Common and Emergent Problems

of the External Genitalia

Dominic Frimberger, M.D.
Associate Professor
Pediatric Urology
Childrens Hospital of Oklahoma
OU Health Science Center
 Pediatric Urology

Penis Testis
Phimosis Hernia/ Hydrocele
Paraphimosis Undescended testis
Adhesions Varicocele
Buried penis Epididymitis/ Orchitis
Penile pain Torsion
Hypospadias Testis
Appendix Testis
Tumor
 Pediatric Urology
Female Genitalia Other
Labial adhesions Disorders of sexual
Mucosal polyp development (DSD)
Imperforate hymen Bladder/Cloacal
Exstrophy
Tumor
Sexual abuse
Trauma
Infection
 Penile Development
At birth
Prepuce retractable in 4%
Meatus can be seen in 50%
6 month of age
Prepuce retractable in 20%
3 years of age
Prepuce retractable in 90%
Minor adhesions present
Puberty
Almost all completely
retractable
Kaplan G, Urol Clin 1983
 Phimosis
Phimosis
Prepuce cannot be retracted over the glans penis
Physiologic Phimosis
Pliant, unscarred preputial orifice
Pathologic Phimosis
Failure to retract secondary to distal scarring of the prepuce

Leonard M, 2007
 Pathologic Phimosis
Occurs mostly by forcefully pulling back
the prepuce in infancy
Scarring after Infection
Failure of the phimotic preputial ring to
retract after childhood

Osburn et al, Pediatrics 1981

Forceful Retraction
PAIN

Glans
becomes raw
with bleeding

NowMom has to retract

2-3/day to prevent adhesions

Real Adhesions will form

SoMom will stop retracting
Result Everybody is MAD
 Solution
No forceful retraction of the prepuce
If no retraction at all after 5 years or scarring
is present from previous attempts
Betamethasone dipropionate 0.05% cream
(Diprolene) no FDA approval under 16 years of
age
Most important: Parent education about the
natural process
Handouts
Perform circumcision on parents request
 Paraphimosis
Tight preputial ring is
trapped behind the
glans after retraction
Very painful
Edematous preputial
skin and glans
Urinary retention
Requires immediate
attention
Pain
Possible necrosis
Management
Compression
Dorsal slit
 Balanoposthitis
Balanitis (inflammation
of the glans)
Posthitis (inflammation
of the foreskin)
Antibiotics
No surgery in acute
inflammation
Circumcision versus
conservative treatment
Often causes later
adhesions or phimosis