9/16/2015 The Pediatric Penis: A maintenance guide from birth through puberty John Gatti, MD Pediatric Urology 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 1 9/16/2015 The Newborn Genital Exam •Penis – Foreskin configuration • deficient? – Meatus • Visible • Orthotopic • large?, figure of “8” – Chordee (curvature) • Ignore the Raphe The Circumcision 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 2 9/16/2015 Contraindications to Newborn Circumcision • Hypospadias • Severe Chordee • Epispadias EPISPADIASHYPOSPADIAS CHORDEE Relative Contraindications to Newborn Circumcision • Large Pre-pubic Fat Pad • Penoscrotal Webbing • Prematurity/ Micropenis • 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 3 9/16/2015 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 4 9/16/2015 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 5 9/16/2015 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 6 9/16/2015 Circumcision Complications Thermal Injury from Cauterization of Clamp Ultimately Resulted In Penile Necrosis Circumcision Complications Glans Prolapse Through Plastibell Ring Cutter to Remove Plastibell 7 9/16/2015 Foreskin Care: Prepuce 101 • Gently retract foreskin to limit when cleaning – Majority of foreskin retracts by age 5 • Use Betamethasone for Pathologic Phimosis – 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 8 9/16/2015 Penile Trauma • Uncommon Injuries • 17 y/o M with GSW to penis • Urethra debrided with EE anastomosis • Testis & Cord intact Scrotal Trauma • Intentional scrotal trauma on the rise! Intentional scrotal injuries 12 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 9 9/16/2015 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 10 9/16/2015 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 11 9/16/2015 GOMCO CIRC: Technique Take down the Frenulum SST Deformity GOMCO CIRC: Technique Mark the Incision Important! GOMCO CIRC: Technique Dorsal Slit 12 9/16/2015 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 13 9/16/2015 Thank You! Questions? 14.