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
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
Dr. J.L. Pippi Salle MD, PhD, staff,
University Health Centre, Montreal
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.
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-
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
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
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.
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
What are the complications
The most common complication is penile trapping
following the circumcision of a concealed penis.
Other complications include:
Indications for circumcisions
Unquestionable indications for
• 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.
• 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
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.
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
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.
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
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.
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 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
white in color. With time the majority diminish in size or drain spontaneously.
Larger cysts may require needle aspiration or formal surgical excision.
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-
abbreviate related complications.
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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
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