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in brief

In Brief

The Michael R. Lawless, MD skin and results in adhesionlike tion of steroid cream for up to 6 weeks Wake Forest University Health attachment of the foreskin to the glans in combination with gentle attempts to Services from birth throughout most of the first retract the foreskin is an effective non- Winston-Salem, NC postnatal year. This attachment is, in surgical treatment reported to be suc- essence, a physiologic that cessful in up to 75% to 85% of cases of inhibits retraction of the foreskin. The phimosis. Surgical treatment includes Author Disclosure tissue layer serves as an effective bar- or preputial plasty (dorsal Drs Lawless and Serwint did not rier against invading pathogens and slit). disclose any financial relationships accumulation of smegma. External occurs when a some- relevant to this In Brief. cleansing of the with mild soap what tight foreskin is retracted and and water is the only genital care cannot be returned to its usual position required in the first year after birth. because of its constricting effect on the Treatment of Phimosis with Topical Forceful retraction of the foreskin prior shaft of the penis. The resulting venous Steroids in 194 Children. Ashfield to natural separation of the epithelial stasis causes painful swelling of the JE, Nickel KR, Siemens DR, et al. layers is painful to the infant. In addi- shaft and glans penis distal to the J Urol. 2003;169:1106–1108 tion to pain, traumatic foreskin retrac- constriction, further impeding replace- Paraphimosis: Current Treatment Op- tion may cause bleeding followed by an ment of the foreskin. This condition tions. Choe JM. Am Fam Physician. even stronger adherence of the foreskin constitutes a urologic emergency and 2000;62:2623–2626 to the glans. requires an immediate attempt to re- Circumcision Policy Statement. American Academy of Pediatrics, Separation of the epithelial layers lieve foreskin constriction. If the con- Task Force on Circumcision. continues over the first few years after striction is not relieved, obstruction of Pediatrics.1999;103:686–693 birth. During this process of natural the urinary tract could lead to imped- A Cost-Utility Analysis of Neonatal lysis, small amounts of smegma may ance of voiding or ischemia, and en- Circumcision. Van Howe RS. Med accumulate and become entrapped. gorgement could lead to gangrene of Decis Making. 2004;24:584–601 This represents neither a pathologic the distal portion of the penis. Sus- state nor a health risk to the child. With tained circumferential pressure on the The foreskin or prepuce is the fold of complete lysis of the epithelial layers, distal swelling of the penis combined skin that covers the head of the penis. the foreskin usually is retractile. Studies with lubrication and forward traction of At about 8 to 9 weeks’ gestation, skin report the foreskin to be retractile in the foreskin may relieve the paraphi- from the body of the penis begins to 90% of uncircumcised males by about mosis. A topical anesthetic or a penile grow forward. It eventually covers the age 3 years. nerve block may be needed to minimize glans penis, often with as much as 1 cm Phimosis refers to the inability to the pain. If manual attempts at relief of of redundant foreskin extending beyond retract the foreskin. This condition can the paraphimosis are not successful, an the glans. The skin on the shaft of the result from a small opening of the emergency dorsal slit of the foreskin is penis becomes keratinized, while the foreskin that prevents retraction or needed to avoid ischemic injury to the surface of the foreskin adjacent to the from adherence of the foreskin to the penis. glans is lined by squamous penis due to chronic inflammation. The Other pathologic states involve in- similar to mucosa of the mouth, vagina, precise age at which the condition is flammation or infection of the foreskin and esophagus. The foreskin has a pro- considered pathologic varies widely known as posthitis. Inflammation of the tective function by internalizing the among different cultures. Treatment of adjacent glans penis is known as bala- glans penis and urethral meatus, similar phimosis may be recommended for boys nitis. Both tissues may be inflamed to the eyelid covering the globe of the 4 to 5 years of age in some countries; in simultaneously. These conditions can be eye. others, the condition is followed years improved by good genital hygiene or by Incomplete separation of the adja- longer before considering a medical or antimicrobial therapy if a bacterial or cent epithelial layers between the fore- surgical intervention. Topical applica- fungal infection of the tissue is sus-

Pediatrics in Review Vol.27 No.12 December 2006 477 Downloaded from http://pedsinreview.aappublications.org/ by 1021292 on February 27, 2020 in brief

pected. In hypospadias, which results sexual pleasure are some of the de- paraphimosis by relieving the edema. from failure of complete fusion of the bated issues. Even the most superficial Granulated sugar also has been shown developing penis, the foreskin covers analysis of the literature addressing the to be effective by creating an osmotic only the dorsal surface of the penis. This benefits and risks of circumcision is gradient that allows fluid transfer away “dorsal hood” represents failure of the beyond the scope of this brief treatise. from the edematous prepuce. Either of foreskin to fuse and serves as a visual The American Academy of Pediatrics these procedures should be performed clue for the presence of hypospadias. Task Force on Circumcision Policy by a health-care professional who has Strongly diverse opinions abound as Statement and the article on cost- experience with such techniques. Cir- to the medical benefits and liabilities to utility of circumcision are good starting cumcision is indicated at a later date to the infant and adult male of retaining points for a review of those data. avoid future recurrence. the foreskin versus losing it through circumcision. Risk of urinary tract in- Comment: As mentioned, paraphi- fection, , cancer of the mosis is a urologic emergency. Hyal- cervix in a sexual partner, sexually uronidase, injected into the prepuce, Janet R. Serwint, MD transmitted diseases, and degree of has been used as a strategy for relief of Consulting Editor, In Brief

In Brief

Hematoma of the Nasal Septum Roytesa R. Savage, MD Minor nasal trauma occurs in children trauma to the nose, such as a fight, a Christina Valvich, MD almost daily. A serious but rare compli- fall, a hit in the face with a ball, or a Brody School of Medicine cation of nasal or facial trauma is a collision with an object. For young chil- East Carolina University nasal septal hematoma, which is a col- dren who have sustained trauma, child Greenville, NC lection of blood between the cartilage abuse also must be considered. The and the bony nasal septum. most common presenting symptom is The nose has a very rich blood sup- nasal obstruction, but pain, rhinorrhea, Author Disclosure ply from the external and internal ca- and fever also may occur. The presence Drs Savage, Valvich, and Serwint did rotid . The Kisselbach plexus is of fever must increase suspicion of not disclose any financial the blood supply for the anteroinferior nasal septal abscess. relationships relevant to this In Brief. nasal septum, which is the location of Intranasal examination is impera- most episodes of epistaxis. When the tive. The septum appears boggy (or nose is subjected to trauma, the blood doughy) and swollen. Pain may be Septal Hematoma and Abscess After vessels may tear, leading to blood col- present that is localized to the septum Nasal Trauma. Lopez M, Liu J, Hart- ley B, Myer C. Clin Pediatr. 2000;39: lection in the space between the carti- along with tenderness to palpation of 609–610 lage and the perichondrium. If the the nose tip. The nasal mucosa has blue, Complications of Nasal and Sinus In- blood continues to collect, the cartilage purple, or cherrylike swelling over the fections. Hengerer A, Klotz D. In: blood supply can be obstructed, causing septum that often obstructs airflow. Bluestone C, Stool SE, Alper C, et al, pressure-induced avascular necrosis of The hematoma may be unilateral or eds. Pediatric Otolaryngology. 4th ed. the nasal cartilage. bilateral, with bilateral lesions being Vol. 2. Philadelphia, Pa: Saunders; A hematoma of the nasal septum more common in the presence of a 2001:1021–1022 may present immediately or, more com- septal fracture. If an intranasal vaso- Nasal Septal Hematoma. Ginsburg C. monly, several days after the initial constrictor has been given to the pa- Pediatr Rev. 1998;19:142–143 Hematoma and Abscess of the Nasal injury. In one study, the time of presen- tient, the mass remains the same size Septum in Children. Canty PA, tation ranged from 1 to 14 days after and is fluctuant when probed. Berkowitz R. Arch Otolaryngol Head the trauma (mean, 5.9 days). Many Management of a nasal septal he- Neck Surg. 1996;122:1373–1376 children or parents recall specific matoma includes consulting an otolar-

478 Pediatrics in Review Vol.27 No.12 December 2006 Downloaded from http://pedsinreview.aappublications.org/ by 1021292 on February 27, 2020 The Foreskin Michael R. Lawless Pediatrics in Review 2006;27;477 DOI: 10.1542/pir.27-12-477

Updated Information & including high resolution figures, can be found at: Services http://pedsinreview.aappublications.org/content/27/12/477 References This article cites 4 articles, 1 of which you can access for free at: http://pedsinreview.aappublications.org/content/27/12/477.full#ref-li st-1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://classic.pedsinreview.aappublications.org/cgi/collection/fetus:n ewborn_infant_sub Urology http://classic.pedsinreview.aappublications.org/cgi/collection/urology _sub Genitourinary Disorders http://classic.pedsinreview.aappublications.org/cgi/collection/genitou rinary_disorders_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: https://shop.aap.org/licensing-permissions/ Reprints Information about ordering reprints can be found online: http://classic.pedsinreview.aappublications.org/content/reprints

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The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/27/12/477

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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