1.Etiology and pathogenesis
In some children, the foreskin opening is so small that the foreskin cannot retract, preventing the development of the penis head or even the entire penis. The urethral opening is often small, and sometimes the foreskin opening is as small as a pinhole, so that difficulties in urination occur. Children with prepuce, due to the secretions accumulated under the foreskin, often stimulate the mucous membrane, can cause the head of the penis foreskin inflammation.
Acquired prepuce is mostly secondary to foreskin infection of the head of the penis and injury to the foreskin and head of the penis. The foreskin mouth has scar contracture formation, losing the elasticity and expansion ability of the skin, the foreskin cannot retreat upward, and often accompanied by urethral stenosis, this kind of prepuce will not heal itself.
2.Epidemiology
Congenital prepuce can be seen in every normal newborn and infant. When the child is born, the foreskin and the head of the penis adhere to each other, and after a few months, the adhesions are gradually absorbed and the foreskin and the head of the penis are separated. By the age of 3 to 4 years old, due to the growth of the penis and the head of the penis, the penis becomes erect, the foreskin can retreat upward on its own, and the head of the penis can be revealed by turning out the foreskin. The prepuce is a normal phenomenon in children and is not pathological. When children are 3 years old, 90% of circumcision heals itself. after 17 years old, only less than 1% have circumcision.
3.Classification
Congenital and acquired prepuce, congenital prepuce is divided into atrophic and hypertrophic, acquired prepuce is caused by inflammation, trauma, etc. to make the foreskin mouth adhesion narrow. Congenital prepuce with the growth of the penis, erection, foreskin can recede upward by itself to reveal the head of the penis.
4.Clinical manifestations
Due to the accumulation of foreskin scale in the foreskin cavity, circumcision of the penis head can be induced in children with prepuce. The manifestation is a significant increase in the number of urination. Acute inflammation of the foreskin can appear red and swollen, serious cases can produce purulent secretions, accompanied by fever and other symptoms of systemic toxicity. The accumulated foreskin scale at the coronal sulcus shows a small, slightly white lump across the foreskin, which is often mistaken for a tumor by parents and is seen. Sometimes the opening of the foreskin is as small as a needle’s eye, and urine accumulates in the foreskin cavity when urinating, making the foreskin expand like a cyst, making the urine line slender and making urination difficult. Long-term difficulty in urination can lead to the formation of bladder and urethral stones and the emergence of vesicoureteral reflux to damage the kidneys.
5.Complications
Ingrown prepuce is a complication of circumcision. If the foreskin of the patient with prepuce is turned over to the head of the penis, if it is not reset in time, it can make the narrow foreskin mouth form a narrow ring in the coronal groove, blocking the head of the penis, the veins of the foreskin and lymphatic reflux, and causing foreskin edema, foreskin edema makes the narrow ring tighter and tighter, forming a vicious circle. The child cries more than once due to severe pain, and may have difficulty in urination. The narrow ring can be seen at the upper edge of the edematous foreskin, and the head of the penis is dark purple and swollen, which can lead to necrosis of the embedded foreskin and the head of the penis if time is too long.
6.Diagnosis
The diagnosis of prepuce can be clearly made only by physical examination.
7.Differential diagnosis
Occult penis; the child is obese, the foreskin is bird’s beak-shaped, the penile skin is not attached to the penis body, and the penile squeeze test is positive.
8.Treatment
For congenital prepuce in infancy, the foreskin can be turned up repeatedly on a trial basis in order to expand the foreskin opening. The technique should be gentle and not overly eager to retract the foreskin up. When the head of the penis is exposed, clean the foreskin, apply antibiotic ointment or liquid paraffin to lubricate it, and then restore the foreskin, otherwise it will cause imbedded prepuce. Most children treated by this method can be cured with age, only a few need to do circumcision. Patients with acquired circumcision need to be circumcised because of the fibrous narrow ring at the mouth of their foreskin. The indications for circumcision vary, and some countries and regions routinely do circumcision after birth because of religious or ethnic habits. Some people believe that circumcision can reduce the incidence of penile cancer and cervical cancer in women after marriage. However, there is information that there is no significant difference in the incidence of these two cancers between Israel, where circumcision is routinely performed, and the Nordic countries, where circumcision is not popular.
The indications for circumcision are.
A fibrous narrow ring at the circumcision orifice.
Recurrent episodes of circumcision of the penile head.
Narrow foreskin opening after the age of 5 years and the foreskin cannot be retracted to reveal the head of the penis. For children with penile prepuce, antibiotics are applied to control inflammation during the acute phase, and the area is soaked several times a day with warm water or 4% boric acid water. After the inflammation subsides, first try to separate the foreskin by hand, local cleaning treatment, and consider circumcision when it is not effective. If the inflammation is difficult to control, a dorsal circumcision should be made to facilitate drainage.
The purpose of treatment of embedded prepuce is to restore the embedded foreskin to its original position. Early embedded foreskin edema is light, you can first apply techniques to make foreskin recovery.
Method: After local disinfection, use a thick needle to puncture the foreskin in several places, squeeze out the edema fluid, apply liquid paraffin in the coronal groove, hold the foreskin of the penis body with the middle and index fingers of both hands, squeeze the head of the penis with the two thumbs, push the head of the penis into the foreskin sac to reset it. If the manual reset fails, a circumcision of the narrow ring of the foreskin should be done.
Surgical method: The stenosis ring is cut longitudinally with a small-headed circular knife in the dorsal median of the penis, 1.0-1.5cm long, with transverse interrupted sutures, and the incision is not sutured when severe infection is combined. If the situation permits, circumcision should be done as far as possible when surgically resetting the embedded foreskin. Otherwise, after the local inflammation and edema have subsided, circumcision will be done at a later date.