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Background: Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited., Objective: This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured., Materials and Methods: Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function., Results: Mean age of patients was 37 years (± 22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m 2 , OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA., Conclusion: We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: to compare the postoperative esthetic and healing aspects of postectomy performed by different surgical techniques, based on the evaluation of different specialty expert professionals., Methods: prospective and randomized clinical trial enrolling 149 preschool children with a medical indication for circumcision, divided into three groups: postectomy with the hemostatic device Plastibell® (PB group), conventional technique (CV group) and conventional with subcuticular stitches (SC group). Pictures were taken from patients at pre-defined angles on the 30th and 60th postoperative days. Photos were evaluated by three specialists (dermatologist, pediatrician and plastic surgeon), who assigned scores from 1 to 5 regarding the esthetic and healing features at each moment. Grades 4 or 5 from all specialists characterized "best result". Data were analysed to compare the used surgical techniques, the judgments from specialties and postoperative complications., Results: most of the patients obtained the "best result" regarding healing (70%) and esthetics (56%). The final overall result showed the PB group as the best for healing (p=0.028) and the SC group as the best for esthetics (p=0.002). For the dermatologist, on the 60th postoperative day, the CV group presented the worst aesthetic result, whereas for the pediatrician and the plastic surgeon, the PB group presented the best healing result and the SC group had the best esthetic result. There was no difference between the groups regarding the presence of complications., Conclusion: the most common surgical techniques used to perform postectomy in children were differently assessed regarding healing and esthetic features by distinct medical professionals. The analysis of these two parameters among experts from related areas diverged among them and over time.

Introduction: The accurate histopathological diagnosis of the phimotic prepuce is indispensable because early diagnosis, treatment, and close follow-up are crucial in genital dermatosis such as lichen sclerosus (LS). This study analyzes the histopathological spectrum of childhood phimosis with special emphasis on LS. We also highlight a peculiar pattern of histopathological evolution in LS, prepuce., Material and Methods: The histopathology slides of all the pediatric preputial circumcision specimens performed for the indication of pathological phimosis (n = 43) during the study period (2012-2017) were analyzed. Eight histopathological features viz. hyperkeratosis, hypergranulosis, epidermal atrophy, acanthosis, dermoepidermal cleft, upper dermal edema and homogenization, mid dermal lymphocytic band, and interface dermatitis were studied in each case, separately in inner preputial surface, tip, and outer preputial surface. On the basis of evolution of the disease and histopathological features, the lesions of LS were classified into early, established, and advanced., Result: LS was found in 32 cases, whereas 11 cases showed nonspecific inflammation and fibrosis. The upper dermal homogenization (n = 29), dermoepidermal cleft (n = 28), and mid dermal band (n = 27) were the commonest histopathological changes. The established and advanced changes were confined to the inner preputial surface (n = 31), and the outer preputial skin surface was unaffected in all the cases. A peculiar histopathological evolution pattern was seen with established or advanced lesions, early lesion, and normal histology on the inner preputial surface, mucocutaneous junction, and outer preputial skin, respectively., Conclusions: LS is a common cause of childhood phimosis. It shows a peculiar histopathological evolution that mandates the thorough analysis of inner mucosal surface.

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.

Preputial dilation is an infrequently reported condition in pigs. The pathophysiology and etiology is unclear. Causes for diverticulum dilation are proposed to be chronic preputial diverticulitis with subsequent fibrosis of the preputial cavity, phimosis of the preputial orifice or the preputial diverticulum, but the large majority of cases are reportedly idiopathic in nature. Surgical interventions include ablative procedures, but many cases are not treated because of an assumed lack of clinical relevance in pigs not used for breeding. We report a case of progressive preputial dilation that recurred after surgical intervention. Histopathological examination revealed no primary inflammatory condition, contrary to literature suggesting a role for inflammatory mediators in pathogenesis. Phimosis of the preputial orifice was noted post mortem and might be a contributing factor. These findings partially contradict the current assumptions in regards to pathophysiology and treatment choices in the literature and warrant further investigation into alternative therapeutic interventions for this condition.

Objective: To explore the clinicopathological characteristics, diagnosis and treatment of penile verrucous carcinoma (VC)., Methods: We retrospectively analyzed the clinical data about 18 penile VC patients at the mean age of 52 (35－66) years. The tumors were cauliflower-like, measuring 2.5－8.7 cm in diameter, all with mucopurulentive discharge. A giant tumor invaded the perineum in 1 case, which had a history of surgical excision of penile condyloma acuminatum. The lesions invaded the glans penis in 2 cases, the shafts in 4 (all with a history of phimosis or redundant prepuce), and the whole penis in 11. Partial penectomy was performed for 2 cases with the proximal coronary sulcus involved and another 2 with the condylomata located in the glans penis and measuring <3.5 cm in diameter. Radical surgery was done for 2 cases of glans VC >3.5 cm in diameter, 11 cases with the whole penis involved, and 1 case with the perineum invaded., Results: Postoperative pathology showed well-differentiated tumor cells, negative surgical margins, papillary epithelia with hyperkeratosis and hyperplasia, and lymphocyte infiltration in the surrounding interstitial tissue in all the cases. Neither recurrence nor metastasis was found during the 1 to 8 years of follow-up., Conclusions: Penile VC is a special type of squamous cell carcinoma with little invasiveness and rare regional lymph node or distant metastasis, for the treatment of which partial penectomy or radical surgery confers good prognosis.

Objective: To evaluate the functional and cosmetic result of modified-triple incision preputial plasty for surgical management of phimosis in children., Materials and Methods: This prospective study involved all consecutive children (age 3-15) with phimosis, managed at our Institution in a one-year period. All patients unable to retract the foreskin and symptomatic with episodes of posthitis or balanoposthitis or ballooning of the foreskin with voiding were initially included. After a two-month trial of topic corticosteroids treatment, for patients refractory to conservative ointment treatment, "trident" preputial plasty was offered. This procedure combines two lateral Z-plasty and one middle Y-V plasty. All the procedures were performed as a day care, in general anaesthesia by two senior surgeons. Outpatient follow-up controls were scheduled at 1 and 2 week, 1, 6 and 12 months after surgery, respectively., Results: A total of 41 patient were enrolled. Mean operative time was 24 minutes (range 15-43). At 12-month follow-up, all but one patients (97.6%) was able to retract the prepuce. Cosmetic and functional results were satisfactory., Conclusion: In selected group of children with phimosis, the "trident" preputial plasty provided excellent cosmetic and functional result. Adequate retraction of the prepuce by the patients soon after surgery is mandatory., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate histopathological results of foreskin removed during circumcision in the pediatric age group and the relationship between these and the degree of phimosis., Study Design: Cross-sectional study., Place and Duration of Study: Department of Urology, Samsun Training and Research Hospital, Samsun, Turkey, from June to December 2014., Methodology: Male children undergoing planned circumcision were examined for the presence and degree of phimosis which was recorded before the operation. After circumcision, the preputial skin was dermatopathologically investigated. Pathological investigation carefully evaluated findings such as acute inflammation, chronic inflammation, increased pigmentation and atrophy in addition to findings of Lichen Sclerosus (LS) in all specimens. The pathological findings obtained were classified by degree of phimosis and evaluated., Results: The average age of the 140 children was 6.58 ±2.35 years. While 61 (43.6%) children did not have phimosis, 79 (56.4%) patients had different degrees of phimosis. Classic LS was not identified in any patient. In a total of 14 (10%) children, early period findings of LS were discovered. The frequency of LS with phimosis was 12.6%, without phimosis was 6.5% (p=0.39). The incidence of histopathologically normal skin in non-phimosis and phimosis groups was 37.7% and 22.7%, respectively. In total, 41 (29.3%) of the 140 cases had totally normal foreskin., Conclusion: Important dermatoses such as LS may be observed in foreskin with or without phimosis. The presence of phimosis may be an aggravating factor in the incidence of these dermatoses.

Background: In adults, human papillomaviruses (HPV), lichen sclerosus et atrophicus (LSA) and phimosis are considered to be major risk factors for penile cancer. In boys, a possible association between phimosis, LSA and HPV has been suggested., Objective: To investigate the role of HPV in the persistence of phimosis in children., Patients and Methods: Out of a cohort of 420 boys presenting with foreskin problems, we prospectively sampled the preputial tissue of 82 patients during circumcision: 46 with steroid-naïve and 36 with steroid-resistant phimosis. All foreskins were assessed clinically and histopathologically with regard to appearance, inflammation, oedema, epithelial degeneration and fibrosis. The viral status of the foreskins was determined by immunohistochemistry and highly sensitive PCR, with subsequent subtyping by DNA hybridization (HPV types 6, 11, 16, 18, 31, 33, 35, 39, 42, 44, 45, 51-54, 56, 58, 59, 61, 62, 66-68, 70, 72, 73, 81-84, 90, 91)., Results: The foreskins appeared normal in 62 boys and suggestive of LSA in one single case. Small cracks or white scars were present in seven steroid-naïve and 12 steroid-resistant foreskins. LSA was diagnosed microscopically in two of the steroid-naïve and six of the steroid-pretreated group. No evidence of HPV was found in any of the juvenile foreskins., Conclusions: Our prospective study has provided evidence that HPV is not usually present in the foreskin of boys with persistent phimosis after their first year of life and that topical glucocorticoid treatment failure is not associated with HPV or any specific histopathological changes., (© 2012 The Authors. Journal of the European Academy of Dermatology and Venereology © 2012 European Academy of Dermatology and Venereology.)

Background: The aim of this article is to evaluate the histopathological findings of foreskin after circumcision for medical indications and to find out if analyzing the biopsy is a waste of resources., Material and Methods: This retrospective analysis was carried out of the medical records and histopathological findings of 112 boys who underwent circumcision from June 2002 to June 2005. The study group consisted of 52 boys that were circumcised for medical indications, while the control group consisted of 60 boys who underwent circumcision for religious belief., Results: The mean (range) age of children in the study group was six (2-12) years. 36 boys had phimosis, 15 had recurrent balanoposthitis and one had paraphimosis as an indication for circumcision. Balanitis xerotica obliterans (BXO) was diagnosed in eight out of 52 biopsies (15%). In five of the eight BXO, the histopathological examination revealed focal lichenoid infiltrate which was considered as early form of BXO. There was no suspicion of BXO in the physical examination of those five patients. Chronic inflammation was reported in seven patients, while minor changes in the form of minimal inflammation and oedema were found in another 15 patients. The rest of the biopsies (22 patients) showed normal preputial pathology. The histopathological examinations of the control group revealed chronic inflammation in three patients and acute inflammation with cellular oedema in another three patients., Conclusions: There is a place for routine biopsy after circumcision for medical indications. The clinical examination failed to suspect 5 of the 8 cases of BXO that were diagnosed by histopathology.

Objective: To evaluate the histopathological characteristics and clinical implication of sarcolemma tissue in prepubertal concealed penis., Methods: After measurement of the penile length, 10 prepubertal children with congenital concealed penis underwent modified Devine's operation (treatment group), and another 10 normal prepubertal children received circumcision (control group). The anatomic features of the penile sarcolemma tissue was observed intraoperatively, and its fibrosis was evaluated by Masson trichrome staining., Results: The penile length of the treatment group was significantly shorter than that of the control group preoperatively ([1.49 +/- 0.17 ] cm vs [4.26 +/- 0.23 ] cm, P < 0.01). The degree of penile concealment was correlated with the distal point of the attachment of its sarcolemma fibrous tissue: the closer the distal attachment point was to the coronary ditch, the more serious was penile concealment. The proportion of the area of collagen fibers in the penile sarcolemma tissue was significantly higher in the treatment group than in the control ([65.6 +/- 6.9]% vs [37.1 +/- 4.7]%, P < 0.01)., Conclusion: Sarcolemma fibrosis was obvious in congenital concealed penis, and the key to its management is drastic removal of all the fibrous sarcolemma tissue.

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.)

Background: Diseases of the foreskin may manifest with an array of pathologic findings, including potentially under-recognized dermatologic conditions. Herein, we summarize an institutional experience in foreskin dermatopathology., Methods: Diagnoses rendered on foreskin specimens between 1982 and April 2009 were obtained through a computer-based keyword search. Cases given normal, non-specific or descriptive diagnoses were reviewed by a dermatopathologist., Results: Keyword search yielded 414 foreskin diagnoses. Interpretations included normal foreskin (n = 131), benign lesions (n = 262) and malignant/dysplastic entities (n = 21). Of 353 cases given normal, descriptive or non-specific diagnoses, 334 were reviewed. Of reviewed cases, 209 (63%) were given more specific diagnoses [e.g. spongiotic dermatitis (n = 115), lichen sclerosus et atrophicus (LSA; n = 41), interface/lichenoid dermatitis (n = 26), psoriasiform dermatitis (n = 7)]. Discrepancy between the clinical and pathologic impression was frequently noted (n = 77)., Conclusions: This study shows benign inflammatory lesions represent the most frequent foreskin pathology. When possible, specific diagnoses should be rendered, as accurate classification may be of clinical importance. There is an abundance of recent literature on the role of circumcision in disease prevention, and this topic is explored. We discuss the theoretical possibility that foreskin inflammation compromises the mucosal/epithelial barrier, thus playing a role in disease transmission., (Copyright © 2012 John Wiley & Sons A/S.)

Objective: To investigate Hong Kong Chinese parents' knowledge and attitudes towards phimosis and circumcision., Design: Questionnaire survey., Setting: Four primary schools in Hong Kong., Participants: Anonymous questionnaires were sent to Chinese parents of boys, aged 6 to 12 years old, studying in primary school Grades 1 to 6. Their social backgrounds, attitudes and beliefs towards phimosis and circumcision were enquired into., Results: The parents of 1479 pupils answered the questionnaire, giving a response rate of 95.8%. In all, 10.7% of schoolboys had undergone circumcision, and 11.8% of the fathers were circumcised. Regarding non-circumcised boys, 28.9% of their parents believed that their sons had phimosis and 15.6% believed they would require circumcision later. Among these parents, 57.9% would consider circumcision for their boys in public hospitals, 96.9% thought that public institutions should provide such service, and 82.6% thought that doctors' opinions were most important when deciding about circumcision. Most parents believed that circumcision could prevent balanitis (82.8%) and improve hygiene (81.8%). Significantly more parents from Mainland China and of lower social class believed that circumcision could improve cosmesis, growth of the penis, sexual potency and fertility, and prevent sexually transmitted diseases and penile cancer., Conclusion: Circumcision is not widely practised in Hong Kong. However, it can be a potential burden on surgical services in public hospitals. There are misconceptions concerning phimosis and circumcision, especially in parents from Mainland China and from lower socio-economic classes. Doctors' opinions are the most important factor guiding parental decisions on circumcision. Thus, family physicians' advice and education are important to avoid unnecessary circumcisions.

Abnormalities of the male genitalia have increased in the last 2 decades in numerous developed countries and remain a frequent reason of consultation in pediatric surgery. The diagnostic spectrum is wide, and surgeons should pay particular attention to these abnormalities because of their potential psychological effect. Anatomically, these abnormalities can affect one of three parts of the penis. First, the foreskin may not be fully retracted. This is normal at birth and can be caused by prepuce adherents that can continue until adolescence. Today, true phimosis is treated with topical corticoids from the age of 3 years. If medical treatment fails, a surgical procedure is required. Second, the urethra can be affected by hypospadia, which is the most frequent abnormality of the urethra. It is associated with ectopic urethral meatus, hypoplastic foreskin, and penis curvature. Its pathogenic background is not clearly understood. Surgery options differ according to the type of hypospadia and according to the surgeon's experience. It is sometimes hard to deal with, especially in a perineal form, where genetic and hormonal studies are recommended. These interventions can lead to complications ranging from stenosis to fistula. Therefore, parents have to be informed of the benefits and risks of the surgical procedures. Epispadias is rare but more serious because of the increasing risk of urinary incontinence. Finally, abnormalities of the corpora cavernosa - often associated with hypospadias - can include penis curvature and micropenis, for which an endocrinological analysis is essential., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate histological alterations in prepuce of patients with phimosis submitted to topic treatment with betamethasone in association with hyaluronidase., Materials and Methods: We studied sixty patients (mean age 4.5), presenting true phimosis and treated with a topical treatment with betamethasone cream (0.2%) + hyaluronidase. The parents of seven of these patients opted for circumcision (control group). The other fifty-three patients were submitted to clinical treatment. The samples were stained with Weigert's resorcin-fuchsin (analysis of the elastic fibers) and Picro-Sirius Red, for analysis of the collagen. The volumetric density of the elastic fibers was determined by stereological methods., Results: Only eight (15 %) of the fifty-three patients submitted to topical treatment presented failure, being indicated for circumcision (histological analysis). We observed an increase of the collagen type III of the patients submitted to topical treatment. The quantification showed a reduction of the volumetric density of the prepuce's elastic fibers of the patients submitted to the cream treatment, when compared to the control group (p = 0.056). The volumetric density of the elastic fibers of the prepuce at the group not submitted to topical treatment showed an average of 14.60% (11.06 to 21.64%); in the group submitted to the cream treatment, the volumetric density of the elastic fibers of the prepuce showed an average of 10.34% (3.45 to 17.9%)., Conclusion: The topical treatment of phimosis with betamethasone 0.2 % + hyaluronidase had a success rate of 85 %. Patients with failure of the topical treatment with steroid had histological alterations in the prepuce.

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.)

Introduction: Androgen actions are exerted upon the androgen receptor (AR), and complete genital virilization of normal 46,XY individuals depends on adequate function and expression of the AR gene in a tissue-specific manner., Objective: Standardization of normal ARmRNA in androgen-sensitive tissues., Materials and Methods: In this study, we determined the quantitative amounts of ARmRNA in peripheral blood mononuclear, urethral mucosa and preputial skin cells of control subjects with phimosis by using RT-PCR., Results: The mean (SD) values of AR expression in blood, urethra and prepuce were: 0.01 (0.01); 0.43 (0.32); 0.31 (0.36), respectively., Conclusion: The AR expression is low in blood and equivalent in urethral mucosa and preputial skin, which may be useful in the diagnosis of individuals with abnormal external genitalia.

Introduction: Lichen sclerosus (LS) of the glans penis is a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and urethra and may lead to severe impairment of sexual and urinary function., Aims: To report our experience of surgical management of LS of the glans penis., Main Outcome Measures: Complications, patients' satisfaction, cosmesis, resolution of pain and puritus, and postoperative sexual function and were recorded retrospectively., Methods: The surgical outcome of the 31 patients who have undergone resurfacing of the glans penis with the use of skin grafting for the management of genital LS in our institute is reported., Results: After a median follow-up of 12.8 months, 26 patients (84%) were fully satisfied with cosmetic and functional results, and 71% of them have resumed sexual activity., Conclusions: Resurfacing of the glans penis represents a simple and reproducible technique for the management of LS and yields excellent functional and cosmetic results., (© 2011 International Society for Sexual Medicine.)

Objective: To compare and evaluate dissection and Plastibell(®) circumcision techniques for the treatment of phimosis., Methods: In 2006-2007, 125 children were submitted to circumcision by the same surgeon. The children were randomly divided into two groups (PD: Plastibell(®) and DC: dissection). In both groups the surgery was performed under general anesthesia and dorsal penile block. The dissection circumcision used the double circular incision technique. Follow-up was done on days 15, 45 and 90 after surgery., Results: Sixty-eight patients were included in DC and 57 in PD. The mean age at surgery was 71.76 ± 31.56 months for DC and 70.95 ± 31.73 months for PD. There was no difference in Kayaba's classification for phimosis or indication for surgery between the groups. Surgical time for DC was 14.64 ± 1.93 min and for PD 3.29 ± 1.48 min (P < 0.001). The incidence of immediate complications was similar, but late complications, especially adhesions, were greater in DC (P < 0.01). The use of pain medication (paracetamol) was similar during the first 2 days after surgery, but was greater in PD from the 3rd day after surgery (P < 0.05)., Conclusions: Plastibell(®) circumcision has a shorter surgical duration with fewer late complications, but requires more analgesic medication after the 3rd day post surgery., (Copyright © 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

A 19-year-old man presented with phimosis and painful swelling of the penis four weeks after augmentation with silicone in Thailand. Histology revealed a foreign body reaction to silicone. Infectious causes were ruled out. Granulomatous foreign body reactions to silicone are common, but there are few case reports on reactions following silicone injection for penis enlargement. Foreign body reactions should be included in the differential diagnosis of penis swelling.

Objective: To explore the influence of concealed penis on the morphology of the corpus cavernosum in rats., Methods: Rat models of concealed penis were established by intra-pocket-suture of the root of the penis. Fifty rats were equally assigned to Groups A (2-month) and B (4-month), each further divided into a buried (n = 15) and a normal subgroup (n = 10). Changes in the morphology of the penile cavernous tissue were observed under the light microscope and transmission electron microscope., Results: Compared with Group A, Group B showed significant ultra-structural pathological changes in the corpus cavernosum, including abnormal arrangement of endothelial and smooth muscle cells, massive hyperplasia of interstitial tissues, narrowed cavernous sinus, atrophic smooth muscle cells, degenerated mitochondria, dilated endoplasmic reticula, decreased dense bodies and contractile fibers, and cytoplasmic vacuolization. No significant differences were found in the appearance and weight of the corpus cavernosum between the buried and normal groups (P > 0.05)., Conclusion: Concealed penis does not significantly affect the appearance and weight of the corpus cavernosum, but causes ultra-structural pathological changes in it with the lengthening of time.

Balanitis, phimosis and foreskin adhesions are common indications for foreskin surgery during childhood. In phimosis, the foreskin cannot be drawn behind the glans penis because of the narrow external opening of the former. It is important to be able to distinguish between physiologic and pathologic phimosis, since their treatment is different. In adulthood, the need for surgery can be caused by phimosis, a difficult sequel of paraphimosis, recurrent inflammations of the glans penis and foreskin, diseases and cancers of the skin as well as difficulties at intercourse due to the shortness of the frenulum of the prepuce of the penis.

Objective: Circumcision has been the traditional method of choice in the treatment of boys with phimosis. Recently, several published studies worldwide have focused their interest on more conservative approaches in management of this condition. These studies advocate the use of topical steroids in the phimotic foreskin. We aimed to investigate the efficacy and safety of a medium potency corticosteroid in boys with different types of prepuce retractabilty., Patients and Methods: A prospective study was performed involving boys referred to our hospital for possible phimosis between January 2004 and February 2008. All were treated initially with fluticasone proprionate 0.05% for a period of 4-8 weeks. Patients were reassessed after 6 months of follow up., Results: A total of 1185 boys with a diagnosis of phimosis were treated with fluticasone proprionate 0.05%. Successful results were achieved in 1079 (91.1%) patients including boys with mild balanitis xerotica obliterans. No side effects were noticed., Conclusion: Our results show that fluticasone proprionate 0.05%, a mild potent corticosteroid, is effective and safe in the treatment of boys with different types of phimosis.

Objective: At our institute we usually send the foreskin after circumcision for pathological examination. Does this make sense or is it merely medical overconsumption?, Material and Methods: A retrospective analysis was carried out of all pediatric patients who underwent a circumcision, from August 2005 to January 2008, for persisting pathological phimosis after treatment with topical steroids. Religious circumcisions were excluded., Results: Balanitis xerotica obliterans (BXO) was diagnosed in 37 out of 135 biopsies (27%). In 19 of the 37 boys with pathological evidence of BXO (51%), the physical examination matched the pathology. Meatal stenosis was found in six cases; four were also diagnosed with BXO., Conclusions: In this study, 27% of all biopsies were positive for BXO. The results show that the diagnosis BXO must be based on biopsy, because clinical findings underestimated the incidence of BXO by almost 50%. BXO implies a higher incidence of meatal stenosis, urethral pathology and has a known association with penile carcinoma. We conclude that there is a place for routine biopsy of the foreskin after circumcision for pathological phimosis, taking into account the potential clinical consequences when BXO is diagnosed.

Objective: Young males with lichen sclerosus (LS) commonly present with phimosis; complete urinary obstruction has also been described in this population, but is much rarer. We present the case report of a boy with acute renal failure secondary to urethral obstruction caused by LS, with a review of the literature regarding the occurrence of complete urinary obstruction and renal failure associated with this disease process., Materials and Methods: A comprehensive review of the literature was conducted using MEDLINE and EMBASE to characterize the association of lichen sclerosus with significant obstructive complications of the urinary tract., Results: The true incidence of LS is unknown. Reported rates have ranged from 10% to 95% of boys presenting with phimosis. Our review identified 14 cases of complicated urinary obstruction (seven in children) and two cases of renal failure secondary to lichen sclerosus (both in boys)., Conclusions: Distinctive features make this inflammatory process identifiable to the astute physician, such that new onset of phimosis in a school-age boy should raise clinical suspicion of the diagnosis. Successful outcomes, with medical and/or surgical therapy, are commonplace in this cohort. If undiagnosed, however, progression of LS can lead to significant morbidity in the form of renal failure.

Graft-versus-host disease (GVHD) often complicates allogeneic stem cell transplantation (SCT) and affects mainly the gut, liver, lung and skin. The microscopic morphological features of late-phase sclerodermatous chronic GVHD in the skin, namely epidermal atrophy, lymphoplasmacytic infiltration, dense dermal fibrosis and adnexal atrophy, are histologically indistinguishable from those in sporadic systemic sclerosis, morphoea and the related condition of lichen sclerosus. Mucosal orifices including those of the genitourinary system may be severely affected. We present three SCT recipients with chronic GVHD and severe posthitis leading to phimosis requiring surgery. The excised prepuces showed features of lichen sclerosus including epidermal atrophy and a subepidermal zone of eosinophilic, homogeneous and hyalinized collagen above a band-like lymphoplasmacytic infiltrate. These cases add further evidence to support the notion that penile lichen sclerosus should be included within the expanding sclerodermoid spectrum of late-stage cutaneous chronic GVHD.

Graft-versus-host disease rarely causes genitourinary problems. We report a case of pathological phimosis in a child secondary to chronic graft-versus-host disease.

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.

Background/purpose: Phimosis, owing to the presence of a preputial fibrotic ring, is surgically treated in 1% of children. During the last decade, however, topical steroid treatment has been proposed for phimosis., Methods: We present a double-blind study comparing 0.1% mometasone furoate topical cream vs moisturizing cream (placebo) for the treatment of phimosis. Children aged from 2 to 13 years (n = 110) presenting with phimosis (Kikiro's classification grade 5) and scheduled for circumcision were included in this trial. The patients were evaluated after 8 weeks of topical treatment with moisturizing cream (n = 54) or steroid cream (n = 56). Nonresponders from both groups received an additional 8 weeks of steroid cream treatment., Results: In the steroid group, the ring disappeared and glans exposure was obtained in 49 (88%) of 56 patients vs 28 (52%) of 54 patients in the placebo group (P < .05). After a second treatment, in the steroid group, 5 of the 7 patients were finally cured vs 22 of the 26 in the placebo group (P < .05). Two children with persisting phimosis (Kikiro's retractability grade 5 and appearance grade 3) in the steroid group (4%) vs 4 children in the placebo group (7%) ended up receiving postectomy., Conclusions: The present investigation adds up and supports the effectiveness of phimosis topical corticoid treatment. Nevertheless, hygiene and preputial traction, when appropriately performed, seem to play an important role in the disappearance of the phimotic ring as well. New studies are necessary to confirm if this is true or not.

The authors analyse treatment of 3235 patients with prepuce pathology aged from 8 days to 16 years, the results of the treatment of preputial sac pathology; describe clinical manifestations of phimosis (physiological, hypertrophic, cicatricial) in children; formulate treatment policy, indications and contraindications for conservative and surgical treatment; provide practical recommendations on hygiene and care for infant and young age boys.

Infection from Histoplasma capsulatum is usually subclinical, but it also can be disseminated in patients with a compromised immune status. Involvement of the external genitalia is a rare finding, occurring by direct contact or hematogenous spread. We present a case of histoplasma posthitis in a 71-year-old man, manifesting with the extremely unusual presentation of phimosis. The diagnosis was confirmed using an immunohistochemical stain.

Objective: To review the differences between physiologic and pathologic phimosis, review proper foreskin care, and discuss when it is appropriate to seek consultation regarding a phimotic foreskin., Sources of Information: This paper is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Children's Hospital of Eastern Ontario Urology Clinic. MeSH headings used in our MEDLINE search included "phimosis," "referral and consultation," and "circumcision." Most of the available articles about phimosis and foreskin referrals were retrospective reviews and cohort studies (levels II and III evidence)., Main Message: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiologic and pathologic phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Great anxiety exists among patients and parents regarding non-retractile foreskins. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins. Referrals of patients with physiologic phimosis to urology clinics can create anxiety about the need for surgery among patients and parents, while unnecessarily expanding the waiting list for specialty assessment. Uncircumcised penises require no special care. With normal washing, using soap and water, and gentle retraction during urination and bathing, most foreskins will become retractile over time., Conclusion: Physiologic phimosis is often seen by family physicians. These patients and their parents require reassurance of normalcy and reinforcement of proper preputial hygiene. Consultation should be sought when evidence of pathologic phimosis is present, as this requires surgical management.

Background: We examined the external genitalia of 2149 elementary schoolboys in the suburban area of Taichung in Taiwan for an understanding of foreskin development before adolescence., Methods: The study's subjects comprised 692 first-grade boys, 725 fourth-grade boys, and 732 seventh-grade boys. The foreskin's condition was classified as: type I (normal prepuce), type II (adhesion of prepuce), type III (partial phimosis), type IV (phimosis) and type V (circumcised foreskin). Other abnormalities of the genitalia also were recorded. All of the examinations were performed by the same urologist., Results: The incidence of type I foreskin was 8.2% in first-grade boys, 21.0% in fourth-grade boys, and 58.1% in seventh-grade boys. The incidence of type IV foreskin was 17.1% in first-grade boys, 9.7% in fourth-grade boys, and 1.2% in seventh-grade boys. Only one boy had balanoposthitis. Other abnormalities included inguinal hernia (n = 2), hydrocele (n = 12), cryptorchitism (n = 8), varicocele (n = 22), and subcoronal-type hypospadia (n = 1)., Conclusions: Physiological phimosis declines with age. Most boys with phimosis in this study did not require treatment.

Objective: To evaluate the characteristics of the preputial development in Chinese boys and indications as well as occasion of circumcision., Methods: The shape and retractability of prepuce were evaluated in 1,015 Chinese boys from 0 to 18 years old without heteroplasia of prepuce and penis., Results: Ratio of children with phimosis decreases progressively with increasing age, from 64.09% in the first group (0 approximately 3 years old) to 7.66% in the fourth group (11 approximately 18 years old)., Conclusion: Phimosis and incomplete separation of the prepuce is normal in the neonate and infant. Prepuce will separate from the glans progressively till adolescence, so it's unnecessary to perform circumcision for them when without any complications.

Difficulty in foreskin retraction and phimosis are risk factors for penile carcinoma that may be related to the anatomically variable length of the foreskin. This observation has stimulated us to postulate the hypothesis that foreskin length is related to penile cancer. To compare the foreskin in the general population and patients with penile cancer, an anatomic classification of foreskin was designed. We examined the foreskin of 215 uncircumcised males without cancer (age range 15-93 years) and the foreskin of 23 patients with cancer (age range 31-90 years). Foreskin types were classified as long (with the preputial orifice located beyond glans meatus and entirely covering the glans), medium (with the preputial orifice located between meatus and glans corona), and short (with the preputial orifice located between corona and coronal sulcus). Phimosis was defined as a nonretractable prepuce of the long type. We found that 77% of noncancer population cases had long foreskin and that only 7% of these cases were phimotic. Cancer patients showed long foreskin in 78% of the cases, and phimosis was significantly frequent in this group (52%) as compared with the other (p <0.001). Coexistence of a long foreskin and phimosis may explain the high incidence of penile cancer in some geographic regions. To better document these findings, a comparison of foreskin types in countries with high and low incidence of penile cancer will be interesting. However, because phimosis appears to be a major factor, the presence of long foreskin may be a necessary but not a sufficient condition for cancer development. For these reasons we support preventive circumcision in patients with long and phimotic foreskins living in high-risk areas. Cancers not related to long foreskins and phimosis may be causally different.

We report a 5-week-old boy who developed severe hyponatremia and hyperkalemia secondary to acute pyelonephritis. The patient presented with non-specific signs, including poor appetite, failure to thrive, and dehydration. An endocrinological evaluation led to a diagnosis of pseudohypoaldosteronism. The patient had phimosis, but no congenital urinary tract malformations. Outflow obstruction secondary to the phimosis appears to have caused pyelonephritis, and renal inflammation decreased responsiveness to aldosterone transiently.

Objective: To assess the accuracy of pre-operative diagnosis of preputial pathology ainongst urologists and general surgeons., Patients and Methods: Data were collected on 460 adult patients having had circumcision performed by either a general surgeon or a urologist over a 10-year period., Results: Pre-operative diagnosis was consistent with final histology in 83% of cases and further management was never altered by the histological result. Re-referral rates were 0% for general surgeons and 2.7% for urologists (P > 0.05) and there were no cases needing further surgical intervention., Conclusions: Routine submission of histological specimens for analysis and out-patient follow-up are not required following circumcision.

This prospective study was designed to evaluate the incidence of lichen sclerosus et atrophicus (LSA) in a pediatric population with hypospadias and phimosis in order to discuss the indications for circumcision and utilization of preputial skin for urethral surgery. All 115 boys, 55 with congenital phimosis, 45 with acquired phimosis, 13 with hypospadias, and 2 with recurrent chronic balanitis, underwent full-thickness biopsies of the foreskin that were examined by a single pathologist. Of the patients with acquired phimosis, 88% showed inflammatory features in the foreskin; 60% had LSA. Of the patients with congenital phimosis, 82% showed inflammatory disease in the prepuce; 30% had LSA. Of the patients operated upon for hypospadias, 61% showed histologic findings of chronic inflammation of the foreskin and LSA was evident in 15%. The high incidence of LSA in the prepuce of patients with phimosis suggests that circumcision should be performed to correct this disease. The frequent presence of chronic inflammation is a possible cause of stenosis when the foreskin is used to perform a urethroplasty in patients with hypospadias.

Purpose: We evaluated the clinical effectiveness of topical steroid application for balanitis xerotica obliterans in children and analyzed the association of any clinical response with histological findings., Materials and Methods: Our double-blind, placebo controlled, randomized study included 40 boys in whom balanitis xerotica obliterans was diagnosed clinically by cicatricial phimosis. The severity of phimosis was graded into 4 groups. Patients were randomized to receive the topical application of 0.05% mometasone furoate or placebo. After 5 weeks phimosis severity was reevaluated and all patients underwent circumcision. Surgical specimens were histologically typed as an early, intermediate or late form of balanitis xerotica obliterans., Results: Seven patients were withdrawn from the study. In the steroid group 7 boys had clinical improvement and 10 had no change. Histological study showed an early, intermediate and late form of balanitis xerotica obliterans in 5, 5 and 7 cases, respectively. Of cases with clinical improvement 5 were the early and 2 the intermediate type. In the placebo group 5 cases worsened clinically and 11 did not change. Histological evaluation revealed an early, intermediate and late form of balanitis xerotica obliterans in 3, 7 and 6 boys, respectively. Of the 5 cases with histological worsening, disease was the early, intermediate and late type in 2, 2 and 1, respectively., Conclusions: Applying a potent topical steroid affects improvement in balanitis xerotica obliterans in the histologically early and intermediate stages of disease, and may inhibit further worsening in the late stage.

Background: Narrowing of the prepuce in men is poorly documented, and the causes are often unknown, except in the case of clinical infections or skin diseases such as lichen sclerosus (LS)., Objective: We conducted a histologic study of circumcision specimens with phimosis or paraphimosis., Methods: This prospective study included 43 men with contraction referred for circumcision., Results: LS was present in 32% of cases, but only 12% of these cases of LS had not been diagnosed before circumcision. In 31% of cases the histologic findings were normal. Subacute nonspecific inflammatory changes were diagnosed in 37% of all cases, and secondary narrowing of the prepuce in 62% of cases. It is probable that this histologic modification of the preputial mucosa is involved in narrowing of the prepuce., Conclusion: Phimosis in young adults is usually not associated with LS (only 14%). In contrast, most older patients had secondary phimosis caused by progressive LS (40%) or subacute nonspecific inflammatory changes (40%). Although all cases of phimosis in men should be treated by complete circumcision to prevent penile cancer, paraphimosis associated with preputial dyspareunia, with the exception of cases associated with LS, can be treated by corrective surgery.

There exists a lack of understanding of normal preputial development which is reflected in the large numbers of inappropriate referrals for circumcision. While the scarred prepuce invariably responds best to formal circumcision a more conservative approach is recommended in those symptomatic patients with non-retractile foreskins. In this study, patients referred to the out-patient department with a phimosis were assessed. Those with a phimosis and secondary preputial scarring were listed for circumcision. Those with a narrowed foreskin and a history of recurrent balanitis or local symptoms such as fissuration, thought suitable for a more conservative approach, were listed for preputioplasty. Those with a phimosis but without local symptoms were reassured and discharged. Thirty patients were referred for preputioplasty. One patient developed a post-operative wound infection which settled with oral antibiotics prescribed by his general practitioner. This left him with further preputial adhesions and he later underwent circumcision. The remaining patients reported no post-operative problems at follow-up. Cosmesis was good with high levels of patient satisfaction expressed. All had easily retractile foreskins at follow-up. Large numbers of patients might reasonably benefit from a lateral preputioplasty when presenting with a symptomatic phimosis in the absence of significant scarring of the prepuce. It avoids the needless loss of the foreskin, the importance of which is only now beginning to emerge.

We prospectively evaluated 75 patients, 30-77 years old, with severe phimosis. All patients were treated surgically by complete circumcision and all surgical specimens were sent for histological evaluation. All patients with histologically proven lichen sclerosus et atrophicus (LSA) (eight patients, 10.6%) were re-evaluated 6 months postoperatively, and all but one were examined 5 years after the operation. All patients with histologically proven balanoposthitis (BP) (47 patients, 62.6%) were also re-evaluated 6 months postoperatively, and 41 patients 5 years after surgery. This group (BP) was the control group of our study. Six months after the operation, the eight patients with histologically proven LSA all had an excellent convalescence, and the lesions observed during the operation resolved in four patients and regressed in two patients. In one patient the glans presented with a pale grey-white-coloured plaque. Biopsy was performed and a well-differentiated squamous cell carcinoma infiltrating the glans was revealed. The control group of patients with histologically proven BP were also re-evaluated 6 months and 5 years after surgery. An excellent convalescence was observed in all patients who completed the follow-up examination. Care must be taken not to underestimate the potential relationship between LSA and squamous cell carcinoma, because the latter is usually invasive, very aggressive and requires immediate treatment.