C To Circ or Not to Circ: Indications, O N Risks, and Alternatives to T I N in the Pediatric U I Population with N G Barbara Steadman Pamela Ellsworth E D gyptian mummies and Circumcision, the removal of the , is perhaps the oldest iden- U wall carvings offer some tified and currently the most frequently performed elective surgical C of the earliest recorded procedure for males throughout the world. Neonatal circumcision history of circumcision may be performed for medical, cultural, or religious reasons. A review A Edating over 15,000 years ago. of risks and benefits of circumcision, individual indications for cir- T Ritualistic circumcision has been cumcision, as well as both medical and surgical alternatives to cir- I carried out in West Africa for cumcision in the pediatric population with phimosis are presented. O over 5,000 years and in the The intent is to offer providers and parents current information that N Middle East for at least 3,000 will assist them in making a responsible decision about pediatric cir- years (Warner & Strashin, 1981). cumcision. Muslims incorporated ritualistic as a pubertal rite of passage into manhood among Soon the list of medical indica- Neonatal Circumcision: older boys. tions grew, and physicians in The World’s Most The transformation of this England and America began to Controversial Operation ancient ritual into a routine med- offer circumcision for masturba- ical operation began late in the Today, approximately 25% of tion, headache, strabismus, rectal men globally are circumcised for 19th century. This was primarily prolapse, asthma, enuresis, and the result of several published religious, cultural, medical, or gout (Gollaher, 1994). By the parental choice reasons (Moses, works by prominent physicians early 20th century, there was of the time. They believed that Bailey, & Ronald, 1998). They are near universal agreement among largely concentrated in the constriction of the glans by the physicians that circumcision prepuce led to nervous irritation United States, Canada, countries should be done on a routine in the Middle East and Asia with in other organ systems. Several basis. published works cited “reflex Muslim populations, and large Rates of circumcision began portions of Africa. Circumcision neuroses,” puzzling syndromes to drop in Britain in 1948, when with no somatic explanation, as is a widely observed religious a nationalized health care system practice performed almost uni- being caused by constriction of analyzed cost versus benefit. the glans (Alanis & Lucidi, 2004). versally among Jewish and Circumcision is currently avail- Islamic societies. Jewish males able through National Health are usually circumcised on the Barbara Steadman, MS, NP, is a Insurance for medical indica- 8th day after birth in a ceremony Urology Nurse Practitioner, UMass tions only. In the early 1970s, called the Bris Milah. Memorial Medical Center, Worcester, both the Australian and the A review of the literature MA. Canadian Pediatric Societies fol- about circumcision yields a mul- lowed, stating that routine titude of information that is Pamela Ellsworth, MD, is a Pediatric neonatal circumcision was not solidly anti or pro circumcision. Urologist, UMass Memorial Medical medically indicated. Despite The pro-circumcision argument Center, Worcester, MA. these changes, rates of circumci- is that infant circumcision pro- sion remained high in the United vides a valid prevention against Note: CE Objectives and Evaluation States. Form appear on page 197. infections and diseases. The

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 181 C Table 1. O Circumcision Incidence Percentage Rate by Region N Region Year T 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 I N Northeast 69.6 68.3 66.5 68.3 68.0 65.4 64.6 66.9 68.9 64.7 U North Central 80.1 79.8 80.9 81.6 82.9 81.4 81.4 81.0 81.0 77.8 I South 64.7 66.1 63.6 64.5 64.6 64.1 63.9 62.5 64.0 57.7 N West 34.2 42.6 36.3 38.0 38.3 36.7 37.3 40.9 32.6 31.4 G All Regions 62.7 64.1 60.2 62.8 63.2 61.5 62.4 63.1 60.1 55.9

E Source: Bollinger, 2005 D U C emphasis is on an increased risk chological problems interfere scientific evidence demonstrates of cancer and AIDS, arguing that with sexual health and well- potential medical benefits of A a full circumcision is the best being. Emphasis should be newborn male circumcision; T prevention over partial proce- placed upon individual solutions however, these data are not suffi- I dures or medical treatment to individual problems, depend- cient to recommend routine (Stuart, 2005). ing upon the degree of severity of neonatal circumcision” (Task O It is the general feeling of the phimosis, variation in cul- Force on Circumcision, 1999, p. N anti-circumcision advocates that ture, preferences, etc. Parents, 693). from an ethical or moral stand- who have the responsibility of point, routine infant circumci- making the decision on behalf of Epidemiology sion is an infringement of per- their sons should be made aware Circumcision today is uncom- sonal rights. Terms such as “bar- of the most recent literature con- mon in Asia, South America, baric” and “mutilation” are fre- cerning the potential health ben- Central America, and most of quently heard in association with efits and risks as well as alterna- Europe. In Canada, 48% of boys circumcision. A great majority of tives to circumcision. are circumcised; in the United anti-circumcision supporters are In the United States, the Kingdom, the number is approxi- extremists, and are not only American Academy of Pediatrics mately 24% (Blecher, 2001). against routine infant circumci- (AAP) (1971) has vacillated on its More recent surveys show a sion but also any form of circum- stance regarding circumcision. In continuing decline in the inci- cision or operation. Anti-circum- 1971, the American Academy of dence of circumcised males in cision proponents maintain that Pediatrics Task Force on Great Britain, and predict only phimosis is a rarity, occurring at Circumcision concluded that 1.5% of boys born today will be a frequency of only 1%. “there are no valid medical indi- circumcised by their 15th birth- However, recent literature cations for circumcision in the day if current trends continue reports that between 2.4% and neonatal period” (AAP, 1977, p. (Rickwood, 2000). 14% of uncircumcised youths 110). Similar views were Circumcision rates in the experience phimosis (Stuart, expressed in 1975 and 1977. United States vary according to 2005). When new evidence showed that racial, ethnic, and socioeconom- Both extremes suggest rou- circumcision effectively reduced ic factors, as well as geographic tine approaches with no consid- male urinary tract infections region. Whites are considerably eration for appropriate individ- (UTIs) and sexually transmitted more likely to be circumcised ual measures. A complete evalu- diseases, the AAP concluded that than blacks or Hispanics (81% ation and physical examination newborn male circumcision “has vs. 65% or 54%). Over the past of the genitalia and the expertise potential health benefits and 10 years, circumcision rates have in being able to identify any mal- advantages as well as disadvan- declined in Caucasians, Hispanics, formation before puberty is para- tages and risks” (Task Force on and African-Americans, but have mount. In that way, any abnor- Circumcision, 1989, p. 391). increased in Asians and American malities can be monitored, and However, the AAP returned to a Indians. In the United States, the conservative treatment can be more cautious view on routine frequency of circumcision varies initiated before physical and psy- circumcision, stating “existing directly with maternal educa-

182 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 tion, a marker for socioeconomic Figure 1. C status (Laumann, Masi, & Physiologic Phimosis: Normal, Nonretractile O Zuckerman, 1997). Prepuce of Infancy Geographically, circumcision N rates have fluctuated over the T past 10 years. From 2002 to 2003, I declines occurred in all four regions of the United States. N Non-circumcision has been a U norm in the West for more than a I decade. The North Central Region continues to have the N highest incidence of circumci- G sion rates (see Table 1). Overall, it is estimated that E less than 60% of American boys are circumcised at birth. These D rates have changed since the U 1970s, when approximately 90% C of all newborn boys were circum- cised in the United States. A Changes in health care coverage T are likely to contribute further to I the decline of circumcision in the United States. Currently, 13 O states are no longer funding new- N born circumcision through Source: Belman, 1990 Medicaid as of 2004.

Physiologic or Pathologic term, when applied to neonates, Table 2. Phimosis? refers to a physiologic process in Physiologic Preputial As a result of the declining which there may be an inability Retraction neonatal circumcision rate in the to retract the foreskin due to nat- Percentage of United States, pediatricians are urally occurring adhesions Boys Able to seeing more uncircumcised between the prepuce and glans. Age Retract Foreskin males than in the past. Many of The natural shedding of skin these physicians are unfamiliar cells from the foreskin lining and At birth 4% with the normal process of fore- the glans helps in the process of At 6 months 20% skin retraction, and will refer separation of these two struc- these male infants and children tures. The epithelial debris At 3 years 90% to pediatric urologists, recom- which has been shed forms a mending circumcision for phi- white cheesy substance known At 17 years 99% mosis. The term “phimosis” as infant smegma which accumu- Source: Choe, 2005 remains ambiguous to many lates under the foreskin. During health care providers, and has the first few years of life, noctur- been applied to that do nal erections assist with expres- not retract, have preputial adhe- sion of the smegma, promoting physiologic phimosis (see Figure sions to the glans, have a “tight- gradual separation of the foreskin 1). By the age of 3, the foreskin ness” with retraction, are elon- from the glans. can be retracted in 90% of uncir- gated, are redundant, are thick- An infant phimosis has an cumcised boys (Choe, 2005) (see ened or inflamed, have a fibrotic easily recognizable tubular form, Table 2). True phimosis (patho- ring, or have a narrowed orifice. which looks like the trunk of an logic) may occur at any age, and elephant. Normal healthy babies can be caused by several under- Definition will playfully pull the “trunk” lying conditions. Phimosis is a condition in forward, which is a natural way Traumatic tearing of the fore- which the narrowed foreskin for infants to release their epithe- skin. This occurs when well- cannot be retracted. This can be lial adhesions. Approximately meaning parents attempt to physiologic or pathologic. This 96% of male newborns have stretch the naturally occurring

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 183 C Figure 2. stricture. The phimotic ring is O Pathologic Phimosis in a 16-Year-Old Male less elastic than the rest of the with a Scarred Phimotic Ring (arrow) from foreskin; therefore, any difficulty N Previous Recurrent Foreskin Inflammation with retraction is magnified dur- T ing erection. A primary phimotic I ring from birth will stretch; a secondary ring developing later N in life will tighten. U Chronic balanoposthitis. This I defines a recurrent infection of the glans and/or foreskin resulting in N inflammation and scarring. The G thick fibrous scar tissue will not stretch, thus making retraction of E the foreskin impossible. The child may present with burning D and spraying with urination, fre- U quent urination, hematuria, or C urinary tract infection. All of these conditions are A associated with a true phimosis T and will require a medical inter- I vention. O Physical Assessment N The majority of referrals to pediatric urologists for circumci- Source: Belman, 1990 sion are for males with a develop- mentally nonretractile foreskin, and not for a true phimosis. Careful examination helps to adherent foreskin by forcefully and foreskin result. Some young delineate between physiologic pulling back on it on their own, children do not feel comfortable phimosis/developmentally non- or at the recommendation of their discussing these issues with their retractile foreskin and patho- primary care provider. Parents parents, and the phimosis may logic/true phimosis. When exam- may not be aware that it is nor- not be addressed until the onset ining the normal but nonretractile mal for the infant foreskin to be of puberty, when the immobility foreskin, the distal portion of the phimotic at birth, or they may be of the foreskin makes erections foreskin puckers with gentle trac- merely trying to hasten the phys- intensely painful. This pain may tion. The narrowed portion is iologic process. This trauma have an effect on the behavioral proximal to the preputial tip. In could result in lacerations, bleed- habits and psychological atti- the child with true phimosis, gen- ing, and inflammation of the tudes of the child. tle traction on the foreskin results foreskin, with subsequent scar Frenulum breve. This term in a cone-shaped foreskin with a formation and a true phimosis refers to a shortened sheet of fibrotic circular band forming the (see Figure 2). skin underneath the glans which distal and most narrow part of the Persistent infant adhesions. joins the glans to the foreskin. prepuce. Adhesions form when the fore- Because it is not adequate in Thus, when initially faced skin adheres entirely or partially length, the frenulum holds the with a child with a nonretractile to the glans and does not release foreskin forward and bends the foreskin, it is important to take by the age of 3 (see Figure 3). A glans downward, a “tethering into account the age of the child tight foreskin predisposes boys to effect.” During intercourse, the and whether or not there is a recurrent UTIs and , as frenulum can tear, causing pain physiologic or true phimosis. In a urine becomes trapped and bal- and bleeding. child less than 3 to 5 years of age loons underneath the foreskin. Phimotic ring. This ring is a with a physiologic phimosis and Because it is not possible for thin band of tough fibrous tissue no medical indication for circum- these boys to fully retract the which curves over the front of cision, parental support and edu- foreskin to clean thoroughly, the inner foreskin and branches cation should be given. Those recurrent infection of the glans out into the frenulum, forming a children older than 5 years of age,

184 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 Figure 3. The majority of complica- C Pathologic Phimosis with Tiny Preputial tions from circumcision are O Opening (arrow) in a 3-Year-Old Boy minor, the most common being local infections and bleeding. N Meatal stenosis is noted exclu- T sively in circumcised males, and I may be secondary to intraopera- tive vascular injury to the frenu- N lar vessels, or from chronic dia- U per irritation. Meatal stenosis I more commonly can cause deflection of the urine stream, N dysuria, and occult hematuria. G Skin bridges can occur if the sep- arated adhesions are allowed to E come into contact with each other again. Small connecting D bands of tissue between the fore- U skin and glans form skin bridges, C which contribute to pain and penile curvature with erection. A In the last 2 decades, more T attention has been paid to the I neonatal pain experience. Descriptive studies have shown a O relationship between neonatal N Source: Belman, 1990 circumcision and the physiologic responses to pain, including increased heart rate, respiratory rate, and serum cortisol level, Table 3. decreased serum oxygen satura- Risks of Circumcision tion, and decreased vagal tone More Common More Serious (Marshall, 1989). Today, anesthe- sia is safe and effective in reduc- Buried penis Urethral fistula ing the physiologic responses Meatal stenosis Injury to glans and frenulum associated with neonatal pain Meatitis/meatal ulceration Sepsis and local anesthesia is recom- mended for neonatal circumci- Poor cosmesis Penile necrosis/amputation sion. Skin bridges Risk of anesthesia Long-term psychological, Removal of too much/too little tissue Hemorrhage emotional, and sexual adverse effects from male circumcision Source: Heinius, Hansson, & Jarhult, 1993 have been reported in anecdotal accounts, but scientific evidence is lacking. It has been proposed that penile sensation and there- with either a physiologic or true Proposed Health Risks of fore sexual satisfaction is phimosis, are candidates for treat- Circumcision decreased in the circumcised ment. Even in this setting, how- Although circumcision is felt male. Research by Masters and ever, circumcision should be by many to be a simple, effective Johnson (1966), however, showed offered as a first-line option only management for the persistent no tactile differences on the glans to those children with a signifi- nonretractile foreskin, there can of circumcised and uncircum- cant urologic history, such as be significant associated risks cised men. Williamson and recurrent balanoposthitis, recur- requiring additional surgeries for Williamson (1988) examined rent urinary tract infections, or a the neonate. For this reason, par- female attitudes toward male cir- history of congenital urologic ents should be made aware of the cumcision. Eighty-seven percent anomalies such as vesicoureteral possibility of such risks (see of college-aged women expressed reflux. Table 3). preference for pictures of circum-

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 185 C cised penises over uncircumcised STD or HIV infection (Kelly et Most insurance providers in O ones, stating that it “looked sexi- al., 1999). the United States reimburse hos- er” (Williamson & Williamson, Penile cancer. Cancer of the pitals for the inpatient neonatal N 1988, p. 10). Few studies have penis is a rare malignancy, which circumcision procedure; although T investigated the relationship can be prevented by circumci- some individuals argue that the I between male circumcision and sion at birth. The risk is much benefit of neonatal circumcision male or female sexual pleasure. higher in uncircumcised men does not justify the cost (Cadman, N with poor hygiene who do not Gafni, & McNamee, 1984; Chessare, U Proposed Health Advantages consistently retract the foreskin for 1992; Ganiats, Humphrey, Taras, & I Of Circumcision thorough cleaning. Circumcision Kaplan, 1991; Lawler, Bisonni, & An investigation of health later in life does not provide the Holtgrave, 1991; Van Howe, 2004). N benefits of circumcision over the same degree of protection against Wayne (2000) went so far as to G past 70 years has led to a vast col- malignancy (Kaufman, Clark, & point out that neonatal circumci- lection of studies indicating a Castro, 2001). sion fails to meet the Health Care E relationship between circumci- HPV and cervical cancer. Financing Administration require- sion and a reduction in occur- Circumcision was shown to sig- ments for reimbursement, and, in D rences of the following medical nificantly reduce the risk of fact, may be fraudulent. Even in U conditions. penile human papilloma virus those children with persistent C Urinary tract infections. Data infection in men and cervical inability to retract the foreskin or from multiple studies suggest cancer in the female partners of pathologic phimosis, circumci- A that uncircumcised male infants men who practice high-risk sion may not be the most cost- T are as much as ten times more behaviors. A moderate but signif- effective treatment (see Table 4). I likely than circumcised male icant reduction was also noted in infants to develop a UTI in their the general population (Svare, Who Should Be O first year of life (Task Force on Kjaer, & Worm, 2002). Circumcised? Who N Circumcision, 1999). Spach Should Not? (1992) surveyed men in their 30s Circumcision: Cost and There are select groups in who suffered from UTIs. He Reimbursement whom circumcision is warrant- found that urinary infection was Although deemed to be a ed, and other groups in which it three times more likely in those “simple minor inpatient proce- is contraindicated. Indications who were uncircumcised. This dure,” neonatal circumcision has and contraindications are listed suggests that the protective factor a huge economic impact. The in Table 5. of circumcision is not confined cost of an inpatient circumcision to childhood. procedure should be one of the Indications Sexually transmitted disease. factors that a well-educated Recurrent UTIs. A 10-year Research suggests that being provider should take into survey in the United States of uncircumcised is a risk factor for account when providing circum- over 200,000 boys found that herpes, syphilis, and gonorrhea. cision counseling to parents of a although uncircumcised boys The most consistent evidence child with physiologic phimosis. made up less than 20% of the shows an association between Mansfield, Hueston, and Rudy population, they suffered more circumcision and a reduction in (1995) estimated that in-hospital than 75% of the urinary tract the risk of genital ulcerative dis- circumcisions resulted in in- infections, a ten-fold increase ease and HIV. Although circum- creased hospital charges for ser- (Wiswell, 1995). cision may not prevent the occur- vices of $234 million to $527 mil- History of balanoposthitis. rence of genital warts, it makes lion in 1990-1991. Van Howe Boys with phimosis and UTIs them more easily visible by the (1998) reported the cost of a post may develop an infection of the patient and his sexual partner, neonatal circumcision to be prepuce and glans, balanoposthi- thus leading to earlier identifica- $3,009 to $3,241 per case. The tis, with a chronically thickened tion and management (Learman, total cost of an in-hospital, non- and inflamed foreskin and possi- 1999). therapeutic neonatal circumci- ble fissure formation. They fre- HIV. Overall, studies report a sion in the United States has quently experience pain, spray- 2 to 8-fold increased risk of HIV risen from $1,154 in 1992 to ing of urine, urinary retention, infection among uncircumcised $1,869 in 1999, an increase of and ballooning of urine under- males. The strongest protective 62%. The total cost of all hospital neath the foreskin. This is sus- effects are seen in those circum- neonatal circumcisions in the pect of a secondary phimosis due cised before 12 years of age. United States was $2.1 billion in to infection, and is generally dif- Circumcision after 20 years 1999 (Bollinger, 2005). ficult to stretch. The stricture is showed no significant effects on less responsive to medical thera-

186 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 Table 4. Table 5. C Cost Comparison of Absolute Indications and Contraindications for Circumcision O Treatment Strategies for Phimosis Indications Contraindications N Recurrent UTIs Prematurity T Treatment Cost Severe balanoposthitis Family history of bleeding disorders I Circumcision $3,009 – $3,241 Balanitis xerotica obliterans Hypospadias/Epispadias N Preputial plasty $2,515 – $2,580 Vesicoureteral reflux Webbed penis U Micropenis Topical steroid $758 – $800 Congenital spinal anomalies Megalourethra I therapy (infants requiring intermittent Ambiguous genitalia N catheterization) Source: Choe, 2005 Bilateral large hydroceles G Buried/concealed penis Congenital penile lymphedema E D U C pies and frequently requires cir- CIC are another population shown some success. Although cumcision. where circumcision is recom- tissue-sparing procedures may be A Congenital urologic anom- mended. These patients have attempted in these individuals, T alies such as vesicoureteral chronic neuropathic bladders circumcision remains the gold I reflux (VUR). Recurrent urinary and require CIC on a routine standard for BXO. tract infections are problematic basis. Those male infants in O and especially significant for male whom the foreskin is unable to Contraindications N infants diagnosed with vesi- be retracted sufficiently to pass a Prematurity. Premature in- coureteral reflux, since infected catheter may require removal of fants may have multiple anom- urine that flows backward from the foreskin. In addition, the bac- alies, which will need to be the bladder to the kidneys can teria, which comfortably reside addressed as the child develops. progress to pyelonephritis, renal under the foreskin, will easily be In addition, the size of the penis scarring, and renal failure. transmitted up the urinary tract makes circumcision technically Although boys with VUR are rou- several times a day during rou- difficult. tinely placed on antibiotic pro- tine catheterizations, predispos- Family history of bleeding phylaxis, Cascio, Colhoun, and ing to infection. disorders. Bleeding is a compli- Puri (2001) point out that such Balanitis xerotica obliterans cation of circumcision and a prophylaxis in boys with VUR is (BXO). Repeated infections may bleeding disorder would further not effective in reducing the bac- result in a rigid fibrous foreskin increase this risk. terial colonization of the fore- with the changes of BXO, includ- Buried/concealed penis. This skin. Because it is so critical that ing lymphocytic infiltration and is a normal-sized penis that lays patients with reflux remain free basal cell degeneration with atro- hidden in a suprapubic fat pad. of UTIs, removal of the foreskin phy. BXO is a rare skin disease of Buried penis can be congenital or is the recommended treatment unknown etiology that affects can occur as a result of circumci- over foreskin-sparing procedures only 6 of 1,000 males (Parsad & sion (see Figure 4). for these individuals. Saini, 1998). It is usually distin- Bilateral large hydroceles. History of paraphimosis. guished by a ring of hardened tis- These boys should not be cir- Paraphimosis occurs when a sue with extensive scarring, a cumcised due to the risk of tight foreskin is retracted behind whitish color at the tip of the penile concealment. the head of the penis but then foreskin, and edema. The hard- Penile abnormalities, such as cannot be replaced. This is an ening of the tissue prevents hypospadias, epispadias, micrope- emergency, and a temporary sim- retraction of the foreskin and can nis, ambiguous genitalia, mega- ple dorsal slit may be required cause meatal stenosis. Definitive lourethra, and webbed penis. With initially, followed by circumci- diagnosis is reached with biopsy. these conditions, the foreskin may sion at a later date. Conservative treatment by be necessary in order to recon- Infants requiring continuous stretching or the use of cortisone struct the penis at a later date. intermittent catheterization (CIC). ointment has not been very suc- Congenital penile lymphede- Male infants with congenital cessful. More recently, carbon ma. This is a rare disease caused spinal abnormalities requiring dioxide laser treatment has by a congenital abnormality of

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 187 C Figure 4. inhibit the mRNA responsible for O Concealed Penis After Circumcision interleukin-1 formation. These actions of corticosteroids on N arachidonic acid metabolism and T interleukin-1 formation produce I the anti-inflammatory, both early phenomena and late manifesta- N tions, and immunosuppressive U effects. I Second, there is a skin thin- ning effect. Steroids inhibit the N dermal synthesis of gycosamino- G glycans (especially hyaluronic acid) by fibroblasts, resulting in E the loss of ground substance sec- ondary to decrease binding of tis- D sue fluid to the hyaluronic acid. U Consequently, the dermal extra- C cellular matrix is reduced, and collagen and elastin fibers become A tightly packed and rearranged. In T addition, steroids have anti-prolif- I erative effects on the epidermis, resulting in a thin epidermis with O virtual deletion of the stratum N Source: Belman, 1990 corneum (Zheng, Lavker, Lehman, & Kligman, 1984). Clearly, the action of topical steroids goes beyond a lubrication the lymphatic system. Extensive ty to retract the foreskin and, effect. Golubovic, Milanovic, resection of tissue and recon- unlike circumcision, do not Vukadinovic, Rakic, and Perovic struction with skin grafting involve the removal of the entire (1996) demonstrated that use of a necessitates preservation of the foreskin. placebo, Vaseline® ointment, had foreskin. little effect on phimosis compared If there is any question of a Topical Steroid Therapy to use of topical steroids. Forty genitourinary congenital abnor- The mechanism of action of boys with phimosis received either mality, infant circumcision topical steroid therapy has not 0.05% betamethasone cream (20 should be delayed until the child been completely identified. It males) or Vaseline (20 males). can be evaluated by a pediatric appears that steroid cream acts Patients were treated twice daily urologist. through local anti-inflammatory for 4 weeks, and outcomes were mechanisms, rather than through assessed. Good retraction of the Alternative Treatments moisturizing or the mere local foreskin was achieved in 19 of 20 To Circumcision effect of the application itself. patients receiving betamethasone, Since the majority of chil- Prior use of moisturizing agents while only 4 of 20 patients receiv- dren presenting for circumcision alone has failed to produce suc- ing Vaseline were able to retract do not have a medical indica- cessful results. the foreskin. tion, it is important to be aware There are two possible mech- Atilla et al. (1997) evaluated of the alternatives to circumci- anisms involved in the action of the effectiveness of a local non- sion and to counsel parents on steroid cream resulting in the res- steroidal anti-inflammatory oint- the pros and cons of all available olution of phimosis. First, there ment, diclofenac sodium, applied therapies for managing nonre- is an anti-inflammatory and three times a day on 52 children tractile foreskin. A variety of immunosuppressive effect. Ac- with phimosis over a 4-week peri- effective alternatives to circum- cording to Kragballe (1989), corti- od. Twenty phimotic patients cision have been described, costeroids stimulate the produc- treated with petroleum jelly including topical steroid thera- tion of lipocortin. Lipocortin served as controls. Of the 32 pies and several variations of inhibits the activity of phospholi- patients treated with diclofenac, prepuce plasty. All of these ther- pase A2, which releases arachi- 24 responded. Older, thicker, apies have as their goal the abili- donic acid. Corticosteroids also fibrous rings did not respond as

188 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 Table 6. C Success Rate of Steroidal and Nonsteroidal Applications O Total # of N Patients/ T Mean Age of Success I Authors Agent Patient Rate N Jorgensen & Svensson, 1993 0.05% clobetosol proprionate 54/69 70% U Muller & Muller, 1993 0.1% estrogen 30/ * 90% I N Wright, 1994 0.05% betamethasone 139/ * 80% G Dewan et al., 1996 1% hydrocortisone 20/ * 65% Golubovic et al., 1996 0.05% betamethasone 20/4.1 95% E Lindhagen, 1996 0.05% clobetosol propionate 30/ * 89% D Atila, 1997 Diclofenac sodium 32/4.6 75% U C Chu et al., 1999 0.06% betamethasone (nonsteroidal anti-inflammatory) 276/6.7 95% A Monsour, 1999 0.05% betamethasone 25/8.3 95% T Pless, 1999 0.05% betamethasone 91/ * 74% I Orsola et al., 2000 0.05% betamethasone 137/5.4 90% O Ashfield et al., 2003 0.1% betamethasone 228/ * 87% N Ellsworth & Berry, 2005 0.05% betamethasone 59/ * 73%

* Author did not report an age range. well to therapy. Of the 20 patients Patient selection is an impor- Patients with BXO repeatedly in the control group, petroleum tant consideration when choos- did not respond to topical steroid jelly did not improve foreskin ing a topical therapy. Parents are treatment. Topical steroid use retractibility in any of them. instructed to apply a small dab of with BXO may have a role as a Although application of a nons- steroid cream directly to the phi- screening tool to identify those teroidal drug may be preferable, motic ring on a twice a day basis patients with more advanced in some cases, to that of a steroid for up to 1 month. The state of the BXO who would require circum- due to safety, it is clearly not as foreskin, the age of the patient, cision (Fortier, Thomine, Mitro- efficacious for the treatment of the proper application of the oint- fanof, Lauret, & Hemet, 1990). phimosis. ment, and the necessity of pulling Of concern to parents and A study was conducted at the back on the foreskin on a regular providers alike is the degree to University of Massachusetts basis are all important, contribut- which there is systemic absorp- Memorial Medical Center evaluat- ing factors to either the success or tion with the application of a ing success rates of phimotic boys failure of the medication. steroidal topical cream, which receiving 0.05% betamethasone Overall, studies using topical can cause hypothalamic-pitu- cream applied twice daily for 4 creams for phimosis have pro- itary-adrenal axis suppression. weeks. Of 42 patients who duced dramatic results. Efficacy Conditions that enhance cortico- received steroid cream, phimosis figures range from 65% to 95%, steroid absorption include resolved in 24 (73%) and persist- with no significant side effects inflammation, use over a large ed in 9 (27%). Success rates were reported. Betamethasone 0.05% surface area, prolonged use, and highest in the older boys (>10 applied twice a day over a 4- the use of an occlusive dressing. years), and lowest in the 3 to 10 week period has consistently Systemic absorption follow- year age group. Treatment failures shown good results; however, ing corticosteroid application for were noted to be secondary to clobetasol proprionate 0.05%, a phimosis should not be a major poor compliance (Ellsworth & less-potent steroid, is also very concern for parent or provider Berry, 2005). effective (see Table 6). when used appropriately. When

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 189 C Figure 5. ously noted, cosmesis may not be O Dorsal Slit ideal. A dorsal slit incision is a N simple and minimally invasive T procedure. The foreskin is pulled I down and held under mild ten- sion. The dorsal foreskin is dou- N ble clamped at the 12 o’clock U position. The crushed tissue is I then incised. The amount of tis- sue left below the coronal sulcus N should be no more than 1 cm G long to prevent edema, adhe- sions, and, occasionally, paraphi- E mosis. Edges are approximated with absorbable sutures. D The simplicity of this tech- U nique, and, in particular, the C avoidance of the frenular area of Source: Stuart, 2005 the penis, makes it a quick, easy, A and safe operation, with few T complications. Patient dissatis- I faction over cosmetic results has topical steroids are used for phi- sue-sparing surgical techniques been reported, “dog ears deformi- O mosis, the surface area being that can achieve full resolution of ty,” and has been touted to justi- N treated is small, and the diaper phimosis. The underlying surgi- fy more complex procedures, replaces a nonocclusive dressing. cal technique for these proce- which allow for a more natural Golubovic et al. (1996) found that dures is the placement of a longi- appearance to the foreskin (see morning cortisol levels were not tudinal incision in the phimotic Figure 5). significantly elevated in patients ring and closing the incision Full dorsal slit with trans- who received betamethasone transversely in order to increase verse closure. A longitudinal ointment versus controls. the circumference of the pre- incision of a few millimeters is Use of steroid ointments have puce, thereby allowing foreskin made on the dorsal preputial not been extensively studied in retraction. The various tech- skin at the maximum point of children younger than 3 years, and niques described here differ in tension. After the outer preputial should be used with caution. In the physical placement and num- skin has been excised, a white general, children less than 3 years ber of incisions in the foreskin. circular and constricting fibrous are primarily evaluated for a phys- Although single plasties do not ring can be visualized and is cut. iologic phimosis, where watchful yield as good a cosmetic result, The inner preputial skin is then waiting would be the recommen- they are easier to perform than divided and any smegma present dation. Elmore, Baker, and multiple plasties in children. is removed. The frenulum is Snodgrass (2002) evaluated 27 evaluated, and if its point of boys with phimosis, ranging in age Dorsal Slit attachment is close to the ure- from 1 to 31 months (mean 11.3), Simple dorsal slit. A simple thral orifice (frenulum breve), it who were treated with betametha- dorsal slit procedure may be per- is divided. Finally, the longitudi- sone 0.05% cream twice a day for formed as a first stage procedure nal incision is closed with loose 1 month. At 1 month, 74% had in boys with symptomatic phi- transverse absorbable sutures fully retractable foreskins, and an mosis (balanitis, paraphimosis), (Cuckow, Rix, & Mouriquand, additional 18% had fully or when urethral instrumenta- 1994). Bacitracin® ointment is retractable foreskins at 2 months. tion is needed but cannot be per- applied directly on the glans There were no adverse effects, formed because of the phimosis. before the foreskin is returned to even in the younger patients. In such cases, formal circumci- its normal anatomical position. sion is often performed at a later The ointment application pre- Surgical Treatment date. A simple dorsal slit can also vents the formation of new adhe- Although circumcision is be performed as definitive treat- sions between the glans and the regarded as the definitive thera- ment for phimosis in families inner foreskin. Parents and chil- py for pathologic phimosis, pre- who request a foreskin-sparing dren are instructed to move the puce plasties are alternative tis- procedure. However, as previ- foreskin back and forth twice a

190 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 day for a few weeks, along with the other, the less-invasive pre- interrupted sutures placed C application of ointment, to pre- puce plasty. Twenty percent of obliquely in the middle of each O vent adhesion formation. the males who underwent cir- incision. This method of prepuce plas- cumcision required an overnight The proposed advantage of N ty has been associated with an hospital stay, 14% had anesthetic this technique is that a slight T edematous and hypertrophied complications, and 6% required rotation and shortening of the I ventral prepuce and a poor cos- re-operation for bleeding. None prepuce is achieved which is metic result. As a result, there of the prepuce plasty group equally distributed around the N have been several variations required re-operation and no whole circumference of the U developed in an attempt to main- bleeding problems were noted, penis, providing improved I tain simplicity of procedure, yet with only 8% requiring an cosmesis. In addition, three par- achieve better cosmetic results. overnight stay (Van Howe, 1998). allel, displaced suture lines are N Lateral preputial plasty. This more likely to prevent re-stenosis G Two Comparative Studies operative variant to the full dor- than an almost continuous ring Of Circumcision and Full sal slit was described by Lane of transverse scars. E Dorsal Slit and South in 1999. Thirty In a study of 197 boys who Saxena, Schaarschmidt, Reich, patients underwent a lateral pre- underwent triple incision plasty, D and Willithal (2000) report a 13 puce plasty. In this procedure, two had early complications of U year experience with 2,554 the foreskin was retracted, the bleeding and infection. Five C patients with nonretractile fore- fibrous ring was identified, and patients had unsatisfactory skin at the Pediatric Surgical two laterally placed longitudinal results resulting from re-stenosis, A University Clinic in Munster, incisions, one on each side of the most likely as a result of not T Germany. Dorsal slit was the penis, were made directly over retracting the foreskin after I technique of choice performed in the fibrous band. The defect was surgery, and subsequently under- 2,177 patients, circumcision in then closed transversely. went circumcision. Eighty-four O 73 (primarily at the request of the Postoperatively, one patient percent of parents, however, N parents frequently for religious went on to circumcision sec- were satisfied with the function reasons, and, in two cases, sec- ondary to wound infection. The and 80% reported a good cosmet- ondary to BXO), and preputial remaining 29 reported no postop- ic outcome (Wahlin, 1992). adhesiolysis was sufficient to erative problems. Lane and Pascotto/Giancotti preputial retract the foreskin in 284 South (1999) reported high plasty. Pascotto and Giancotti patients. patient satisfaction. Advantages (1998) described a modification The dorsal slit with trans- to this procedure were attributed to the triple incision preputial verse closure procedure resulted to (a) the lateral placement of the plasty described by Wahlin in satisfactory aesthetic results, incisions, which are thought to (1992). Twenty-two children an extremely low rate of postop- provide improved cosmesis over underwent a triple incision erative complications, 1.8% min- the dorsal approach, and (b) the preputial plasty, adding frenulo- imal to mild edema, with a recur- technique avoids the frenular tomy and two more incisions rence rate of only 0.8% in this area of the penis, thereby reduc- between the previously de- series. Cosmetically, unaccept- ing time and risk. scribed three incisions, which able foreskin due to long inci- Triple incision plasty. This are left to heal spontaneously. sions was documented in only procedure, one of several vari- Followup evaluations at 6 to 24 0.27% of the cases. In the cir- ants of the dorsal slit, was origi- months showed good cosmetic cumcision group, mild to severe nally described by Welsh in 1936 results with no recurrence in all edema was reported in 38.4%, (Fischer-Klein & Rauchenwald, 22 children. mild bleeding in 6.8%, and a 2003), and was improved upon La Vega slit (ventral slit). longer hospital stay in 19.2%. by Wahlin (1992). During this Dean, Ritchie, and Zaontz (2000) Two patients returned to the procedure, the prepuce is retract- described treatment of eight operating room for revision after ed until the stenotic ring is patients in the Dominican bleeding. In comparison, fewer exposed. Three longitudinal full- Republic with severe phimosis complications were associated thickness skin incisions are with a self-described variant of with dorsal slit versus circumci- made across the stenotic ring the dorsal slit procedure. This sion with edema (1.8% vs. down to the inner preputial procedure allowed for preserva- 38.4%) and bleeding (0.1% vs. layer, equally distributed over tion of the appearance of an 6.8%). the dorsal, left, and right circum- intact foreskin, which is cultural- Another study reviewed two ferences of the penile shaft. With ly important in this country. A similar groups of males, one the foreskin retracted, rhomboid- ventral slit was made, the frenu- undergoing circumcision, and shaped defects are closed with lum was divided, and the sutures

UROLOGIC NURSING / June 2006 / Volume 26 Number 3 191 C were placed in the distal foreskin traumatizing treatment option economical alternative to cir- O to triangulate the slit into a V pat- than conventional circumcision. cumcision for treating phimosis. tern. In all eight males, the oper- Multiple Y-V plasties (the Success rates are quite high, N ative time was less than 10 min- Ebbehoj procedure). Hoffman, especially when patient selection T utes, the foreskins were able to be Metz, and Ebbehoj (1984) is appropriate and parents are I fully retracted, and the appear- described a method in which adequately instructed on appli- ance of the penis was consistent multiple Y-V plasties relieve the cation. In those children in N with that of an intact foreskin. phimosis without resecting any whom topical steroid therapy has U The surgical result was only preputial tissue. Four longitudi- failed, there remains a variety of I apparent with the penis elevated, nal incisions are made in the foreskin-preserving surgical op- thereby exposing the ventral outer layer, incising the edge of tions for treating phimosis. N aspect. There were no initial or the preputial ring. The foreskin is Compared to circumcision, these G late (1 year postoperative) com- then retracted, and the incisions less-invasive techniques are asso- plications. are continued in the inner layer, ciated with lower morbidities E Balloon dilation. He and all four curving a little until they and cost. Furthermore, depend- Zhou (1991) evaluated the effica- reach the neighboring curved ing on the tissue-preserving tech- D cy of balloon dilation in 512 boys incision. Care is taken with the nique used, satisfactory cosmesis U with phimosis, ages 5 months to ventral incision to clear the area is also achieved. C 12 years. Treatment consisted of of the frenulum, thus avoiding Thus, those males who were placing a specially designed bal- excess bleeding. not circumcised at birth now A loon catheter which was gradual- A saw-toothed incision is have medical and surgical T ly inflated. Under local anesthe- made along the circumference. options, which will decrease the I sia, 1% lidocaine topical anes- The Vs of the saw-toothed inci- likelihood of requiring circumci- thesia, the preputial orifice was sion are converted into Ys by lon- sion at an older age. As health O pulled slightly opened with gitudinal incisions in both direc- care providers in the United N curved retractors, a balloon tions. The tips of the flaps are fas- States see more and more uncir- catheter was inserted in place, tened with sutures, transforming cumcised male children, it is and the retractors were removed. each Y into a tall narrow V. This important for these children and The balloon was inflated gradu- procedure takes less than 30 min- their parents to understand the ally until the opening of the fore- utes, and functional and cosmet- natural history of physiologic skin was 3 to 5 mm greater than ic results are excellent (Hoffman phimosis. Additionally, it is the the maximal diameter of the et al., 1984). responsibility of health care glans for a period of 30 seconds. Additional variations to this providers to present the manage- Dilatation was repeated three technique include the Z plasty, a ment options available for the times before the balloon was four V flap repair described by treatment of the persistent nonre- removed. The foreskin was fully Emmett (1982), and helicoid tractile foreskin and/or patholog- retracted several times. Of the plasty performed by Codega, ic phimosis. These options are 512 treated males, 509 were com- Guizzardi, and Di Guiseppe particularly important for those pletely cured after a single bal- (1983). Unfortunately, there is lit- individuals whose religious, cul- loon dilatation. Three patients tle objective data to support the tural, or personal preference is to required two to three applica- claims of excellent results with retain the foreskin. • tions of balloon dilatation to these procedures, and no compli- accomplish foreskin retraction. cation rates are reported. The References Balloon dilation was report- more complex nature of these Alanis, M., & Lucidi, R. (2004). Neonatal circumcision: A review of the ed to be simple and safe, requir- procedures has increased the risk world’s oldest and most controver- ing no sophisticated skills or for complications and has limit- sial operation. Obstetrical and equipment. The success rate was ed their acceptance by specialists Gynecological Survey, 59(5), 379- 99%, in this series, and was rec- in plastic surgery and urology. 395. ommended for males 2 to 4 years American Academy of Pediatrics, Summary Committee on Fetus and Newborn. of age (He & Zhou, 1991). (1971). Standards and recommenda- However, in older children with Although there continues to tions for hospital care of newborn recurrent infection and a fibrotic be considerable debate over the infants. Journal of the American ring, several attempts are neces- merits of circumcision, it is clear Academy of Pediatrics, 5, 110. Ashfield, J., Nickel, K., Siemens, D., sary and the procedure should that preservation of the pediatric Macneily, A., & Nickel, J. (2003). not be performed in the presence foreskin, even in the presence of Treatment of phimosis with topical of inflammation. Balloon dilation phimosis, is a viable option. steroids in 194 children. Journal of appears to be a simple and less- Steroid topical cream is a pain- Urology, 169(3), 1106-1108. less, less-complicated, and more Atilla, K., Dundaroz, R., Odabas, O., Ozturk, H., Akin, R., & Gokcay, E.

192 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 (1997). A nonsurgical approach to Emmett, A.J. (1982). Z-plasty reconstruc- analysis of its medical value. Family C the treatment of phimosis: Local tion for preputial stenosis – A surgi- Medicine, 23(8), 587-593. nonsteroidal anti-inflammatory oint- cal alternative to circumcision. Learman, L.A. (1999). Neonatal circumci- O ment application. The Journal of Australian Journal of Pediatrics, 18, sion: A dispassionate analysis. Urology, 158(1), 196-197. 219-220. Clinical Obstetrics and Gynecology, N Belman, A. (1990). Clinical pediatric Fischer-Klein, C., & Rauchenwald, M. 4(24), 849-861. T urology (3rd ed.) (p. 1018). (2003). Triple incision to treat phi- Lindhagen, T. (1996). Topical clobetasol Philadelphia: Saunders. mosis in children: An alternative to propionate compared with placebo I Blecher, M. (2001). Cutting to the point on circumcision? BJU International, in the treatment of unretractable N circumcision. Retrieved March 7, 92(4), 459-462. foreskin. European Journal of 2006, from www.webmd.com/con- Fortier, B., Thomine, E., Mitrofanof, P., Surgery, 162, 969-972. U tent/article/3609.220 Lauret, P., & Hemet, J. (1990). Lichen Mansfield, C., Hueston, W., & Rudy, M. Bollinger, D. (2005). United States circum- sclero-atrophique preputial de l’en- (1995). Neonatal circumcision: I cision incidence. The Circumcision fant. Annals of Pediatrics (Paris), 37, Associated factors and length of hos- N Reference Library. Retrieved March 7, 673-676. pital stay. Journal of Family Practice, 2006, from www.cirp.org/library/sta- Ganiats, T., Humphrey, J., Taras, H., & 41(4), 370-376. G tistics/USA Kaplan, R. (1991). Routine neonatal Marshall, R.E. (1989). Neonatal pain asso- Cadman, D., Gafni, A., & McNamee, J. circumcision: A cost-utility analysis. ciated with caregiving procedures. (1984). Newborn circumcision: An Medical Decision Making, 11(4), Pediatric Clinics of North America, E economic perspective. Journal of 282-293. 36, 885-903. Canadian Medical Association, 131, Gollaher, D.L. (1994). From ritual to sci- Masters W., & Johnson, V. (1966). Human D 1353-1355. ence: The medical transformation of sexual response. Boston: Little, U Cascio, S., Colhoun, E., & Puri, P. (2001). circumcision in America. Journal of Brown & Co. Bacterial colonization of the prepuce Social History, 28, 5-36. Monsour, M. (1999). Medical manage- C in boys with vesicoureteral reflux Golubovic, Z., Milanovic, D., ment of phimosis in children: Our A who receive antibiotic prophylaxis. Vukadinovic, V., Rakic, I., & Perovic, experience with topical steroids. The Journal of Pediatrics, 139(1), 160- S. (1996). The conservative treat- Journal of Urology, 162(3), 1162- T 162. ment of phimosis in boys. British 1164. Chessare, J. (1992). Is the risk of urinary Journal of Urology, 78(5), 786-788. Moses, S., Bailey, R., & Ronald, A. (1998). I tract infection really the pivotal issue? Heinius, J., Hansson, J., & Jarhult, J. Male circumcision: Assessment of O Clinical Pediatrics, 31(2), 100- 104. (1993). Phimosis – Ett overvarderat health benefits and risks. The Choe, J. (2005). Phimosis, adult circumci- problem? Lakartidningen, 90, 4107. Journal of Sexual Health and HIV, N sion and buried penis. Retrieved He, Y., & Zhou, X. (1991). Balloon dila- 74(5), 368-373. March 7, 2006, from http://www. tion treatment of phimosis in boys. Muller, I., & Muller, H. (1993). Eine Neue emedicine.com/med/topic2873.htm Chinese Medical Journal, 104(6), conservative Therapie der phimose. Chu, C., Chen, K., & Diau, G. (1999). 491-493. Monatsschr Kinderheilkd, 141, 607- Topical steroid treatment of phimosis Hoffman, S., Metz, P., & Ebbehoj, J. (1984). 608. in boys. Journal of Urology, 162(3), A new technique for phimosis: Orsola, C., Caffaratti, J., & Garat, J. (2000). 861-863. Prepuce-saving technique with mul- Conservative treatment of phimosis Codega, G., Guizzardi, D., & Di Guiseppe, P. tiple Y-V plasties. British Journal of in children using a topical steroid. (1983). Helicoid plasty in the treat- Urology, 56, 319-321. Urology 2000, 56(2), 307-310. ment of phimosis. Minerva Chirugica, Jorgensen, E., & Svensson, A. (1993). The Parsad, D., & Saini, R. (1998). Oral 38, 1903-1907. treatment of phimosis in boys with a stanozolol in lichen sclerosis et Cuckow, P., Rix, G., & Mouriquand, P. potent topical steroid (clobetasol atrophicus. Journal of American (1994). Preputial plasty: A good alter- proprionate 0.05%) cream. Acta Academy of Dermatology, 38(2), native to circumcision. Journal of Dermato-Verereologica, 73(1), 55-56. 278-279. Pediatric Surgery, 29, 561-563. Kaufman, M., Clark, J., & Castro, C. Pascotto, R., & Giancotti, E. (1998). The Dean, G., Ritchie, M., & Zaontz, M. (2000). (2001). Neonatal circumcision: treatment of phimosis in childhood La Vega slit procedure for the treat- Benefits, risks, family teaching. The without circumcision: Preputial ment of phimosis. Journal of Urology, American Journal of Maternal/Child plasty. (1998). Minerva Chirugica, 55(3), 419-421. Nursing, 26(4), 197-201. 53(6), 561-565. Dewan, P., Tieuh, H., & Chieng, B. (1996). Kragballe, K. (1989). Topical corticos- Pless, T. (1999). Topical steroids in the Phimosis: Is circumcision necessary? teroids: Mechanism of action. Acta treatment of phimosis in children. Journal of Pediatric Child Health, 32, Dermatovenereologica, 69, 7-10. Ugeskr Laeger, 161(47), 1162-1164. 285-289. Kelly, R., Kiwanuka, N., Wawer, M.J., Rickwood, A. (2000). Towards evidence Ellsworth, P., & Berry, A. (2005). Serwadda, D., Sewankambo, N.K., based circumcision of English boys: Acceptance and success of topical Wabwire-Mangen, F., et al. (1999). Survey of trends in practice. 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UROLOGIC NURSING / June 2006 / Volume 26 Number 3 193 C Svare, E., Kjaer, S., & Worm, A. (2002). Wahlin, N. (1992). “Triple incision plas- Zheng, P., Lavker, R., Lehman, P., & Risk factors for genital HPV DNA in ty”. A convenient procedure for Kligman, A. (1984). Morphologic O men resemble those found in preputial relief. Scandinavian investigations on the rebound phe- women: A study of male attendees at Journal of Urology and Nephrology, nomenon after corticosteroid- N a Danish STD clinic. Sexual 26(2), 107-110. induced atrophy in human skin. T Transmission and Infection, 78, 215- Warner, E., & Strashin, E. (1981). Benefits Journal of Investigative Derma- 218. and risks of circumcision. Canadian tology, 82, 345-352. I Task Force on Circumcision of the Medical Association, 125, 967- 976. N American Academy of Pediatrics. Wayne, E. (2000). Focus on the foreskin, (1989). Report of the task force on not its destruction. Clinical U circumcision. Pediatrics, 84(4), 388- Pediatrics, 39(1), 65. CE test located on page 197. 391. Williamson, M., & Williamson, P. (1988). I Task Force on Circumcision of the Women’s preferences for penile cir- N American Academy of Pediatrics. cumcision in sexual partners. (1999). Circumcision policy state- Journal of Sex Education Therapy, G ment. Pediatrics, 103(3), 686-693. 14, 8-12. Need CE Credit? Van Howe, R. (2004). A cost-utility analy- Wiswell, T. (1995). Neonatal circumci- sis of neonatal circumcision. sion: A current appraisal. Pediatrics, Visit the “Education” E Medical Decision Making, 24, 584- 1(2), 1-7. 601. Wright, J. (1994). The treatment of child- section at D Van Howe, R. (1998). Cost effective treat- hood phimosis with topical steroid. U ment of phimosis. Pediatrics, 102(4), Australian and www.suna.org C 43. Journal of Surgery, 64, 327-328. A T I O N

194 UROLOGIC NURSING / June 2006 / Volume 26 Number 3