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Genital graft-versus-host disease (GVHD) is an underdiagnosed and poorly recognized complication, especially in the pediatric population. We report our data on children with genital manifestations of GVHD and their unique clinical features. The study included children up to age 18 years who underwent hematopoietic stem cell transplantation (HSCT) over a 20-year period from February 2002 to February 2022. A total of 1035 children underwent HSCT during the study period. Genital GVHD was documented in 164 children (15.8%). Among these 164 children, 23 (14%) were age <2 years, 98 (59.8%) were age 2 to 10 years, and 43 (26.2%) were age ≥10 years. The conditioning regimen was myeloablative in 122 children (74.4%) and reduced intensity in 42 children (25.6%). Donor type was matched related donor in 62 (37.8%), matched unrelated donor in 44 (26.8%), and haploidentical in 34 (20.7%). Peripheral blood stem cells (PBSCs) were used in 78.7% of the children (n = 129), and sex mismatch was noted in 31.1% of genital GVHD cases (51 of 164). The overall incidence of chronic oral GVHD was 33% (342 of 1035), and of these, 47.9% (164 of 342) also had genital GVHD. Patients with genital GVHD ultimately may require surgical management; 21.5% (22 of 103) of boys with genital GVHD ultimately required circumcision for phimosis, and 1 female patient developed hematocolpos necessitating surgical management. Our case series highlights the significant association between chronic oral GVHD and genital GVHD. Given the strong association between oral GVHD and genital GVHD in children, it is imperative to examine the genital area in all children on follow-up for chronic GVHD. Donor-recipient sex mismatch and use of PBSC grafts predispose to chronic genital GVHD. Early identification and treatment of genital GVHD may help prevent complications, including scarring and phimosis., (Copyright © 2023 The American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. All rights reserved.)

Objective: Lichen sclerosus (LS) is a chronic inflammatory skin disease. In male patients, it usually involves the glans penis and foreskin and can cause phimosis or meatal stenosis. The aim of this cross-sectional case-control study was to identify clinically important comorbidities in male patients with LS., Materials and Methods: By searching Turku University Hospital electronic health records, the authors identified 630 male patients diagnosed with LS between 2004 and 2020. To investigate possible comorbidities, the authors compared this patient group to a 10-fold larger control group., Results: The incidence of LS increased during the study period, from 5 to 27.5 per 100,000 men. Patients were most often diagnosed at 21 to 25 years of age. Patients with LS exhibited markedly increased risks of penile carcinoma (odds ratio [OR], 81.0; 95% CI = 10.82-3516.7; p < .001) and carcinoma in situ of the penis (OR = 60.5; 95% CI = 7.32-2738.9; p < .001). Patients also more commonly exhibited lichen planus (OR = 16.8; 95% CI = 8.97-32.39; p < .001), psoriasis (OR = 3.3; 95% CI = 1.80-5.70; p = .004), angina pectoris (OR = 1.8; 95% CI = 1.10-2.81; p = .013), obesity (OR = 2.6; 95% CI = 1.72-3.77; p < .001), type 2 diabetes (OR = 2.3; 95% CI = 1.74-3.09; p < .001), and hypertension (OR = 1.9; 95% CI = 1.53-2.37; p < .001). The most commonly performed urological procedures were operation for phimosis, uroflowmetry, and ultrasound measurement of residual urine., Conclusions: Genital malignancies, other dermatological conditions, and diseases related to metabolic syndrome should be considered when treating patients with LS., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP.)

Purpose: To assess the expression of selected cytokines in penile lichen sclerosus (PLS) and associate them with the occurrence of micro-incontinence (MI) in different stages of PLS., Methods: The skin biopsies from 49 PLS affected, and 13 from nonlesional foreskins (healthy control adult males undergoing circumcision due to phimosis caused by short frenulum) were obtained. All specimens were used for RNA extraction and RT-qPCR. Quantitative assessment of the gene expression of interleukin 1-A (IL-1A), interleukin 1-B (IL-1B), interleukin 1 receptor antagonist (IL-1RN), interleukin 6 (IL-6), transforming growth factor β1 (TGF-β1), and interferon-gamma (INF-γ) was performed. To determinate the presence of MI, the patients were asked about voiding patterns, especially leaking tiny drops of urine from the urethral meatus after urination., Results: IL-1A, IL-6, and INF-γ mRNA levels were approximately 150, 16, and 59 times higher in PLS than in control samples, respectively. The highest IL-1A mRNA levels were observed in early PLS (n = 13), INF-γ in moderate PLS (n = 32), while IL-6 in severe PLS (n = 4). MI was noted in 45 PLS patients vs. 0 in control (p < 0.0001). IL-1A and IL-6 vs control ratios were concentration (ca.) 400 and 30 times higher, respectively, in MI PLS samples than in PLS without MI., Conclusion: Occlusion and irritating urine effect are associated with the clinical progression of penile LS with increased mRNA expression of IL-1A, INF-γ, and IL-6 pro-inflammatory cytokines in the foreskin., (© 2022. The Author(s).)

Lichen Sclerosus (LS) is a chronic inflammatory skin disease with unknown etiology. In pediatric age the main disease "lichenlinked" is the phimosis in male. This is a retrospective study that reports the experience of our clinic and review of the literature. We included all patients affected by pathological phimosis, treated by circumcision between January 2015 and May 2020, older than 6 years old and with an histopathological diagnosis of lichen sclerosus. The aim was to identify prognostic factors based on histological report to plan the clinical management of patients. Statistical analysis was done. We included 207 patients. The mean age of children was 9,78 years (5-18 years, DS±3.29). Based on the histological features we divided patients in 2 groups: early lesions (70/207, 34%) and advanced (137/207, 66%). In term of complications lichen linked we considered meatal stenosis that needed of urethral dilatations. We included 7 patients (7/207, 3,4%). We report P value Statistical Significance in many aspects. An early diagnosis of LS and surgical treatment of foreskin are essential to prevent early and late complications in children. The size of sample is a limit of the study but results encourage our management.

Balanitis Xerotica Obliterans is a chronic, progressive, sclerosing inflammation of unclear etiology. It involves the external genitalia of males and more specifically the prepuce and its frenulum, the glans, and the external urethral meatus while it may extend to the peripheral part of the urethra. Recent studies have noted an increasing incidence in the paediatric population. It is the most common cause of secondary (pathologic) phimosis. Even more, in boys with physiologic phimosis that does not respond to conservative treatment, Balanitis Xerotica Obliterans should be considered as the underlying condition. In this study, we present all the latest data and attempt to create a diagnostic and curative algorithm regarding this condition.

Objective: To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis., Materials and Methods: The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists., Results: Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1)., Conclusion: LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: An uncircumcised male infant with a history of urinary tract infection (UTI), physiologic phimosis, and a normal renal ultrasound is a common patient referred to pediatric urology clinics. Topical steroid creams have been shown to effectively release physiologic phimosis., Objective: The objective of this study was to test the hypothesis that use of steroid cream for physiologic phimosis is associated with a lower UTI recurrence in uncircumcised male infants with normal renal ultrasounds., Study Design: Uncircumcised males younger than 12 months referred for a UTI with a normal renal ultrasound were included. A longitudinal data set was created, and recurrent UTIs were identified. The proportion with a recurrent UTI was compared between those who received a prescription for a steroid cream for phimosis and those who did not. The morbidity of the initial and recurrent UTIs was also described. The association of recurrent UTI with vesicoureteral reflux (VUR) was also evaluated., Results: A total of 192 uncircumcised males with a median age of 5.8 months (interquartile range [IQR]: 3.5-7.9 months) were included. Twenty-seven patients were treated with a course of betamethasone valerate 0.1% cream, and 165 were not (Summary Table). There were no significant differences between groups in the frequency of voiding cystourethrogram (VCUG), diagnosis of VUR, or use of continuous prophylactic antibiotics (CAP). During a median follow-up of 8.7 months (IQR: 3.1-17.5 months), none of the patients treated with steroid cream had a recurrent UTI compared with 27 of 165 (16%) patients not treated (P = 0.02). Among the 173 patients whose initial UTI was febrile, recurrent febrile UTIs occurred in no treated patients and 23 of 150 (15%) untreated patients (P = 0.047)., Discussion: The results of this study are consistent with those of a previous randomized trial of steroid cream for physiologic phimosis which found lower recurrent UTI in those whose foreskins became retractable. In addition, the results are consistent with the declining incidence of UTIs in uncircumcised males mirroring the natural history of physiologic phimosis resolving. This study is limited by its retrospective nature and non-standardized follow-up., Conclusion: The use of steroid cream for physiologic phimosis is associated with a decreased risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound. In this group, steroid cream for physiologic phimosis is a well-tolerated and simple alternative to circumcision to potentially decrease risk of recurrent UTI., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Previous histological studies have shown a variable incidence of genital lichen sclerosus (LS). However, the results of these studies were inconsistent. To overcome the limitation of individual studies, we performed this systematic review to explore the true incidence of LS., Methods: A comprehensive search of Pubmed, Embase, Web of Science and Cochrane Library was performed including cross-referencing independently by two assessors., Results: A total of 22 articles published from 1980 to 2017 were included in our study. The proportion of LS in those with phimosis had been described in many literature studies, ranging from 2 to 95%. The actual incidence of LS is thought to be clinically underestimated by as much as 50%., Conclusions: The true incidence of LS in boys is more common than previously realized. LS may be observed in foreskin with or without phimosis. The presence of acquired phimosis may be an aggravating factor in the incidence of LS. The diagnosis LS must be based on biopsy for acquired phimosis because clinical findings underestimated the incidence of LS.

Purpose: Children with single ventricle physiology (SVP) have been shown to have a high morbidity and mortality after non-cardiac surgical procedures. Elective circumcision is one of the most common pediatric operations with low morbidity and mortality. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine peri-operative course and outcomes., Methods: We performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with non-single ventricle physiology or children undergoing circumcision in combination with another case were excluded. Demographics, surgical characteristics, and outcomes were analyzed. Descriptive statistics were performed, all medians were reported with interquartile range., Results: 15 males underwent elective circumcision with a median age at the time of surgery of 1.13 (1.03, 1.38) years. Eighty-four percent underwent their circumcision after their 2nd stage cardiac operation. Most common operative indication was uncomplicated phimosis. Median operative time was 20 (16, 27) mins. Median total length of stay was 229 (185, 242) mins with no admissions. Post-operative complications included two (16%) hematomas with one requiring surgical intervention. There were no deaths., Conclusion: Children with SVP who undergo elective circumcision may have a higher risk of bleeding.

Two major pathways of penile carcinogenesis are known: human papillomavirus (HPV)-induced penile cancer and HPV-negative cancers associated with chronic dermatoses. Therefore, modern measures for prevention of penile cancer may for example include prophylactic HPV vaccination. The resulting B‑cell-mediated immunity to HPV capsid proteins is effective protection against future HPV infections. Contrarily when treating existing HPV infections or HPV-associated cancers an antigen-specific T‑cell immunity is necessary. To date, screening and treatment of precancerous lesions to prevent penile cancer are not established in the German health care program and the highly expected therapeutic HPV vaccines are still on the horizon. In this article, we focus on possible strategies to prevent HPV-related penile cancer on different levels of carcinogenesis.

Penile cancer is often an obvious visual diagnosis but histologic verification should be obtained prior to treatment. The clinical examination should determine the tumor stage and whether it has infiltrated the cavernous bodies and/or the urethra and it should adequately assess the inguinal lymph nodes. Preoperative imaging of the lesion is only indicated in equivocal cases. Curative treatment requires the complete removal of the primary tumor and all metastatic lymph nodes. Lymph node management is the key prognostic factor in the treatment of penile cancer. No imagining technique such as the ultrasound, CT, MRI or PET/CT is able to adequately detect micrometastatic lymph nodes. Therefore, invasive (inguinal) lymph node diagnosis is indicated for all tumour stages from pT1G2. Over 90% of penile cancer cases can be cured with early diagnosis and adequate treatment if routine self-examination and physical examinations are regularly performed.

Background: Penile cancer represents a rarity in daily clinical practice., Objectives: The aim is to identify global differences concerning the incidence, social and risk factors., Methods: The past and current epidemiologic literature is analyzed concerning incidence rates and risk factors. The latter are discussed concerning their potential with regard to disease prevention., Results: Globally, incidence rates of penile cancer range from low to nonexistent. Distinct differences are found when comparing industrialized countries with emerging and developing countries. Phimosis seems to be a crucial risk factor in the formation of penile cancer. Additionally, chronic inflammatory diseases of the penis were found to be associated with a higher risk., Conclusions: Preventive measures should be considered in relation to the rarity of the disease, especially in the valuation of circumcision during early childhood. Regular clinical examination of the penis is a sensible measure of early detection.

The true HPV prevalence in the foreskins of infants and children has been little documented, but reporting on this prevalence is of great importance given its impact on the rationale for treating asymptomatic boys. We searched multiple databases from 1960 to 2016 for observational or prospective studies that reported on HPV prevalence in foreskins. We conducted a meta-analysis using a random-effects model to pool for HPV prevalence in the foreskins of infants and children. Eight studies, with a total of 556 infants and children with phimosis, were eligible for the meta-analysis. The pooled overall prevalence of general HPV, high-risk HPV, low-risk HPV, HPV 16/18, HPV 16, and HPV 18 were 17.3 (95%CI: 0.8-46.3), 12.1 (95% CI: 0.9-31.5), 2.4 (95% CI: 0.0-11.2), 4.8 (95% CI: 0.0-16.8), 1.7 (95% CI: 0.0-5.1), and 0 (95% CI: 0-0.5), respectively. The estimated HPV prevalence in foreskins was not zero among infants and children, which implies HPV transmission other than by sexual contact. Considering that high-risk HPV is detected in asymptomatic infants and children, future studies are warranted to determine whether preventive treatments in asymptomatic infants and children could be effective in preventing persistence or transmission of high-risk HPV.

Purpose: Lichen sclerosus (LS) is a chronic inflammatory skin condition that frequently involves the anogenital region. Ongoing research is focused on finding more effective treatments for tissue repair and reducing symptoms. The aim of this study is to evaluate the effectiveness of platelet-rich plasma (PRP) local injections in penile LS., Methods: Forty-five male patients affected by penile LS underwent injections of autologous PRP in the affected skin areas. Age at diagnosis and at first treatment, number of treatments, clinical conditions (phimosis, splitting, inflammation, synechiae, meatus stenosis), symptoms (pain, burning, itching), and functional impairment were considered. Treatment efficacy was also evaluated through the Investigator's Global Assessment (IGA) on a six-point Likert scale and the Dermatology Life Quality Index (DLQI)., Results: The patient age at LS diagnosis was 36.20 ± 9.19 years, while the mean age at the first PRP treatment was 42.96 ± 11.32 years (p < 0.001). The number of treatments/patient ranged from 2 to 10. The follow-up was 17.60 ± 5.63 months. After PRP injections, it was observed in all patients a significant improvement in clinical conditions, with reduction/disappearance of symptoms. Topical steroid therapy, interrupted before PRP treatment, was not restarted by any patient. Only one patient underwent a later circumcision procedure. Both IGA scale and DLQI score showed a significant difference (p < 0.001) before and after PRP treatment., Conclusions: PRP treatment in penile LS seems to be helpful to regenerate scarring, reduce symptoms, and improve patient quality of life. Further studies are necessary to evaluate long-term results.

Circumcision can be a viable option for phimosis in a 10-yr-old boy, also if asymptomatic, in the presence of skin alterations or if the parents prefer avoid observation. Morbidity is minimal if the procedure is performed in a hospital setting., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

In a 10-yr-old boy with no abnormalities or symptoms other than nonretractability of the foreskin, the foreskin should be preserved. If treatment is needed, local corticoid application should be used as first-line therapy, as it gives excellent results in up to 90% of cases, before removing this sensitive part of the body., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

We report a case of Fournier's gangrene in a 12-year-old boy from St. Boniface Hospital in Fond-des-Blancs, Haiti. Fournier's gangrene, a fulminant necrotizing fasciitis of the penis and scrotum, is a rare and life-threatening infection that requires hospitalization, broad-spectrum antibiotics, and surgical debridement.1-3 It is usually associated with impaired cellular immunity due to systemic disorders such as diabetes and liver disease.4,5 This patient had none of those risk factors, but had severe, longstanding phimosis, for which circumcision had been recommended many years before. This case illustrates how lack of access to basic surgical care for an easily treatable condition leads to advanced presentation of a severe disease process. [Full article available at http://rimed.org/rimedicaljournal-2016-12.asp].

Purpose: There has been increasing interest in understanding the natural history of HPV and the diseases that it causes in men. HPV infection is strongly associated with penile cancer, lack of neonatal circumcision and phimosis. We investigated the incidence of HPV infection in asymptomatic men and patients with phimosis., Materials and Methods: We assessed 110 asymptomatic men and 30 patients who underwent circumcision due to phimosis. DNA was extracted from swabbed samples collected from asymptomatic men and from foreskin samples collected at circumcision. Polymerase chain reaction using consensus primers for detecting HPV-MY09/11 was performed to detect generic HPV DNA. HPV genotyping was done by polymerase chain reaction amplification with primers for the E6 gene DNA sequences HPV6, HPV11, HPV16, HPV18, HPV31, HPV33, HPV35, HPV45 and HPV58., Results: HPV was present in 46.66% of patients with phimosis, of whom 50% had high risk HPV genotypes. Of asymptomatic cases 16.36% were HPV positive but only 1 sample showed high risk HPV. We detected a significantly high rate of HPV genital infection in patients presenting with phimosis compared with asymptomatic men (p = 0.00167). The prevalence of high risk HPV genotypes in patients with phimosis was also statistically significant (p = 0.0004)., Conclusions: We found a robust association between phimosis and the genital HPV prevalence in men and a significant frequency of high risk HPV. Other studies are needed to investigate the occurrence of factors that can increase the incidence of penile carcinoma and determine its impact on female genital infection in cervical cancer., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Congenital megaprepuce is a specific form of buried penis. Children affected by this malformation usually suffer from a subjective difficulty in voiding which is the main indication for early surgical correction. The aim of this study was to report a single center's 12-year experience in the treatment of megaprepuce in children, describing the surgical procedure we used to treat it and the results., Patients and Methods: We retrospectively reviewed the charts of all children who underwent congenital megaprepuce repair between January 1999 and August 2011 in our institution. Fifty-two children were operated during the study period. Our single surgical technique, not an original one, consists of fixing the penile shaft at the base of the penis, and widely reducing the inner prepuce., Results: Four children (8%) underwent revision surgery but according to our criteria a very good result was observed in only 23 patients, and a less good but still acceptable result in 25 patients., Conclusion: Our 12-year experience in the surgical treatment of congenital megaprepuce demonstrated satisfying results from a safe and simple surgical technique, but to achieve the optimum result remains difficult., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Eight elderly patients (average age 76.1±4.3 years) with balanitis xerotica obliterans (BXO) accompanied by phimosis presented with difficulty in urination. Preoperative average international prostate symptom score, average maximum urinary flow rate, and average volume of residual urine were 20.7±6.3 points (n＝8), 5.1±3.6 ml/s (n＝5), and 85.4±77.3 ml (n＝8), respectively. Some of the patient's complaints, such as severe dribbling of urine, urinary stream division, and ballooning of the foreskin, were not included in the items of the major questionnaire on urination. Dorsal incision and circumcision was performed in all patients, and all were pathologically diagnosed with BXO. Meatoplasty was performed in one patient with a meatal stenosis. No coexistence of penile cancer was observed. Statistically significant improvements were observed in subjective and objective findings after treatment. In conclusion, BXO with phimosis in elderly patients should be considered as a cause of lower urinary tract symptoms.

Purpose: Lichen sclerosus is a potentially important factor in the ongoing debate concerning the pathology of persistent congenital phimosis. We assessed the molecular differences of congenital phimosis in boys with and without lichen sclerosus compared to age matched boys with fully retractable foreskins to gain more insight into the pathogenesis of fibrotic remodeling of the prepuce., Materials and Methods: A total of 150 boys were circumcised in a prospective study between 2007 and 2009. Using target gene specific preamplification and quantitative real-time polymerase chain reaction based low density arrays, we measured the mRNA expression of 45 tissue remodeling associated genes in foreskins of boys with absolute phimosis and lichen sclerosus (8 patients) and those of an age matched group of boys with phimosis but no lichen sclerosus (8), as well as a control group with foreskins without delimitable changes (6). Complementary protein expression and inflammatory infiltrates were assessed by immunohistochemical analysis., Results: Cellular composition, inflammatory infiltrate and microenvironment as seen in histologically proven lichen sclerosis differed significantly from the other groups. In particular, lichen sclerosis was characterized by over expression of bone morphogenetic protein 2 and its corresponding receptor, matrix metalloproteinases 1 and 9 and tissue inhibitor of metalloproteinases 1, cytokine chemokine ligands 5 (RANTES) and interleukin 4, and transforming growth factor-β2 and its corresponding receptor. There were no major molecular differences between specimens from boys with congenital phimosis without signs of lichen sclerosis and controls., Conclusions: Distinct expression patterns of tissue remodeling associated genes are evident in boys with congenital phimosis and lichen sclerosis, while congenital phimosis without lichen sclerosis represents a physiological condition., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Lichen sclerosus (LS) is a chronic, inflammatory condition which commonly involves the anogenital skin. This condition may affect the foreskin, glans, frenulum, meatus and urethra in males. It manifests itself with voiding symptoms. Obstructive uropathy is an extremely rare clinical presentation in childhood. This study reports the case of a 13-year-old boy presenting with obstructive uropathy due to LS and reviews the published data on the diagnosis, management and follow-up of this condition.

A high-functioning 82-year-old man presented with lower lumbar pain and pubic tenderness. On admission he was afebrile with a normal white count. A grossly elevated C reactive protein was noted. CT scan of the pelvis showed a fluid collection anterior to the pubic symphysis and to the right of the midline measuring 2.0 × 2.2 cm. Pseudomonas aeruginosa was cultured from the fluid collection. The patient had no history of intravenous drug use, pelvic surgeries, malignancies or trauma. We report what we believe is the first documented case of P aeruginosa infection of the pubic symphysis in an elderly patient that did not have any of the traditional risk factors associated with neither P aeruginosa septic arthritis nor infections of the pubic symphysis. Instead, we propose that phimosis with chronic infection of the foreskin and balanitis may have led to septic arthritis.

Penile squamous cell carcinoma (SCC) is uncommon in Europe, where it accounts for approximately 0.7% of all malignant tumors in men. The main risk factors are poor hygiene, lack of circumcision, human papillomavirus (HPV) infection, and certain chronic inflammatory skin diseases. HPV infection is detected in 70% to 100% of all penile in situ SCCs and in 30% to 50% of invasive forms of the disease, mainly basaloid and warty SCCs. In situ tumors can be treated conservatively, but close monitoring is essential as they become invasive in between 1% and 30% of cases. The treatment of choice for penile SCC is surgery. Inguinal lymph node irradiation is no longer recommended as a prophylactic measure, and it appears that selective lymph node biopsy might be useful for reducing the morbidity associated with prophylactic inguinal lymph node dissection. Survival is directly related to lymph node involvement. Improving our knowledge of underlying molecular changes and their associated genotypes will open up new therapeutic pathways., (Copyright © 2011 Elsevier España, S.L. and AEDV. All rights reserved.)

Phimosis is a common condition in which the foreskin cannot be retracted over the glans penis. First appearing at 8 weeks gestation as a ridge of thickened epithelium, the prepuce grows forward over the developing glans. Physiological phimosis is common in male patients up to 3 years of age. Balanoposthitis is an inflammation of the foreskin and glans and occurs in 4-11% of uncircumcised boys. Lack of circumcision has been identified as a risk factor for urinary tract infection in infants as well as several sexually transmitted diseases and penile cancer in adults. Local steroid application showed satisfactory success rates of more than 80% and is recommended as first choice therapy. Male circumcision carried out under the age of 14 years without medical indications is unlawful and classified as bodily harm under German law.

Actinobaculum schaalii is a small, Gram-positive, facultative anaerobic, CO2-requiring rod. It is now an acknowledged uropathogen, but often overlooked because of its slow growth. It is part of the normal bacterial flora in the urogenital area, but can be the cause of both local and invasive infections. We present a case of A. schaalii urosepsis in a 68-year-old male with phimosis caused by a severe lichen sclerosus et atrophicus. The only bacteria found in blood and urine was A. schaalii.

We report two cases of borderline leprosy patients, one with scrotal lesions, the other presenting with leprosy on the prepuce with phimosis.

This report presents a case of a 65-year-old male suffering from a penile cutaneous horn. This lesion is usually seen in sun-exposed areas and its occurrence on the penis is rare. One-third of cases of penile horns are associated with underlying malignancies. Standard treatment is electrosurgical excision with removal of a broad base.

We report a case of urinary retention caused by true phimosis in a 67-year-old man with untreated diabetes mellitus. The patient could not void in a stream, and urine dropped out of the external urethral orifice with manual compression of the penis. Subsequently, he visited our hospital due to urinary retention. Ultrasonography revealed right hydronephrosis and ballooning of the foreskin. An emergency dorsal slit was performed, and hydronephrosis showed immediate improvement. Histopathologically, fibrosis and inflammation of the foreskin were observed. The mechanisms responsible for urinary retention in this case are discussed.

Objective: To determine the prevalence of diabetes in men presenting with phimosis, and to establish the incidence of undiagnosed diabetes in men presenting with acquired or life-long phimosis., Patients and Methods: We prospectively collected data on 100 men (mean age 38.5 years, range 17-82) who presented to our department with phimosis during 2006. Urinary glucose levels and random serum glucose levels were analysed, and if abnormal, the patient had further diagnostic tests for diabetes., Results: In all, 31 men presented with a life-long history of phimosis and 69 with a history of acquired phimosis. There was no history of diabetes and no abnormal serum glucose levels in those with life-long phimosis. Eighteen of 69 (26%) of those with acquired phimosis had a history of type 2 diabetes. Type 2 diabetes was newly diagnosed in four of 50 (8%) men presenting with acquired phimosis and no history of a glycaemic disorder. A further two (4%) were diagnosed with impaired fasting glycaemia and impaired glucose tolerance. Urine analysis was positive for glucose in all new diagnoses of glycaemic disorders, except in one man., Conclusion: Diabetes can be associated with acquired phimosis in almost a third of cases, and 12% of men presenting with acquired phimosis and no history of diabetes were diagnosed with a disorder of glycaemic control. Therefore it is important that serum glucose levels are analysed when assessing men with acquired phimosis.

Lichen sclerosus et atrophicus is a chronic inflammatory sclerotic and atrophic disease of unknown cause that predominantly affects male and female genital skin. This study was designed to evaluate histological characteristics of congenital and acquired phimoses among pediatric (n=60) and adult (n=60) male patients who were admitted for circumcision to the Clinics of Urology and Pediatric Surgery of Kaunas University of Medicine Hospital between 2000 and 2003 and to determine the rate of lichen sclerosus et atrophicus and other histological diagnoses among them. This study demonstrates that 45.1% of congenital and 62.3% of acquired phimoses show histological signs of lichen sclerosus et atrophicus. The rate of lichen sclerosus et atrophicus was statistically significantly higher among patients with acquired than congenital phimosis. Boys with acquired narrowing of prepuce were statistically significantly 3.9 times more likely to develop lichen sclerosus et atrophicus than those with congenital phimosis. There were no statistically significant differences between rates of lichen sclerosus et atrophicus and other dermatological diagnoses among pediatric and adult male patients if the type of phimosis (acquired or congenital) was considered. Histological features of lichen sclerosus et atrophicus and other histological diagnoses in boys and men with phimosis were detected with equal frequency irrespective the age of the subjects. The rate of lichen sclerosus et atrophicus was similar among all boys (56.7%) and men (53.3%) treated for phimosis. Only the type of phimosis had a statistically significant influence on the rate of lichen sclerosus et atrophicus and other histological diagnoses.

Penile squamous cell carcinoma has been commonly reported in the past decades. We describe a rare case of a huge squamous cell carcinoma of the penis in a 65-year-old patient with a 4-year history of tumor growth, for which total penectomy, perineal urethrostomy and bilateral inguinal lymphadenectomy were carried out. We suggest that aggressive surgical intervention should be recommended for those with well-differentiated penile carcinoma regardless of the size of the tumor.

Objective: To discuss the diagnosis and treatment of penile carcinoma in circumcised men., Methods: We reviewed 17 cases of penile carcinoma detected 1 month to 16 years after circumcision performed in our hospital from January, 1997 to December, 2004., Results: Of the total number, 11 cases were diagnosed as penile carcinoma 1 - 12 months and the others 3 - 16 years after the circumcision. Sixteen of them were treated by partial penectomy, anti 1 first by extensive circumcision and later by partial and total penectomy successively after recurrence. Cloquet nodes biopsy showed 16 cases to be pathologically well-differentiated and I case moderately differentiated penile squamous carcinoma. One died of extensive metastasis, but the other 16 remained disease-free survivals., Conclusion: Circumcised adult men, especially those over 40 years of age, are likely to develop penile carcinoma. Patients with inflammation, plaque or ulcer in the prepuce should be checked by pathological biopsy and followed up closely. For Stage-I penile squamous carcinoma, partial penectomy is shown to be an effective therapeutic option, and Cloquet's nodes biopsy is necessary for all patients.

The effect of hydrocortisone (HC), the steroid of lowest potency, and physiotherapy (PT) on non-retractile physiologic phimosis (PP) and the reduction of subsequent recurrent UTI was evaluated in male infants with UTI. Seventy-eight male infants with febrile UTI and nonretractile PP were prospectively randomized into HC (Plancol, n=39) and control (Vaseline, n=39) groups. Topical application of HC as a thin film around the preputial margin twice a day for four weeks with PT was instructed. The response rate in the HC group was 89.7% (35/39), which was significantly higher than the rate (20.5%; 8/39) in the control group (P<0.05). In the HC group, the response rate was much higher (96.1%) in the subgroup with PT than in the group without PT. Most of the response (88.5%) was observed within two weeks. During the following year, the recurrent rate of UTI was 7.1% (2/28) in the infants with retractile prepuces, which was significantly less than than the rate (29.6%; 8/27) in infants with nonretractile prepuces (P<0.05). In conclusion, topical HC and PT for 2-4 weeks proved to be a simple, safe and effective treatment for nonretractile PP in infants with UTI, and this procedure was beneficial in reducing recurrent UTI.

Few population-based case-control studies have assessed etiologic factors for penile cancer. Past infection with high-risk human papillomavirus (HPV) is a known risk factor for penile cancer; however, few previous studies have related the HPV DNA status of the tumor to potential demographic and behavioral risk factors for the disease or evaluated whether in situ and invasive penile cancer share risk factors. Little information is available on the role and timing of circumcision in the etiology of penile cancer. We conducted a population-based case-control study in western Washington state that included 137 men diagnosed with in situ (n = 75) or invasive (n = 62) penile cancer between January 1, 1979, and December 31, 1998, and 671 control men identified through random digit dialing. Cases and controls were interviewed in person and provided peripheral blood samples. Case and control blood samples were tested for antibodies to HPV16 and HSV-2, and tumor specimens from cases were tested for HPV DNA. Men not circumcised during childhood were at increased risk of invasive (OR = 2.3, 95% CI 1.3-4.1) but not in situ (OR = 1.1, 95% CI 0.6-1.8) penile cancer. Approximately 35% of men with penile cancer who had not been circumcised in childhood reported a history of phimosis compared to 7.6% of controls (OR = 7.4, 95% CI 3.7-15.0). Penile conditions such as tear, rash and injury were associated with increased risk of disease. Among men not circumcised in childhood, phimosis was strongly associated with development of invasive penile cancer (OR = 11.4, 95% CI 5.0-25.9). When we restricted our analysis to men who did not have phimosis, the risk of invasive penile cancer associated with not having been circumcised in childhood was not elevated (OR = 0.5, 95% CI 0.1-2.5). Cigarette smoking was associated with a 4.5-fold risk (95% CI 2.0-10.1) of invasive penile cancer. HPV DNA was detected in 79.8% of tumor specimens, and 69.1% of tumors were HPV16-positive. The proportion of HPV DNA-positive tumors did not vary by any risk factors evaluated. Many risk factors were common for both in situ and invasive disease. However, 3 factors that did not increase the risk for in situ cancer proved significant risk factors for invasive penile cancer: lack of circumcision during childhood, phimosis and cigarette smoking. The high percentage of HPV DNA-positive tumors in our study is consistent with a strong association between HPV infection and the development of penile cancer regardless of circumcision status. Circumcision in early childhood may help prevent penile cancer by eliminating phimosis, a significant risk factor for the disease., ((c) 2005 Wiley-Liss, Inc.)

OBJECTIVES To determine whether physiological phimosis with or without ballooning of the prepuce is associated with noninvasive urodynamic or radiological evidence of bladder outlet obstruction. PATIENTS AND METHODS From August 2001 to October 2002 all boys with a foreskin problem and referred to one paediatric surgeon were assessed in special clinics. Those with physiological phimosis were recruited for the study and had upper tract and bladder ultrasonography (US), followed by uroflowmetry and US-determined postvoid residual urine volumes (PVR). Data were compared between boys with and with no ballooning of the prepuce. The project was approved by the local research ethics committee and informed consent was obtained from all study participants. RESULTS In all, 54 patients were referred for circumcision; 32 boys with physiological phimosis completed the uroflow and US investigations. Ballooning of the foreskin was present in 18 boys (mean age 6.8 years, range 3-12); 14 had physiological phimosis with no ballooning (mean age 6.5 years, range 4-11). Upper tract US and bladder wall thickness were normal in all boys. The mean maximum urinary flow rate (Q(max)) was not significantly different in boys with ballooning and those without (mean 15.3 mL/s, sd 4.4, range 9-24, vs 15.4, sd 2.9, range 10.7-20, P = 0.96). In addition, all Q(max) values were within the normal range when correlated with voided volume and compared with age-related nomograms. Most boys had flow rate patterns showing a normal bell-shaped curve; a few (9%) had subtle changes in the flow-rate profile, with either a plateau-type curve or slow initial increase in flow and prolonged time to achieve Q(max). The two groups had comparable mean PVRs (3.5 mL, sd 5.1, range 0-18 with ballooning vs 6.1, sd 10.7, range 0-38 without, P = 0.37). Only one patient had a marginally abnormal PVR. CONCLUSIONS Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding. Minor abnormalities in the flow-rate pattern in this patient group deserve further study.

Although rare in developed countries, carcinoma of the penis is an important problem in the developing world. Circumcision done in childhood offers the greatest protection against this disease. Poor penile hygiene and phimosis are strong risk factors for development of penile carcinoma. Early disease can be treated by conventional resection of the penis, or in selected patients by organ preserving techniques including Mohs micrographic surgery, and laser and radiation therapy. For more advanced primary disease, partial or total penectomy is needed. Elective or therapeutic lymph-node dissection is recommended for inguinal metastatic disease, and depending on the disease status, unilateral or bilateral inguinal or ilioinguinal lymphadenectomy might be needed. The role of chemotherapy, as adjuvant or primary treatment in metastatic disease, needs to be defined in prospective clinical trials, which can be done in developing countries.

The purpose of this article is to describe a series of patients undergoing ultrasound-guided suprapubic cystostomy catheter placement in the Emergency Department. A series of 17 consecutive patients who underwent emergent real-time ultrasound-guided suprapubic cystostomy in the ED over a 2-year period is reported. The procedure was facilitated by direct ultrasound imaging of the bladder using a Digital Sonoace 5500 machine. Procedural notes and follow-up records were analyzed for efficacy, safety, and complications. The results demonstrated that trans-abdominal ultrasound confirmed urinary retention before drainage in each of the 17 cases enrolled. Each patient required emergent suprapubic cystostomy catheter placement for acute urinary outflow obstruction because urethral bladder catheterization was not possible or was contraindicated. Continuous real-time ultrasound-guided percutaneous suprapubic cystostomy placement and decompression of the bladder was successful in all 17 (100%, 90-100% CI: 95%) cases. There were no complications reported. In conclusion, real-time ultrasound imaging of the bladder was successful for the purpose of aiding the guidance of a suprapubic cystostomy catheter placement in the ED and might represent an improvement from the standard blind method presently used.

Abstract The incidence of von Recklinghausen's disease is most frequent among neurocutaneous syndrome. It is an intractable neurological disease. About half of the disease is caused by an autosomal dominant inheritance and another half by mutation. It is characterized by neurofibroma which arises on various parts of the body and gradually increases with age. We recently encountered a case where a growth of neurofibroma within the foreskin had disturbed voiding.