Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids

OBJECTIVE

The objective of our study was to assess the efficacy of topical steroids in the treatment of phimosis and evaluate patients using the Diagnostic and Statistical Manual-III-Revised (DSM-III-R) test with the aim of eliminating castration anxiety of circumcision in the phallic period.

METHODS

One hundred and forty-nine children with phimosis who required circumcision were included the study. The average age of the children was 4.47 years. All children underwent the DSM-III-R test and their parents were questioned. Patients were separated randomly into three groups. Group I comprised 51 children who would undergo circumcision; group II comprised 50 children who would be treated with a topical corticosteroid (0.05% bethamethasone cream) twice daily for 1 month; and group III comprised 48 children who would be treated with a topical placebo cream. On the 5th day of treatment, parents were told to retract the prepuce and were given hygiene routine instructions. Patients were seen immediately after treatment and again 2 months later.

RESULTS

In group II, 16 of the 50 children had non-retractable prepuce. Forty-two cases of phimosis were corrected after treatment. Eight patients received further monthly treatment and five benefited from the second course of treatment. In group III, 17 of the 48 patients had non-retractable prepuce and four had satisfactory results. Forty-four patients received placebo treatment for another month and eventually, 40 children underwent circumcision in this group. DSM-III-R test results showed a significant shift to anxiety in the circumcision group. The were no significant differences in the other groups.

CONCLUSION

Topical steroids for the treatment of phimosis is a highly effective treatment alternative to surgery. It avoids or delays circumcision and can be practised during the phallic period to decrease castration anxiety. The treatment is suitable for patients from any religious or cultural background.

Triple incision to treat phimosis in children: an alternative to circumcision?

OBJECTIVE

To evaluate the functional and cosmetic results and patient satisfaction after triple incision plasty for phimosis in children.

PATIENTS AND METHODS

The study included 197 boys who had a triple incision for phimosis (mean age 5.8 years, range 0.25-18). The indications for preputial surgery were recurrent balanoposthitis, ballooning during micturition and severe phimotic stenosis. The results after surgery were assessed using a questionnaire about the child's/parent's satisfaction, and an outpatient follow-up examination for functional and cosmetic preputial appearance.

RESULTS

Of 128 parents/children responding, 108 (84%) were satisfied with the function and 102 (80%) reported a good cosmetic outcome. Triple incision as preputioplasty would be recommended to other parents by 119 (93%) respondents. Ninety-one (71%) of the parents feared disadvantages in their son's later life if the child had been circumcised. The outpatient examination showed an excellent functional and cosmetic outcome in 71 (77%) of the children.

CONCLUSION

Triple incision is a simple, fast and safe technique for preputial relief, with good functional and cosmetic results, and was well accepted by the patients.

[The use of corticosteroid cream to treat phimosis]

Many of the boys diagnosed with 'phimosis', who are referred for circumcision, do not have a dermatopathology and thus there is no indication for surgery. If an unretractable prepuce causes hygienic problems, and also in the case of dermatopathology, topical corticosteroid application may be an effective alternative to circumcision. In a literature search 13 studies were found on the effectiveness and the safety of topical steroid application for phimosis. Three of the studies were placebo controlled. A total of 1121 boys with an unretractable prepuce were treated with a topical corticosteroid, which was mostly applied twice daily. After a treatment duration of 4 to 8 weeks, about 75% of the patients achieved complete retractability of the prepuce. In the studies evaluated, local or systemic adverse effects were not noted. Different types of corticosteroids gave similar results. Topical corticosteroid application for the treatment of unretractable prepuce complaints seems to be effective and safe, and is therefore recommended before surgical intervention is considered.

Circumcision for phimosis and other medical indications in Western Australian boys

OBJECTIVE

To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999.

DESIGN AND SETTING

A population-based incidence study using hospital discharge data of all circumcisions performed in all WA hospitals during the study period.

MAIN OUTCOME MEASURES

Changes in the incidence rate of circumcision for medically indicated reasons.

RESULTS

The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. Phimosis was the most common medical indication for circumcision in all age groups. The rate of circumcision associated with phimosis was eight times that associated with balanoposthitis and 21 times that of balanitis xerotica obliterans. Boys aged less than five years had the highest rate of circumcision to treat phimosis, at 4.6 per 1000 person-years, representing about 300 circumcisions per year. Boys aged less than five years living in country areas were 1.5 times more likely to be circumcised for phimosis than boys living in metropolitan Perth.

CONCLUSION

The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.

Concealed penis

A small phallus causes great concern regarding genital adequacy. A concealed penis, although of normal size, appears small either because it is buried in prepubic tissues, enclosed in scrotal tissue penis palmatus (PP), or trapped due to phimosis or a scar following circumcision or trauma. From July 1978 to January 2001 we operated upon 92 boys with concealed penises; 49 had buried penises (BP), while PP of varying degrees was noted in 14. Of 29 patients with a trapped penis, phimosis was noted in 9, post-circumcision cicatrix (PCC) in 17, radical circumcision in 2, and posttraumatic scarring in 1. The BP was corrected at 2-3 years of age by incising the inner prepuce circumferentially, degloving the penis to the penopubic junction, dividing dysgenetic bands, and suturing the dermis of the penopubic skin to Buck's fascia with nonabsorbable sutures. Patients with PP required displacement of the scrotum in addition to correction of the BP. Phimosis was treated by circumcision. Patients with a PCC were recircumcised carefully, preserving normal skin, but Z-plasties and Byars flaps were often required for skin coverage. After radical circumcision and trauma, vascularized flaps were raised to cover the defect. Satisfactory results were obtained in all cases although 2 patients with BP required a second operation. The operation required to correct a concealed penis has to be tailored to its etiology.

[Should circumcision be performed in childhood?]

OBJECTIVE

To evaluate prepuce development and retractibility in a group of boys. To point out the value of circumcision and prepucial forced dilation during childhood.

METHODS

Prepuce development and retractibility were evaluated in 400 boys ages between 0-16 year old.

RESULTS

In boys under 1 year prepuce retractibility (assessed only in children who did not undergo forced dilation previously) was type I (non retractile) in 71.5% whereas type V (completely retractile) was only 5.5%. In adolescent boys type I prepuce was observed in 1 boy only, 1.6%, whereas type V was observed in 82.3%. Furthermore, it was observed that at the time of examination for the study 106 boys who had undergone forced dilation at an earlier age had balano-prepucial adhesions again, which demonstrates that prepuce adheres again to glans penis in many boys after a forced dilation is performed. Only 11 boys were considered in need for circumcision, three of them for prepucial orifice stenosis, which prevented normal micturition, causing a prepucial sac, one case due to a constrictive ring below the prepucial edge that would have prevented ulterior retractability, two cases with repetitive balanopostitis, and five cases secondary to xerosol balanitis, accounting for 2.7% of all examined boys.

CONCLUSIONS

Incomplete separation between prepuce and glans penis is normal and common among new-borns, progressing until adolescence to spontaneous separation, at which time it is complete in the majority of boys. Accordingly to the criteria we have sustained for years and present study's findings, circumcision has few indications during childhood, as well as forced prepucial dilation.

Preoperative oral granisetron for the prevention of vomiting following paediatric surgery

BACKGROUND

We evaluated the efficacy of granisetron, 5-hydroxytryptamine type 3 receptor antagonist, given orally, preoperatively, for the prevention of postoperative vomiting in children undergoing general anaesthesia for surgery (inguinal hernia, phimosis-circumcision).

METHODS

In a randomized, double-blinded manner, 100 children, ASA physical status I, aged 4-11 years, received orally placebo or granisetron at three different doses (20 microg x kg(-1), 40 microg x kg(-1), 80 microg x kg(-1)) 60 min before surgery (n=25 of each). The same standard general anaesthetic technique was used.

RESULTS

The percentage of patients being emesis-free during 0-6 h after anaesthesia was 56% with placebo, 64% with graniseron 20 microg x kg(-1) (P=0.773), 88% with granisetron 40 microg x kg(-1) (P=0.027) and 92% with granisetron 80 microg x kg(-1) (P=0.01); the corresponding rate during 6-24 h after anaesthesia was 60%, 68% (P=0.768), 92% (P=0.02) and 92% (P=0.02) (P-values versus placebo). No clinically serious adverse events were observed in any of the groups.

CONCLUSIONS

In summary, preoperative oral granisetron 40 microg x kg(-1) is effective for the prevention of vomiting following paediatric surgery (inguinal hernia, phimosis-circumcision). Increasing the doses to 80 microg x kg(-1) provides no demonstrable additional benefit.

Perioperative management of a child with very-long-chain acyl-coenzyme A dehydrogenase deficiency

Very-long-chain acyl-coenzyme A dehydrogenase deficiency is an inborn error of fatty acid metabolism. The clinical presentation of this disease in children is either a severe form with onset of symptoms in the first months of life, cardiomyopathy, metabolic acidosis, myopathy and a high mortality, or a less severe form manifesting mainly with hypoglycaemia. Perioperative fasting and (even emotional) stress can trigger metabolic decompensation through the altered metabolism of endogenous fatty acids resulting in hypoglycaemia, acute cardiac and hepatic dysfunction and rhabdomyolysis. We report the perioperative management of a 9-year-old boy suffering from the severe form of this disease who underwent circumcision. Metabolism was kept stable in this child by using a glucose--electrolyte infusion throughout the perioperative period to avoid the biochemical consequences of fasting and a benzodiazepine--opioid technique combined with regional anaesthesia to minimize the stress response. Considering reports about a possible interference of propofol with fatty acid oxidation and to avoid the unnecessary administration of fatty acids, propofol should not be used in these patients.

[Administration of diprivan during urological surgery in children]

In 56 children, aged from 6 to 14 years, while performing urological operations the narcosis using ketamine was applied and in 43--basing on diprivan and anesthesy with phentanyl. In all the children premedication was conducted using atropine, dimedrol and sibazone. Pain in the vein while diprivan was injected occurred in 6 (14%) of children, involuntary movements--in 16 (37%). While application of diprivan in all the children the mild arterial hypertension was observed, bradycardia was absent on all stages of anesthesy period. The waking up period duration after conduction of anesthesy using ketamine had constituted at average (86.9 +/- 13.1) min, and using diprivan--(35.2 +/- 11.3) min (P < 0.01). Anesthesy basing on diprivan owes significant advantages in comparison with narcosis using ketamine during performance of urological operation in a child.

[Surgical procedures in penis cancer]

In the period of 1980-1999 (20 years) in Colentina Surgical Clinic were admitted and operated 16 patients with the diagnosis of pennial cancer (histopathology--squamocellular carcinoma), 13 of whom being from Colentina Dermatological Clinic. The mean age was about 64 years old, 10 cases presenting phimosis. Surgical procedures undergone were represented by partial pennial amputation with bilateral superficial inguinal lymphadenectomy (10 cases), total pennial amputation with superficial inguinal lymphadenectomy (4 cases), respectively emasculation with bilateral inguinal-iliopelvic lymphadenectomy (2 cases). In the postoperative period 3 patients presented lymphedema and lymphorrhagia, solved by conservative management. All the patients benefited of favorable evolution on the period they have responded to the controlled postoperative follow up (1-3 years).

Preputial calculi: a case report

The patient was a 92-year-old male whose chief complaint was urinary retention. The X-ray film showed multiple overlapping calcification shadows in the penile region. Renal insufficiency was speculated to be due to post-renal obstruction. Under the diagnoses of closure of the preputial orifice by balanoposthitis followed by urinary retention and preputial calculi, an urgent dorsal incision of the prepuce was made. Then, stone removal and indwelling catheter placement were performed. Renal function recovered soon after the operation, and the patient could urinate freely without catheterization. This case reminds us of the significance of surgical treatment for phimosis in elderly patients.

Circumcision in paediatric surgery using an ultrasound dissection scalpel

In contrast to electrocautery, the ultrasound dissection scalpel allows tissue dissection and haemostasis to be performed without the danger of thermal tissue damage or burning caused by uncontrolled active current. In a clinical application study performed on 24 boys with an average age of six years, we examined whether the use of this instrument is also practical in a routine operation such as circumcision. It was possible to perform all operations with the ultrasound dissection scalpel (Ultracision, manufactured by Ethicon) by the classic technique without the additional use of electrocautery for haemostasis. Although dissecting speed is slower than with conventional instruments, the fact that simultaneous haemostasis is possible meant that operations could be carried out quickly and with minimal bleeding. There were no perioperative complications such as haemorrhaging or burning. All children were examined postoperatively over an average of 3 weeks (range 1-8 weeks). Wound healing was completely without complications for 22 patients (92%). One patient (4%) suffered a candidal infection in the first postoperative week. One further patient (4%), who was already suffering preoperatively from an extended chronic inflammation of the prepuce, developed pronounced swelling postoperatively. Heavy scarring occurred subsequently in both cases. Our results show that the advantages of the ultrasound dissection scalpel, e.g. gentle tissue dissection with simultaneous haemostasis, can also be used to advantage for a technically simple operation such as circumcision without having to fear the risks of electrocautery.

Surgical correction of buried penis: a review of 60 cases

BACKGROUND/PURPOSE

The authors reviewed 60 cases of buried penis, treated in a single institution with postoperative follow-up for at least 6 months. The review was aimed at providing information that might help to optimize the results in future surgical correction of this uncommon, but not rare, congenital disorder.

METHODS

From January 1, 1989 to December 31, 1998, 62 boys with buried penis were treated with 1 of the following procedures: group 1A (n = 6), preputial unfurling alone; group 1B (n = 8), modified preputial unfurling; group 1C (n = 12), penoplasty devised by the first author with preservation of the preputial skin; and group 2 (n = 36), penoplasty with trimming of the inner preputial skin. Postoperative follow-up of more than 6 months after operation was achieved in 60 of 62 patients for a total of 25 patients in group 1 (A through C) and 35 patients in group 2.

RESULTS

Recurrent buried penis developed in 8 of 60 patients (13%), and redundant penile skin with or without lymphedema occurred in 18 (30%). The complications occurred in 18 of 25 patients (72%) in group 1 (A through C) but in only 8 of 35 (23%) in group 2. The difference was significant (P =.001). Most of the complications were mild and acceptable. A second procedure was required in 5 of the 25 patients in group 1 but in none of group 2. The second procedures were required to correct recurrent buried penis in 1 and to resect excess redundant penile skin in 4.

CONCLUSION

The superior results achieved in group 2 suggest that in addition to penoplasty with adequate fixation of the unfurling prepuce, resection of excess inner preputial skin is required to achieve an optimal outcome in children requiring surgical correction of buried penis.

[Circumcision--criticism of the routine]

Circumcision is one of the most frequent operative procedures done in males. About 120 circumcisions are performed every 5 minutes over the world [14]. Three different reasons lead to circumcision: 1) Medical reasons in present of a pathologic phimosis. 2) Circumcisions done due to religious, social or cultural rea-reasons. 3) Finally in many countries circumcision is performed as "routine-circumcision" in the newborn period. While in the United States the number of routine-circumcisions decreases (about 60% of all male newborns) South-Korea has a rate near to 100%. Even with no religious or cultural background in Germany circumcision often is performed without scrutinizing medical indication. Circumcision is regarded as an procedure with no complications and no disadvantage for the patient. In general circumcision has no medical benefit neither in decreasing the incidence of urinary tract infections nor of sexual transmitted diseases nor of neoplasias. Medical indication for circumcision is given in present of pathologic phimosis in 4% of all males. Postoperative complications range up to 2% and "circumcision is the amputation of the prepuce from the rest of the penis, resulting in permanent alteration of the anatomy, histology and function of the penis...". There are many reports about having discomfort and disadvantages after circumcision as well to the males as to the sexual partners. This challenge the legality of neonatal involuntary circumcision because legality is based on saving the children's best interests.

Circumcision: a refined technique and 5 year review

The vast majority of circumcisions currently performed in the UK are for phimosis or balanitis and the patients are not looking for the denuded glans appearance of a ritual circumcision. We present a refinement of the sleeve technique of circumcision, which involves Horton's test to define the proximal incision margin, and bipolar electro-dissection. A review of all patients undergoing circumcision at the Wordsley Plastic Surgery Unit, in a 5-year period, has shown this technique to be safe with a haematoma rate of only 1.4%, and an overall complication rate of 3%.

Primary lymphedema of the penis: surgical correction by preputial unfurling

Primary lymphedema of the penis (PLP) is a rare disease. We report a case in a 2-year-old, uncircumcised boy where the uninvolved inner preputial skin was unfurled to cover the penile shaft. The uninvolved inner preputial skin is often elongated, and provides a suture-free cover of sufficient length for the small penile shaft of pediatric patients.

Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect

OBJECTIVE

To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments.

METHODS

Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information.

RESULTS

Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million.

CONCLUSION

As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.

A study of clinical opinion and practice regarding circumcision

AIM

To establish clinical opinion regarding appropriate indications for circumcision and to examine actual clinical practice.

METHODS

A questionnaire was sent to all NHS hospital consultants in the Yorkshire region of the UK identified as having a role to play in the management of boys (under 16 years of age) requiring circumcision. Retrospective data on actual clinical practice during a three month study period were also collected via a simple proforma.

RESULTS

Of 153 questionnaires sent, 64 were returned. Responses revealed varying opinions regarding appropriate indications for circumcision within each consultant group, and between paediatricians and surgeons. Surgeons were generally more inclined to recommend circumcision for each of the indications listed in the questionnaire. Analysis of clinical practice revealed that almost two thirds of procedures were carried out for phimosis, and nearly half of these children were under the age of 5 years.

CONCLUSION

There are differences in the clinical opinions of surgeons and paediatricians on what constitutes an appropriate indication for circumcision. Paediatricians' opinions are generally more in line with current evidence than those of surgeons, possibly resulting in many unnecessary circumcisions.

[Postectomy for phimosis: 5-year-experience]

Phimosis, i.e. congenital or acquired preputial stenosis, is one of the most frequent problems encountered in surgery departments. Circumcision remains the most frequently adopted surgical treatment, but, since this operation entails the sacrifice of the prepuce and frenulum, the penis loses its natural protection. The Authors describe five years of experience with postectomy, a technique which spares both the prepuce and frenulum while repairing the preputial phimosis, defining its benefits compared with circumcision.

Persistent anaphylactic reaction after induction with thiopentone and cisatracurium

A 6-year-old boy presented for surgery for phimosis. The anaesthetic technique included intravenous induction with thiopentone and neuromuscular blockade with cisatracurium. Severe persistent bronchospasm and central cyanosis followed the administration of these drugs. A continuous i.v. infusion of epinephrine at 0.2 microg. kg(-1) x min(-1) was necessary to break the severe refractory bronchial hyperresponsiveness. There was no previous exposure to anaesthetic drugs and no definite family history of allergy. Through increased serum eosinophil cationic protein, tryptase and histamine levels and IgE levels specific to cisatracurium, we demonstrated an IgE-mediated anaphylactic reaction to cisatracurium in the child's first exposure to this new neuromuscular blocking agent. Anaphylactic reactions to new anaesthetic drugs may be challenging to recognize and treat during general anaesthesia in children. The pathogenesis, diagnosis and management of life threatening persistent allergic reactions to intravenous anaesthetics are discussed.

Pagetoid dyskeratosis of the prepuce. An incidental histologic finding resembling extramammary Paget's disease

BACKGROUND

Pale cells resembling those of paget's disease have been seen as an incidental finding within the epidermis in a variety of benign papules most commonly located in intertriginous areas. This lesion, called pagetoid dyskeratosis, is considered a reactive process in which a small part of the normal population of keratinocytes is induced to proliferate. Among the inductors friction is suspected. As far as we know, these cells have not been reported in the penis.

METHODS

Here we describe the location of the lesion in the foreskin and the incidence of this lesion in a group of 281 unselected patients surgically treated for phimosis. In selected cases histochemical staining and immunohistochemical studies were performed.

RESULTS

Pagetoid dyskeratosis was found in 105 cases (37.4%) but only in 5 cases (1.8%) the lesion was conspicuous. The cells of pagetoid dyskeratosis show an immunohistochemical profile different from the surrounding keratinocytes characterized by premature keratinization. Pagetoid dyskeratosis cells must be distinguished from the artefactual clear cells of the epidermis, from reactive melanocytes, and from pale-cell acanthosis. In cases in which pagetoid dyskeratosis shows a florid expression there is a hazard of overdiagnosis to the patient. The main differential diagnosis includes extramammary Paget's disease, pagetoid squamous cell carcinoma in situ, epidermotropic metastasis, superficial spreading malignant melanoma, clear cell papulosis, and penile koilocytoses.

CONCLUSIONS

The pathologist should be familiar with the histologic features of pagetoid dyskeratosis in the foreskin in order to avoid misdiagnosis and unnecessary treatment. Routine histologic study is usually sufficient to identify the lesion.