthesia or under general anesthesia if they are extensive.
- Meatal stenosis
- When the narrowing at the meatus is producing an upwardly deflected, narrow stream (which can make aiming into the toilet difficult) or is causing straining and prolonged voiding, treatment is indicated.
- A meatotomy can be done in the office using EMLA anesthesia or as an outpatient surgical procedure.
- Epidermal inclusion cysts
- These subcutaneous islands of skin cells will progressively enlarge over time.
- Complete excision is generally curative.
- Balanitis
- When the inflammation and irritation seem to be from chronic dampness and exposure to urine, treat with barrier creams or ointments.
- Keeping the area clean and dry will help prevent future episodes.
- If there are small whitish plaques (not smegma), associated with redness, yeast may be present and an antifungal cream such as 1% clotrimazole can be used to help speed the healing.
- Antibiotics as necessary (see "Medication ")
- In cases where there is purulent drainage and cellulitis of the penis, which can often be rapidly spreading over 24 hours, treatment with antibiotics is recommended.
- Genital infections of this nature should be taken quite seriously, and if treatment as an outpatient is attempted, close follow-up (return visit in 24 " 48 hours) is prudent.
Ongoing Care
Patient Education
- It is important that all parents of uncircumcised boys teach them proper hygiene habits during toilet training.
- Guidance for parents:
- Do not forcibly retract the foreskin.
- Gently clean with warm water during baths and dry after.
- Retract the skin when voiding in toilet-trained boys.
- Always place the foreskin back over glans after voiding or retraction of foreskin.
Additional Reading
- Blalock HJ, Vemulakonda V, Ritchey ML, et al. Outpatient management of phimosis following newborn circumcision. J Urol. 2003;169(6):2332 " 2334. [View Abstract]
- Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology. 2000;56(2):307 " 310. [View Abstract]
- Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr. 2006;45(1):49 " 54. [View Abstract]
Codes
ICD09
- 752.65 Hidden penis
- 752.63 Congenital chordee
- 752.69 Other penile anomalies
- 607.1 Balanoposthitis
- 753.6 Atresia and stenosis of urethra and bladder neck
- 607.89 Other specified disorders of penis
- 605 Redundant prepuce and phimosis
ICD10
- Q55.64 Hidden penis
- Q54.4 Congenital chordee
- Q55.69 Other congenital malformation of penis
- N48.1 Balanitis
- N48.83 Acquired buried penis
- Q55.61 Curvature of penis (lateral)
- N47.1 Phimosis
- N48.89 Other specified disorders of penis
- Q64.33 Congenital stricture of urinary meatus
- N47.5 Adhesions of prepuce and glans penis
SNOMED
- 253849004 Congenital buried penis (disorder)
- 4287008 chordee (disorder)
- 253852007 Webbed penis (disorder)
- 44882003 Balanitis (disorder)
- 236756001 Acquired buried penis (disorder)
- 48337000 Congenital stricture of urinary meatus (disorder)
- 449826002 Phimosis (disorder)
- 249263004 Adhesions of foreskin (finding)
FAQ
- Q: The foreskin is stuck down to my son 's penis. Does that mean he needs another circumcision?
- A: Not necessarily. If there is minor redundancy and a small physiologic adhesion, then no treatment is needed.
- Q: My uncircumcised son had some thick white drainage from his foreskin. Is that from an infection?
- A: Probably not. The thick white material is probably shed skin cells, which have been slowly separating the foreskin from the glans, this is also known as smegma (Greek for soap).