9/16/2015

The Pediatric Penis: A maintenance guide from birth through puberty

John Gatti, MD Pediatric

Disclosure • I have no financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

The Newborn Genital Exam

• Scrotum/Inguinal Canal – Well formed – Palpable testes – Hernia or hydrocele

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The Newborn Genital Exam

•Penis – configuration • deficient? – Meatus • Visible • Orthotopic • large?, figure of “8” – (curvature) • Ignore the Raphe

The Debate

Yes No • UTI risk • Comp Risk (1%) – 23% lifetime • Sensation/ Function – 10-fold first year of life • Insurance Coverage? • STD Risk – HIV (50% reduction) Cultural Preferences – HPV (40% reduction) • Penile Cancer • Cost/Risk if done later Morris, J Urol, 2013

Circumcision Debate

• Revised AAP Policy Statement of 2012… – Inform parents in non-biased manner – Support parental choice – Decision remains in parents hands

Pediatrics, 2012

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Contraindications to Newborn Circumcision

• • Severe Chordee • Epispadias

EPISPADIASHYPOSPADIAS CHORDEE

Relative Contraindications to Newborn Circumcision

• Large Pre-pubic Fat Pad • Penoscrotal Webbing • Prematurity/ • Large Hernia/Hydrocele

Mayer 2003

Dilemma - MIP Variant

• MIP = Megameatus Intact Prepuce – Glanular Hypospadias with Normal Foreskin MIP Variant – Generally Discovered After the Dorsal Slit

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MIP – What to do?

• AAP says • Gatti says, “STOP!” “Circ away, my friend!”

Why the discrepancy?

• Pediatric guidelines recommend aborting any planned circumcision and to refer to a pediatric urologist for repair between the ages of 6-12 months.

– Timing: complications increase as children age – Accurate diagnosis: increased cost of a free-hand circumcision versus neonatal circumcision. • 10-fold + cost increase – Risk of General Anesthesia in Infancy

1. Elder, J. Nelson Textbook of Pediatrics 19th Edition. Saunders, 2011. 2. Schoen EJ, et al. J Urol 175: 1111-5, 2006.

Hypospadias Referrals 2011

Diagnosis

100% 90% 80% 70% 60.58% 60% 50% Diagnosis 40% 26.92% 30% 12.50% 20% 10% 0% Hypospadias Other Normal

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So what?

• 40% of patients had NO hypospadias • 8 of 11 with hypospadias had been circ’d – Uneventful operative hypospadias repair • 12 of 14 normal required OR circ – Increased cost – General instead of local anesthetic – Hypospadias repair in the setting of distal hypospadias was not affected by prior neonatal circumcision • 12 with Congenital Chordee/Torsion – OR repair, but did they need it?

Recommendations Within Reason:

• Hooded foreskin and obvious hypospadias – Refer • Normal foreskin and questionable hypospadias – Finish the circumcision • Megameatus discovered after dorsal slit – Dealer’s choice

Circumcision Complications

Hematoma

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Circumcision Complications

Concealed Penis

Circumcision Complications

Webbed Penis

Circumcision Complications Glans Amputation with Clamp Device

• Circumcision Injury – Glans is an excellent graft bed – Performed primary anastomosis with catheter

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Circumcision Complications

Thermal Injury from Cauterization of Clamp

Ultimately Resulted In Penile Necrosis

Circumcision Complications

Glans Prolapse Through Plastibell

Ring Cutter to Remove Plastibell

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Foreskin Care: Prepuce 101

• Gently retract foreskin to limit when cleaning – Majority of foreskin retracts by age 5 • Use Betamethasone for Pathologic – 0.05% 2-3x/day x 1-2 months – If fails or recurrs • Repeat or consider circumcision

Adhesions

• Can be lysed in office using topical anesthetic – Dense skin bridges: • Clamped and lysed using topical anesthetic • Skin tags left by loose plastibell string handled similarly – Compress base of penis – Apply abx ointment to subcoronal sulcus 3x/d x 7d • Can see the purple hue of the coronal margin? – leave these filmy adhesions alone

Penile Trauma

• Common Injuries

– Falling toilet seat • Supportive mgt – Zipper trauma • Break median bar – Strangulation by human hair •Nair

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Penile Trauma

• Uncommon Injuries • 17 y/o M with GSW to penis • debrided with EE anastomosis • Testis & Cord intact

Scrotal Trauma • Intentional scrotal trauma on the rise!

Intentional scrotal injuries

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10

8

6

4 Number of reported incidences reported of Number

2

0 1 2006 2007 2008Year 2009 2010

Arther, 2011

Intentional Scrotal Trauma

• 17 yr old • Hit in groin by brother with a “Timberland” boot • Presents to ED 4 days later

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Meatal Stenosis: The Over-diagnosis • Does the meatus look small? Most do! – Parents will describe • Dorsally (or transversely) deviated, pinpoint stream – “Has to stand on his head to hit the toilet” – “Must point it straight down” – Without these, explore voiding/stooling pattern – Usually seen at time of toilet training – Only s/p circumcision (abrasion vs. ischemic) – Treatment- meatotomy (OR vs. Office)

Priapism

• Rare in absence of Sickle Cell Disease – Painful erection lasting > 4 hours – Surgical Emergency: • Team approach with Hematology – Hydration, oxygenation, pain/anxiety management – Surgical therapy with corporal irrigation, vasoconstrictors, shunt – Despite treatment, long-term erectile dysfunction is common – Can see with hypercoagulable states • Lymphoma, leukemia

Priapism

• High Flow Priapism (Non-Emergent) – Usually after trauma • Arterovenous Fistula – Painless – Treatment: • None • Vasoconstrictors (chronic) • Embolization – Concerns for erectile dysfunction

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Erectile Dysfunction

• Rare in Pediatrics • Large Psychogenic Component • Evaluation Deferred into Adulthood with Adult Urologists – Non-invasive imaging (Doppler US) – Treatments: • Phosphodiesterase Inhibitors • Penile Prostheses

Miscellaneous

• Penile Pain – Largely associated with voiding dysfunction • Chordee – Late presenting – followed through puberty • Various Skin Lesions • Suture Sinus Tracts • Inclusion Cysts at Circumcision Scar or Meatus • Pearls at raphe or glans margin

GOMCO CIRC: Assessment

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GOMCO CIRC: Technique

Take down the Frenulum

SST Deformity

GOMCO CIRC: Technique

Mark the Incision

Important!

GOMCO CIRC: Technique

Dorsal Slit

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GOMCO CIRC: Technique

•Size to cover 2/3+ of glans

•Most newborns 1.3-1.45

• Clamp and bell MUST match

GOMCO CIRC: Technique

GOMCO CIRC: Technique

Personal fan of Skin Glue

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Thank You!

Questions?

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