Differentiation of the genitalia occurs between the ninth and thirteenth gestational week. The prepuce of the glans penis, which forms the foreskin, is adherent to the underlying glans penis and remains so throughout gestation and during the first several years of postnatal life. The foreskin of the newborn and infant cannot easily be retracted. Doing so shears the attachments between the epithelial layers of the glans penis and the foreskin. This normal adherence of the foreskin of the infant and toddler to the underlying glans penis is referred to as physiologic phimosis and is a part of normal male child physical development and maturation. It can persist in some (3 to 6 percent) boys into the grade-school years, spontaneously resolving during early puberty in the vast majority of boys.
FORESKIN PEARLS Secretions and sloughed epithelial cells (smegma) from the surface of the glans penis accumulate under the foreskin and contribute to the gradual elevation and separation of the foreskin from the surface of the glans penis. The thin foreskin may reveal such accumulations of smegma, referred to as foreskin pearls. They ultimately will decompress at the terminus of the foreskin's attachment to the glans penis. If unassociated with evidence of cellulitis (erythema, warmth, induration, and tenderness), they do not represent an infectious complication and require no treatment beyond an explanation and reassurance for the concerned parent.
PHIMOSIS It is important to differentiate physiologic phimosis, as mentioned above, from pathologic phimosis. Phimosis is pathologic when a previously retractable foreskin is no longer retractable or when foreskin retraction is unachievable beyond puberty. Pathologic phimosis is rare in children. It may complicate circumcision or may result from repeated trauma, infections, or chemical irritation. It may be suspected if, during examination of the comfortably retracted foreskin, the foreskin appears rolled or thickened, rather than thin and effaced as the foreskin is pushed gently toward the base of the penis.
Pathologic phimosis associated with obstruction of urinary stream, recurrent urinary tract infections, or recurrent bouts of balanoposthitis represents an indication for referral to a urologist or pediatric surgeon for elective circumcision. Nonsurgical management of pathologic phimosis has been proposed. Case reports and case series reports of balloon dilatation and topical steroids suggest a limited role for these approaches.
PARAPHIMOSIS Regardless of the reasons for foreskin retraction, timely replacement of the foreskin ring distal to the glans penis is necessary. Failure to do so will result in the formation of painful edema in the foreskin and glans penis secondary to venous congestion caused by the constriction by the preputial ring. Ultimately, vascular insufficiency may threaten the viability of the glans penis and foreskin. This condition, known as paraphimosis, is an emergent urologic condition.
Differential diagnostic considerations include penile infections (balanoposthitis), idiopathic penile edema (insect bites, contact dermatitis, etc.), and, more important, a circumferentially constricting foreign body (hair, clothing, rubber band, etc.). Among the most pressing duties of the examining physician is the identification and removal of any constricting foreign body. The profound edema of the glans penis and the foreskin may make this task exceedingly difficult.
Management rests largely with the control of swelling and of pain, using systemic analgesia, dorsal penile nerve block, or both. Control of edema may be achieved by application of cool, compressive (1-in Surgical Cling) dressings, starting at the distal penis and wrapping proximally. Alternatively, the glans penis may be cooled with ice water-filled latex examination gloves. Reexamination of the penis for the presence of a constricting foreign body should then be performed.
Once the diagnosis of paraphimosis has been confirmed, it is reduced using a variety of techniques. The most commonly successful reduction technique involves the simultaneous distal traction of the foreskin using the index and third fingers of each hand while the thumbs push the swollen glans penis back through the paraphimotic ring of the foreskin. The use of a gauze sponge between the third and index fingers of each hand and the foreskin aids considerably in traction on the foreskin. If this technique is unsuccessful, a surgical release of the edematous foreskin is indicated, ideally in conjunction with urologic consultation. Either a single puncture of the foreskin using a 21-gauge needle or (more definitively) a dorsal slit of the edematous foreskin ring should restore vascular supply to the glans penis.
Discharge from the emergency department is appropriate following demonstration of spontaneous voiding of the bladder. Outpatient consultation with a urologist or a pediatric surgeon is appropriate and should be coordinated through the child's primary care physician.
BALANOPOSTHITIS Balanitis is an inflammation of the glans penis. Balanoposthitis is an inflammatory process that also involves the foreskin. The cause of balanoposthitis in preadolescent boys is usually infection but may occasionally be trauma, including chronic friction, zipper injuries, and contact dermatitis, or a fixed drug eruption (tetracycline or clotrimazole). Even rarer are plasma-cell balanitis and balanitis xerotica obliterans. As many as 3 percent of boys experience balanoposthitis, the vast majority of whom are uncircumcised.
The microbiology of infectious balanoposthitis reveals an abundance of gram-positive and gram-negative organisms. Most infections of the foreskin and glans penis represent invasion by normal flora and are usually polymicrobial. Contributing factors to the development of these infections (e.g., poor hygiene) are unproved and controversial. Candida albicans may be the pathogen in prepubertal children, and recurrences of balanoposthitis due to this organism should alert the physician to the possibility of immunocompromise, such as occurs with diabetes mellitus. Group A b-hemolytic streptococcus has been reported as an infectious organism, and its identification (via rapid antigen detection of associated thin, purulent discharge) warrants aggressive and specific antistreptococcal therapy. Sexually transmitted organisms are responsible for many cases of balanoposthitis in older adolescents.
Physical examination of a child with balanoposthitis reveals redness (100 percent), swelling (91 percent), discharge (up to 73 percent in one series but usually far less common), and soreness. Systemic fever and constitutional symptoms are atypical. Any urethral discharge is swabbed for detection of streptococcal antigen, and rapid antigen assays that test negative are cultured. If the rapid streptococcal antigen test result is negative, a smear of the discharge is examined using Gram stain. The presence of polymorphonuclear leukocytes on Gram stain of a urethral smear of a prepubertal boy whose rapid test for Streptococcus pyogenes is negative should alert the physician to the possibility of a sexually transmitted infection. The emergency physician should be cognizant of the forensic diagnostic criteria for documentation of infections due to Neisseria gonorrhoeae and Chlamydia trachomatis in his or her community and should select the appropriate culture methods, DNA probes, or other rapid diagnostic tests accordingly.
Management of the more common nonspecific balanoposthitis involves local hygiene measures, including sitz baths and gentle cleaning of the foreskin sulcus and glans penis. The soothing effect of a warm-water sitz bath also facilitates voiding in many children with voluntary urinary retention due to dysuria from a variety of causes. Some clinicians recommend the application of 0.5% hydrocortisone cream to the affected parts. Antimicrobial topical ointments that do not contain neomycin have been traditionally recommended, but their utility is unproved. Occasionally, 5 to 7 days of amoxicillin or a first-generation cephalosporin may be useful in recalcitrant cases or in cases associated with more advanced cellulitis. Circumcision is considered in cases of recurrent balanoposthitis.
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