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5.4 Indications for Referral
1.Testicular torsion: Once the diagnosis is suspected, referral to a pediatric urologist is mandatory.
2.Torsion of the appendix testis or epididymis: Referral is dependent on the comfort level of the primary care provider with the diagnosis.
3.Epididymo-orchitis: If an anatomical congenital anomaly of the urinary tract is found, then a referral to a pediatric urologist is warranted.
4.Hernia/hydrocele: Referral to a pediatric urologist or surgeon is warranted after the diagnosis is made.
5.Spermatic varicocele: Referral to a pediatric urologist or interventional radiologist is warranted if there is an indication for treatment as listed above.
6.Spermatocele: Referral is not necessary if the patient is asymptomatic.
7.Trauma: Referral is dependent on the degree of injury. Contusions can be managed by the primary care provider.
8.Insect bite: Referral is generally not necessary.
9.Testicular tumors: Referral to a pediatric urologist and an oncologist is warranted once the diagnosis is suspected.
Suggested Readings
1.Gatti JM, Murphy JP. Acute testicular disorders. Pediatr Rev. 2008;29:235.
2.Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: An overview. Am Fam Physician. 2009;79:583.
3.Ross JH. Prepubertal testicular tumors. Urology. 2009;74:94.
4.http://www.cdc.gov/std/treatment/2006/updated-regimens.htm, 2009
5.Homayoon K, Suhre CD, Steinhardt GF. Epididymal cysts in children: Natural history. J Urol. 2004;171:1274.
6.Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: Direction, degree, duration and disinformation. J Urol. 2003; 169:663.
7.Diamond DA. Adolescent varicocele: Emerging understanding. BJU Int. 2003;92(Suppl 1):48.
Chapter 6
Disorders of Male External
Genitalia: Problems of the
Penis and Foreskin
Prasad P. Godbole
Key Points
››A non retractile foreskin at birth is normal. Spontaneous retractility begins around 2 years of age.
››Majority of boys will have a retractile foreskin by 10 years of age and 95% by 16–17 years of age.
››The only absolute medical indication for circumcision is penile malignancy and balanitis xerotica obliterans.
››Most inflammatory conditions of the foreskin can be managed conservatively in primary care.
6.1 Introduction
The management of foreskin conditions varies amongst medical practitioners from observation to circumcision. A number of conditions may affect the foreskin and may lead to a specialist referral. This chapter deals with common foreskin problems, their etiology and management in primary/emergency care. Indications for referral will be highlighted. Circumcision will be dealt with in another chapter.
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56 P.P. Godbole
6.2 Common Foreskin Conditions
1.Non retractile foreskin: Almost all boys have a non retractile foreskin at birth. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls presenting as yellowish white cysts under the foreskin which are then extruded. Foreskin retractility begins after 2 years of age. This process is spontaneous and does not require manipulation. A non retractile foreskin on gentle attempted retraction pouts like a flower-physiologi- cal phimosis (Fig. 6.1). The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16–17 years of age.1
2.Balanoposthitis: inflammation of the glans and the foreskin.
3.Balanitis: inflammation of the glans that often spreads along the shaft and may occur in the circumcised population.
4.Posthitis: inflammation restricted to the foreskin itself.
5.Balanitis Xerotica Obliterans(BXO): a lesion akin to lichen sclerosus et atrophicus. This causes true phimosis – pathological phimosis. This causes a shutter type foreskin with no pouting of the inner foreskin on gentle retraction (Fig. 6.2). It is rare before 5 years of age.
6.Paraphimosis: results when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing edema of the glans and foreskin and inability to manipulate the foreskin back over the glans (Fig. 6.3).
7.Hooded foreskin: is an abnormal dorsal hemiforeskin which is deficient ventrally and is usually associated with hypospadias (Fig. 6.4).
6.3 Treatment of Conditions of the Foreskin
1.Non retractile foreskin:This does not require any treatment if the foreskin is healthy. Topical steroids are known to hasten
retractility of the foreskin and may be considered .2, 3
On no account should the parents be asked to forcibly retract
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a
b
FIGURE 6.1. (a, b) Healthy non retractile foreskin-physiological phimosis: note the inner foreskin “pouts like a flower”.