Managing the paediatric foreskin

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Copyright CMP Information Ltd. Dec 7, 2004

hydrocortisone; betamethasone

• What are the proven benefits and disadvantages of circumcision?
• How should a 'physiological' non-retractile foreskin be treated?
• How does balanitis xerotica obliterans present in practice?

Claire Clark MRCS, Specialist Registrar

James S Huntley DPhil, MRCS, Lecturer

FRASER D Munro FRCS, Consultant Surgeon

DERRICK Wilson-Storey MD, FRCS, Consultant Surgeon, Department of Paediatric Surgery,  Royal Hospital for Sick Children,Edinburgh

Since ancient times the foreskin has been the nub of heated medical and ethical debates.¹ Historically, circumcision was done primarily for religious reasons, until the 1890s when an orthopaedic specialist called JHC Simes popularised the operation on medical grounds: The operation of circumcision is one which is demanded for hygienic purposes; one which is frequently necessary for pathological conditions; and finally, one which is of unquestionable prophylactic importance.¹

Many myths concerning the benefits of circumcision persist in the Western world. Circumcision used to be thought to reduce the incidence of cervical cancer in partners, but this view is now discredited. With some theoretical justification, circumcision has been proposed to decrease HIV transmissibility. However, the mucosal tissue of the prostate, urethra and seminal vesicles secrete a substance rich in lytic material that lubricates the mucosal surface of the glans and foreskin, thus forming a protective barrier against STDs, and the foreskin itself may in fact be a protective factor in STD transmission. Rather than circumcision, emphasis should be on education concerning responsibleand safe sex.

Thankfully, the circumcision rate is declining in the UK. This is due to more widespread understanding of the nature of foreskin development and retractability, and alternative treatments including topical steroid cream, adhesiolysis and foreskin-conserving surgery (preputioplasty).

However, the foreskin remains a source of considerable concern for boys and parents alike.

In a recent study² we assessed 100 consecutive 'problem foreskin' referrals to the paediatric surgical service in South-East Scotland, and followed all patients to discharge.

A large proportion (71 per cent) did not require surgical intervention, and 29 per cent had a physiologically normal foreskin for their age and were discharged at their initial visit.

Conversely, there were six cases of balanitis xerotica obliterans (BXO) - a serious foreskin pathology mandating circumcision - and none of these were documented in the referral.²

The purpose of this article is to outline the natural development of retractability, relevant pathologies, variations of normality, and treatment pathways for common foreskin problems.

* The natural history of the foreskin In the fetus the inner surface of the prepuce and glans receive a common epithelium, which separates around the time of birth. This separation results from cellular keratinisation under the influence of androgen.

Gairdner³ found that foreskin retractability increased with age; on average foreskins were 50 per cent retractable by the end of the first year, 75 per cent by the end of two years, and 90 per cent by the end of three years. Oster⁴ found the prevalence of non- retractable foreskins between the ages of six and 17 years decreased from eight to one per cent without surgical intervention. The unretractable, non-problematic foreskin should therefore be considered normal up to the age of 17.

Note:

The authors here blindly have quoted outmoded data on development of preputial retractability in boys. They of all people should know better. For better information see:  The Development of Retractile Foreskin in the Child and Adolescent.

Figure 1 shows a normal pouting, non-retractile foreskin.

Religious circumcision
Circumcision for reasons of religious observance remains common. In the UK there is marked inter-regional variation in NHS funding for circumcision on cultural or religious grounds.

Our policy is to perform such circumcisions in the NHS, believing this to be preferable to unregulated surgery in less-than-ideal environments, which may lead to potentially disastrous complications. However, funding for such non-essential surgery is frequently questioned in the modern NHS.

Foreskin conditions

* Phimosis is Greek for 'muzzling'. It is the inability to retract the foreskin due to a narrow preputial ring (see figure 2).

A pathological phimosis may be caused by recurrent infection of the foreskin causing scarring and narrowing of the preputial ring. Such narrowing is not to be confused with the physiological asymptomatic non-retractile foreskin, as shown in figure 1, which requires no treatment.

'Ballooning' of the foreskin (urine collecting under the foreskin during micturition) is often attributed to a phimotic foreskin. If the patient does not have repeated episodes of infection, then ballooning is considered a variant of normal.

Treatment
We do not recommend treatment for the prepubertal boy with a 'physiological' non-retractile foreskin that is asymptomatic. However, in boys with conditions such as recurrent posthitis or balanitis the primary treatment is a topical steroid cream: 1.0 per cent hydrocortisone cream or 0.1 per cent betamethasone cream topically to the foreskin, 3-4 times daily for an 12-week period is effective in 80 per cent of cases.

The non-retractability can recur with cessation of the cream, but the problem usually resolves permanently with a second course. The steroid appears to work by thinning the skin of the phimotic area and increasing its elasticity.⁵

* Balanitis and balanoposthitis describe inflammation of the glans and prepuce respectively. Usually these terms are reserved for inflammation due to infection, but foreskin inflammation can occur due to other conditions, such as ammonia dermatitis, foreskin fiddling, and a combination of smegmaand congenital adhesions.

Balanoposthitis presents with an acutely inflamed and painful glans that is discharging pus. Treatment consists of gentle washing in warm water and either topical or oral antibiotics. Recurrent balanitis is not an absolute indication for circumcision. Figure 3 shows an acute balanitis.

* Adhesions Some authors suggest that adhesions may develop between the glans and the prepuce due to balanoposthitis. These are said to be distinct from the congenital adhesions due to delayed desquamation of the epithelial cells.

We feel that the majority of adhesions are congenital and there is little evidence to support acquired adhesions. Treatment is only indicated if the patient is symptomatic; for example, there may be recurrent balanoposthitis, or an asymmetric stream. Adhesiolysis can be performed by foreskin retraction under local anaesthetic cream, or under a general anaesthetic as a day patient.

* Smegma During the separation of the foreskin from the glans, epithelial cells and keratin debris collect under the foreskin as smegma. Sometimes these form soft white lumps, or 'smegmomas'. These naturally discharge with eventual retraction of the foreskin and do not require treatment.

Balanitis xerotica obliterans
BXO is a chronic progressive atrophic sclerosis of the glans and prepuce, leading to urethral stenosis. BXO is also known as lichen sclerosus et atrophicus of the glans.

The epidermis of the foreskin becomes atrophic with areas of hyperkeratosis. The foreskin becomes non-retractable, and erections are painful. There may be spraying of urine and, in the later stages, urinary retention. On examination, there is circumferential white scarring of the distal foreskin (see figure4).

The treatment for BXO is circumcision with close follow-up to exclude meatal stenosis. In the adult population BXO has been proposed as a pre-malignant condition, but there is no evidence that childhood BXO holds any increased malignant risk.

In the event of meatal stenosis, further surgery (such as meatotomy) may be required to maintain a patent urethra.⁶

Paraphimosis
This is an acutely painful condition in which a retracted foreskin cannot be pulled forward over the glans. This usually occurs due to a narrow preputial ring, and represents a surgical emergency as delay can lead to glandular necrosis.

Paraphimosis is occasionally seen in infants as a result of parental foreskin retraction, after advice from health professionals that frequent foreskin retraction is necessary.

The prepuce can be reduced with the aid of a local or general anaesthetic. Following reduction, treatment is advised with an 8- week course of steroid cream. If this fails, a circumcision could be considered.

SURGICAL TREATMENTS

Preputioplasty
This foreskin-conserving operation is indicated if attempts at foreskin retraction show a clear fibrous ring (see figure 6) preventing full exposure of the glans. There are several different types, but the principle one involves longitudinal incision(s) down to Buck's fascia in the region of the phimotic band being closed transversely, thus broadening and loosening the foreskin. The patient is then encouraged to maintain foreskin retractability on a daily basis.

Circumcision
This involves excision of a distal segment of foreskin and muco-cutaneous repair using absorbable sutures. Circumcision is often thought of as a minor procedure; however, it has the potential for great morbidity, including:

• Injury to the glans penis and urethra (eg, during electrocautery)
• Haemorrhage (occurs in 1-7 per cent)
• Meatitis and meatal ulceration (8-31 per cent)
• Meatal stenosis
• Removal of incorrect amount of skin
• Infection (4-6 per cent - see figure 7)
• Urethral fistula
• Unrecognised hypospadias

Cases have been recorded of gender reassignment being carried out because of significant complications of circumcision. We would recommend circumcision for only certain conditions, including BXO.¹

Clinical focus

• Foreskin retractability increases with age; on average foreskins are 50 per cent retractable by the end of the first year, 75 per cent by the end of two years, and 90 per cent by the end of three years. [ Note: Here the authors once again parrot the inaccurate and outmoded data.]  It has also been found that the prevalence of non-retractable foreskins between the ages of six and 17 years decrease from eight to one per cent without surgical intervention. The unretractable, non-problematic foreskin should therefore be considered normal up to the age of 17
• Phimosis is Greek for 'muzzling'. It is the inability to retract the foreskin due to a narrow preputial ring. A pathological phimosis may be caused by recurrent infection of the foreskin causing scarring and narrowing of the preputial ring. Such narrowing is not to be confused with the physiological asymptomatic non- retractile foreskin, which requires no treatment. 'Ballooning' of the foreskin (urine collecting under the foreskin during micturition) is often attributed to a phimotic foreskin. If the patient does not have repeated episodes of infection, then ballooning is considered a variant of normal
• In boys with conditions such as recurrent posthitis or balanitis the primary treatment is a topical steroid cream: 1.0 per cent hydrocortisone cream or 0.1 per cent betamethasone cream topically to the foreskin, 3-4 times daily for an 12-week period is effective in 80 per cent of cases
• Balanitis xerotica obliterans (BXO) is a chronic progressive atrophic sclerosis of the glans and prepuce, leading to urethral stenosis. BXO is also known as lichen sclerosus et atrophicus of the glans. The epidermis of the foreskin becomes atrophic with areas of hyperkeratosis. The foreskin becomes non-rectractable, and erections are painful. There may be spraying of urine and, in the later stages, urinary retention. On examination, there is circumferential white scarring of the distal foreskin. The treatment for BXO is circumcision with close follow-up to exclude meatal stenosis
• Circumcision is often thought of as a minor procedure; however, it has the potential for great morbidity, including: injury to the glans penis and urethra (for example, during electrocautery); haemorrhage (occurs in 1-7 per cent); meatitis and meatal ulceration (8-31 per cent); and meatal stenosis

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