Phimosis: Inability to retract the foreskin of the penis. This is a common issue in boys that are uncircumcised and can lead to pain and tearing of the foreskin. Once the foreskin is torn, it heals with scar and eventually cannot be retracted. (see pic) Inability to retract the foreskin may be noted in the newborn male normally, and over time the foreskin will eventually separate and retract. Retraction of the foreskin and failure to bring the foreskin back over the head of the penis in an uncircumcised boy can lead to development of paraphimosis – a medical emergency.
Evaluation: Patients that present with pain on retraction of the foreskin, recurrent infections of the penis or foreskin, bleeding on attempts at retraction of the foreskin – diagnosis is based on the history and physical examination.
Management: Topical betamethasone cream may be successful in some boys in permitting the phimosis to soften and allowing retraction of the foreskin. When there is a tight phimotic scar, patients are best served with circumcision. If the patient has had a prior episode of paraphimosis, then circumcision is typically warranted.
Concealed penis/Hidden penis
The penis appears completely buried in the fat of the suprapubic area. This may be seen prior to or following circumcision. In some boys with this condition, doing circumcision can lead to scarring and trapping of the penis.
Evaluation: Can be identified on physical examination. If identified, circumcision should be deferred and the patient should have repair of the concealed/hidden penis in conjunction with the circumcision, to prevent eventual trapping of the penis (see pic). Older boys with this condition may be unable to stand to void.
If the opening of the urethra is not located at the tip of the penis, but rather on the ventral (inferior) aspect of the penis. There is an increasing incidence around the world – may be related to environmental or hormonal factors. Greater incidence in boys conceived using artificial reproductive techniques. May be associated with a penile curvature (chordee). Appearance is usually typical and easily identified at birth.
Evaluation: Typically noted during physical examination in infancy. Variants with complete foreskin may not be identified until the time of circumcision. If hypospadias is present, circumcision should be deferred. If hypospadias is identified at the time of the circumcision, the procedure should be aborted and the patient referred to pediatric urology for management.
Management: The management is surgical reconstruction, usually at around age 6 months. Most milder forms of hypospadias, can be managed with a single surgical procedure, however, more severe forms (see pic) may require multiple procedures for reconstruction. Potential complications of repair include urethrocutaneous fistula (opening from reconstructed channel to the outside) or meatal stenosis (narrowing of the opening of the urethra)