Penile and Foreskin Problems

BASICS

DESCRIPTION

Penile problems:
- Buried penis
  - Poor skin fixation at the penoscrotal/penopubic junction or significant surrounding pubic and prepubic fat resulting in a hidden appearance
- Webbed penis
  - Poor separation of penile skin from scrotum, obscuring penoscrotal angle
- Chordee
  - Penis curvature with erection, can be lateral, ventral (downward, most common), or dorsal curve (upward)
  - Usually associated with abnormal foreskin
- Hypospadias
  - Abnormal urethral meatus location along dorsal surface of penis
  - Severity depends on location: on or below the glans being least severe and penoscrotal junction or perineal being most severe
  - Usually associated with dorsally hooded foreskin and ventral chordee
- Balanitis
  - Glans inflammation
  - Probably overdiagnosed owing to physiologic drainage of smegma or urea dermatitis from failure to retract foreskin during voiding in potty-trained boys
  - Infections can present with significant cellulitis of the penis, edema, and fever.
  - Most common causative organisms are gram positive bacteria and yeast.
Foreskin (preputial) problems:
- Balanoposthitis
  - Inflammation of glans and prepuce
  - 4% of uncircumcised boys age 2 to 5 years
  - See description of balanitis.
- Phimosis
  - Physiologic attachment of the prepuce to the glans which is normal and protective early in childhood; with age, will gradually separate to allow retraction of the foreskin
  - Chronic inflammation can result in a ring of fibrotic scar tissue that prevents the foreskin retraction; in extreme cases, can impact voiding (ballooning or urine trapping).
- Paraphimosis
  - When retracted prepuce is not replaced, it constricts penile shaft causing glanular and foreskin edema preventing replacement of prepuce over glans. This leads to ischemia and is a urologic emergency.
Postcircumcision problems
Penile adhesions
- Physiologic: thin attachments joining the penile skin to the glans
- Surgical: Penile skin bridges are dense scar adhesions that cannot be separated.
Meatal stenosis
- Narrowing of the urethral meatus
- If severe, can produce an upwardly deflected, narrow, “laser-like” stream. Children may strain with prolonged voiding.
Epidermal inclusion cysts
Small, enlarging white lesions growing subcutaneously along the scar from circumcision that usually require surgical excision

ETIOLOGY

Buried penis
- Incomplete circumcision due to poor skin fixation, lack of penile shaft skin, or removal of too much/too little foreskin
- Buried appearance is further worsened by obesity with prominent surrounding pubic fat.
Chordee
- Asymmetry in tunica albuginea of corporal bodies creating foreshortening of one side
Hypospadias
- Arrested development with failure of ventral urethral and prepuce fusion
- Multifactorial with genetic, hormonal, and environmental risk factors
Balanitis/balanoposthitis
- Unclear, possibly: infection, mechanical trauma, contact irritation, and contact allergies
Phimosis
- Likely due to chronic irritation of the prepuce from improper hygiene habits, such as voiding through closed foreskin or repetitive forceful retraction
Paraphimosis
- Failure to replace retracted prepuce
Penile adhesions
- Physiologic adhesions: adherence of prepuce to corona in both uncircumcised boys or postcircumcision
- Surgical adhesions (skin bridges): development of thick scar bands between the penile shaft skin and the glans postcircumcision
Meatal stenosis
- Recurrent irritation of the meatus, likely from rubbing against moist diapers; occurs almost exclusively in circumcised boys
Epidermal inclusion cysts
- Small islands of epithelium buried beneath the skin surface that progressively accumulate desquamated skin cells