107 Focus on cme at McGill University By J. L. Pippi Salle, md, PhD and Roman Jednak, md

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enile problems are prevalent in children and adolescents.

Correct identification is usually possible by careful

physical examination and is essential to avoid related com-


The Canadian Journal of CME / September 2002  107

Focus on CME at

McGill University

By J.L. Pippi Salle, MD, PhD and Roman Jednak, MD

Penile Problems








A three-year-old boy comes to the office because the

parents cannot expose the glans due to a narrow

preputial ring. What is the best management?

Normally, the prepuce is unretractable at birth. This is because, ini-

tially there is a physiologic adherence between the glans and the

inner preputial skin. There is also a relatively narrow preputial ring.

With age, a gradual separation of the preputial adhesions will

occur. As a result of production of smegma, a whitish secretion pro-

duced by the inner preputial sebaceous glands. Usually, this devel-

opmental process is completed when the child reaches seven years

of age, but it can continue until later in childhood.



Figure 1: Fibrotic phimotic ring with

associated BXO.

Penile Problems

108 The Canadian Journal of CME / September 2002

Dr. J.L. Pippi Salle MD, PhD, staff,

University Health Centre, Montreal

Children’s Hospital

Dr. Roman Jednak MD, staff, University Health

Centre, Montreal Children’s Hospital

For many three-year-old boys, it is “normal” to present with physiologic phimosis which eventually

resolve so that the foreskin can be retracted completely. For this reason, unless complications arise, such

as recurrent balanoposthitis, urinary tract infection or paraphimosis, management should remain conser-

vative. Clinicians should allow a period of observation for spontaneous resolution of the physiologic phi-

mosis avoiding unnecessary surgical manipulation and possible psychological trauma.

We  wouldn’t encourage penile manipulation to dilate the preputial opening during the observation

period. In our opinion, forceful manual dilation may be traumatic and can create microlacerations, which,

upon healing, form permanent scars and produce an acquired phimosis. In this scenario, surgical inter-

vention will almost certainly be necessary. Intermittent treatment with 0.1% triamcinolone cream in cases

where there is a mild, non-fibrotic phimotic ring is useful and we encourage its use prior to surgical con-

sultation. In about 10% of cases of phimosis there is severe scarring (whitish fibrotic ring) (figure 1)

caused by balanitis xerotica obliterans (BXO), a genital variation of lichen sclerosus et atrophicus. If

BXO is present, surgical correction is recommended because this is a progressive disease that can even-

tually involve the urethra and cause meatal stenosis or urethral strictures. 




A five-year-old male presents com-

plaining that he cannot exteriorize

the glans. On examination there is

no phimosis,

but only bal-

anopreputial adhesions (figure 2).

What is the suggested management?

The inner prepuce is initially attached to the

glans and will undergo a gradual process of

separation. In some cases, the production and

accumulation of smegma can be significant,

leading to the trapping of a significant amount.

This may give the impression of a whitish

“cyst” around the corona (figure 3). 

Completing the process of separating the

prepuce from the glans can eliminate progres-

sive accumulation of smegma. In some cases,

these cysts can undergo a bacterial superinfec-

Penile Problems

110 The Canadian Journal of CME / September 2002

What are the indications for circumcision?

This remains a hotly debated subject. There are several articles in the liter-

ature advocating routine neonatal circumcision on the basis of a number of

specific medical benefits. These include protection against the development

of urinary tract infection (UTI) and sexually transmitted disease (STD), as

well as protection against the development of penile cancer. In addition, the

partners of circumcised men may also benefit from a decreased incidence

of cervical cancer. 

Opponents to circumcision claim that the procedure can lead to

decreased sensation in the glans as well as to the development of psycho-

logical problems. Furthermore, they feel that addressing

certain lifestyle issues and stressing good hygiene are more

than sufficient prevention for some of the secondary prob-

lems reported in uncircumcised men. 

Are there contraindications 

to circumcision?

The presence of a concealed or buried penis is an absolute

contraindication for routine circumcision. The buried penis

is concealed in the suprapubic fat, leaving only the foreskin

and penile shaft skin visible (figure 4). When this diagnosis

Penile Problems

110 The Canadian Journal of CME / September 2002

tion. This can lead to an abscess-like collection between the glans and prepuce. Clinically this is

characterized by penile erythema, local edema and a suppurative discharge. Treatment with warm

sits baths and oral antibiotics can be effective. 

This complication is not an indication for circumcision unless it is recurrent and associated with




Figure 2: Balanopreputial adhesions.

Figure 3: Smegma accumulation behind

the glanular groove. An abscess can form.

Figure 4: A buried penis. Only foreskin and penile

skin are visible, while penis shaft is buried.

Penile Problems

112 The Canadian Journal of CME / September 2002

is missed, circumcision may remove the penile skin in

its entirety. This can lead to scarring and trapping of

the concealed penis beneath the suprapubic skin (fig-

ure 5). In some cases such scarring is intense and can

cause severe urinary obstruction with the formation of

a large urinoma around the penis (figure 6).

Correcting the problem can be quite challenging

since once the penis is released from the suprapubic

fat, achieving appropriate skin coverage can be diffi-

cult. It is important that recognition of this type of

anatomical variant is mandatory by all professionals

who perform circumcision. When severe phimosis is

associated with a concealed/buried penis, circumci-

sion is best performed by pediatric urologists utilizing

alternative techniques.

What are the complications 

of circumcision?

The most common complication is penile trapping

following the circumcision of a concealed penis.

Other complications include:

• Hemorrhage

• Infection

Table 1

Indications for circumcisions

Unquestionable indications for 

circumcision are:

• Phimosis secondary to BXO.

• Paraphimosis (penile constriction 

caused by a prolonged retraction of 

the prepuce beyond the corona).

• Recurrent balanitis in diabetic 


Relative indications are:

• Recurrent balanitis.

• UTI in the first 12 months of life.

• Urological malformations which 

predispose to UTI, such as moderate 

or severe vesicoureteral reflux, 

posterior urethral valves with 

significant dilatation of the upper 

urinary system, ureteroceles following 

incision, or any other malformations 

that cause significant urinary stasis. 

Figure 5: Penile trapping after circumcision on a buried

penis. Penile skin was inadvertently removed.

Figure 6: Obstruction to urine flow during micturition cre-

ates a large collection of urine around the trapped penis.

Penile Problems

114 The Canadian Journal of CME / September 2002

• Glans amputation

• Penile necrosis

• Meatal stenosis

• Psychological trauma

Although circumcision is the most common surgical procedure per-

formed, it is not complication free and on rare occasion, can result in

serious morbidity. Therefore, circumcision should be reserved for

patients having the aforementioned medical indications. 

I was instructed to perform forceful retraction of

the prepuce and on one occasion the phimotic ring

constricted the glans causing extreme pain and

swelling. What caused this and how should the

condition be treated?

This is the typical description of a boy with

phimosis who developed paraphimosis follow-

ing forceful retraction of the prepuce (figure

7). When paraphimosis occurs, it should be

reduced immediately  since progressive

venous congestion eventually leads to edema

and pain. When prolonged , paraphimosis may

even result in ischemia of the distal penis. The

patient should be brought to the emergency

room immediately for specialized care if

reduction is not readily accomplished. A cir-

cumcision should be performed two or three

weeks following reduction since recurrence is

very common.

Why does my son have recurrent episodes of penile

redness and suppuration?

Infections of the foreskin (posthitis) and glans (balanitis) are usually bacte-

rial, viral, or fungal in origin. Bacterial balanoposthitis is often secondary to

Figure 7: Paraphimosis with intesnse progressive preputial

edema after forceful retraction of a phimotic prepuce.

Penile Problems

The Canadian Journal of CME / September 2002  115

the accumulation of infected smegma. Often there are

underlying predisposing medical conditions, such as dia-

betes or an immunosuppressed state. Viral balanoposthitis

is usually caused by the herpes virus and is extremely rare

in children. Fungal balanoposthitis is common and usual-

ly  associated with the prolonged administration of wide

spectrum antibiotics. Balanoposthitis is treated conserva-

tively. Warm sit baths, oral antibiotics, or a topical anti-

fungal cream usually resolves the problem. In cases of

recurrent bacterial balanoposthitis, circumcision may be


My son underwent circumcision and

subsequently developed an upward devi-

ation of his urinary stream when void-

ing. Is this normal? How can it be


This child developed meatal stenosis, the most common

late complication following circumcision. A small mea-

tus is often seen following circumcision, but this does not

preclude a normal urinary stream. In cases where a sig-

Figure 8: Classification of hypospadias.

Figure 9a: Glanular hypospadias

Figure 9b: Proximal hypospadias with a typical

redundant dorsal foreskin.

Penile Problems

116 The Canadian Journal of CME / September 2002

nificant narrowing of the meatus has occurred the

stream can take on a characteristically thin appear-

ance and is directed upwards. The child may take a

longer time to void and can even empty the bladder

incompletely. Although the diagnosis is evident on

inspection, the best documentation is obtained by

performing uroflowmetry and measuring post-void

residual urine in the bladder. Meatotomy is indicat-

ed when there is poor flow, a significant post void

residual or significant deviation of the urinary

stream. The meatus is enlarged surgically and post-

operative meatal dilation is performed to avoid

recurrence of the stenosis.

My son was born with hypospadias

and I was instructed to seek spe-

cialized care. What is hypospadias

and when should it be corrected?

Hypospadias is a congenital malformation of the

penis. Urethral development is incomplete and the

urethral meatus opens in a ventral position. More

severe hypospadias usually presents with a proxi-

mal meatus (perineal/penoscrotoal) and is associat-

ed with some degree of chordee (ventral curvature

of the penis). The classification of hypospadias is

based on the location of the meatus without taking

penile curvature into account (figure 8). 

The majority of patients present with distal hypospadias with or without

chordee (figure 9a). Proximal hypospadias (penoscrotal, perineal, proximal

penile) represents the most severe end of the spectrum and is usually cor-

rected utilizing preputial flaps (figure 9b). Hypospadias can be associated

with other genital anomalies. Undescended testes and inguinal hernias are

associated problems in up to 10% of patients. Patients with severe hypospa-

dias and undescended testes should be investigated for an intersex condi-

Figure 10: Penile torsion.

Figure 11: Epispadias. The distal urethra is completely

open dorsally.

Penile Problems

118 The Canadian Journal of CME / September 2002

tion. They require a karyotype as well as an

endocrinologic evaluation. On occasion a voiding

cystoureterogram is warranted to assess for the pres-

ence of a large utricle (pseudovagina). There is an

increase incidence of hypospadias in male siblings (~

15%) and in offspring (~ 8%). Surgical correction

aims for construction of a straight penis and normal

urethra, thereby giving the penis a normal cosmetic

appearance. Surgery is best performed prior to toilet-

training, at around six to 18 months of age. This

avoids operating during the psychologic phase of

genital awareness, which usually occurs after two

years of age. The surgery is usually done in one stage

as an outpatient procedure. Recent advances in surgi-

cal technique have significantly reduced the inci-

dence of postoperative complications and improved

the cosmetic outcomes.

Penile Torsion

Some children are born with a deviation of the penile

raphe and some degree counterclockwise penile rota-

tion termed penile torsion (figure 10). When the

degree of torsion is mild (< 90 degrees) there is no

need for surgical correction. Surgical repair is war-

ranted in more severe cases and the procedure is per-

formed between six to 18 months of age. 


Rarely (one in 40,000 births), male babies can be

born with the urethral meatus opening on the dorsal aspect of the penis; a con-

dition known as epispadias (figure 11). Surgical correction focuses on the

same goals as those described for hypospadias. In some cases with a proximal

urethral meatus the urinary sphincter is insufficient and the patient therefore

presents with total urinary incontinence. In these situations additional bladder

neck surgery is required to achieve urinary continence.

Paraurethral Cyst

Paraurethral cysts are uncommon, but can cause significant anxiety for both

parents and caregivers due to the very apparent location of the cystic lesion

around the urethral meatus (figure 12). Typically the cyst is smooth, soft and

Figure 13: Short frenulum causing painful erection in an


Figure 12: Paraurethral cyst

Penile Problems

120 The Canadian Journal of CME / September 2002

white in color. With time the majority diminish in size or drain spontaneously.

Larger cysts may require needle aspiration or formal surgical excision.

Tight Frenulum

A normal frenulum should allow for erection without glanular tilt (figure 13).

A short frenulum may cause pain during erection and bleeding if torn during

sexual intercourse. Unless there is clear early evidence of a problem, most chil-

dren should wait until puberty before being evaluated for a frenulectomy


Micropenis is a condition where the penis, though normal anatomically, is

markedly small. The strict definition of micropenis is one in which the

stretched penile length is more than 2.5 SD below the mean for patient age.

From a term newborn to be classified as having micropenis the stretched penile

length should be less than 1.9 cm. The majority of patients referred for evalu-

ation of micropenis actually have a buried/concealed penis. Careful examina-

tion pressing on the suprapubic fat should exteriorize the penile body and

establish the diagnosis. Micropenis can be related to abnormal hormonal stim-

ulation. In some cases, no hormonal abnormalities are recognized and the eti-

ology is considered to be idiopathic. Once the diagnosis of micropenis is con-

firmed, consultation with a pediatric endocrinologist and urologist is warrant-

ed. In some cases, successful testosterone administration can significantly alle-

viate the emotional distress felt by the families of boys with the condition..


Penile problems are prevalent in children and adolescents. Correct identifica-

tion is usually possible by careful physical examination and is essential to

abbreviate related complications. 

Recommended Readings:

1. Campbell’s Urology, 8th ed. Edited by P.C.

Walsh, A.B., Retik, E.D. Vaughan, Jr., and A.J.

Wein. Philadelphia, W.B. Saunders, 2002.

2. Adult and Pediatric Urology, 4th ed. Edited by

Gillenwater, J.Y., Grayhack, J.T., Howards,

S.S., and Mitchell, M.E. Philadelphia,

Lippincott, Williams, and Wilkins, 2002.

3. Clinical Pediatric Urology, 4th ed. Edited by

Bellman, A.B., King, L.R., and Kramer, S.A.

London, Martin Dunitz Ltd., 2002

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