Smegma

Smegma is formed from desquamated cells and accumulates beneath the adherent foreskin. It appears as asymmetrical accumulations of yellow-tinged material, predominantly in the coronal groove beneath the foreskin (Fig. 9.1.1). There may be sufficient smegma to produce a noticeable swelling, which may be misdiagnosed as a dermoid cyst or tumour. It is often misinterpreted as being mid-shaft because a small child’s coronal groove may be a long way from the tip of the foreskin. Smegma is normal, and is released spontaneously as the foreskin separates from the glans. When it is released, it may be associated with some redness and irritation of the foreskin for a day or so; this, too, is a normal process.

Fig. 9.1.1 (A) Accumulation of smegma beneath the normal foreskin. The swellings caused by the smegma are in the region of the coronal groove. (B) On retraction, smegma appears as accumulations of material beneath a foreskin that has not yet separated from the glans.

Balanitis

Infection can develop beneath the foreskin and, if severe, pus may appear from the end of the foreskin. Balanitis is often associated with phimosis. Infection may cause considerable redness and swelling of the penile shaft, necessitating treatment with either topical or oral antibiotics.

Phimosis

In phimosis the opening at the tip of the foreskin has narrowed down to such a degree that the foreskin cannot be retracted (Fig. 9.1.2). The external urethral meatus is not visible. Phimosis must be distinguished from the normal adherence of the foreskin to the glans. In most boys, phimosis can be treated by topical application of steroid ointment (e.g. betamethasone valerate ointment) to the tight, shiny part of the partially retracted foreskin. This usually obviates the need for circumcision. However, marked previous inflammation, infection, skin splitting and balanitis xerotica obliterans (BXO) can lead to marked scarring of the foreskin and phimosis, and in many of these children the only reasonable treatment is circumcision. Sometimes the severity of phimosis is such that there is ballooning of the foreskin on micturition, and on rare occasions it may even cause urinary retention with a distended bladder. A degree of phimosis is common in infancy but tends to resolve spontaneously in the first few years of life, and is not considered abnormal in this age group.

Fig. 9.1.2 In phimosis, the foreskin is narrowed and cannot be retracted.

Paraphimosis

Paraphimosis occurs when a mildly phimotic foreskin has been retracted over the glans and has become stuck behind the coronal groove, causing oedema of itself and the glans (Fig. 9.1.3). It is a painful and progressive process. Treatment involves gentle manipulation of the foreskin forwards; this may require a general anaesthetic. Circumcision is not performed at this time, but a few children may need it subsequently if the phimosis does not respond to topical application of steroid ointment.

Fig. 9.1.3 In paraphimosis, the foreskin is stuck behind the coronal groove.

Hypospadias

It is important to recognize hypospadias when it is present (Fig. 9.1.4). The dorsal foreskin looks square and hangs off the penis, whereas the ventral foreskin is deficient, and the shaft of the penis is bent ventrally. The two main problems in hypospadias are:

Fig. 9.1.4 In hypospadias, the ventral shaft of the penis is angulated and shortened (chordee), the urethral meatus is ventrally placed and the foreskin is deficient on the underside. (A) Ventral aspect; (B) lateral aspect.

Circumcision is absolutely contraindicated in hypospadias because the skin of the foreskin is used during the hypospadias repair. Severe hypospadias may be indicative of an intersex abnormality. For example, when there is penoscrotal hypospadias and a bifid scrotum, the scrotum should be examined carefully for testes, as some of these children may be females with congenital adrenal hyperplasia; the labioscrotal folds are labia rather than scrota, and the presumed urethral opening may in fact be the entrance to the vagina (see Chapter 19.3).

Circumcision

The indications for circumcision remain controversial. Phimosis resulting from balanitis xerotica obliterans (see above) is the only undisputed indication. In many countries, circumcision has been abandoned in the neonatal period because of its relatively high complication rate. Apart from the risk of septicaemia and meningitis when performed in the relatively immunologically immature neonate, there are a number of problems that may occur during circumcision at any age. These include removal of too much or too little foreskin, postoperative bleeding and infection. Haemorrhage postoperatively occasionally requires surgical reintervention. The most troublesome and common complication of circumcision is abrasion and ulceration of the sensitive glans, particularly near the urethral meatus. As the meatal ulceration heals it may produce meatal stenosis and require a meatotomy to re-establish an adequate urinary stream.

Epispadias

Epispadias is a very rare condition in which the urethra opens on to the dorsal aspect of the base of the penis. Epispadias is part of a spectrum of lower abdominal wall defects in which ectopia vesicae (bladder exstrophy) and cloacal exstrophy are the most severe forms. Boys with epispadias are often incontinent of urine because the sphincter of the bladder neck is also deficient.

Inguinal hernia

After the testis has descended into the scrotum during the seventh month of pregnancy, the canal down which it migrates, the processus vaginalis, should obliterate. Failure of obliteration of the processus vaginalis may produce an inguinal hernia, a hydrocele or an encysted hydrocele of the cord.

A widely patent proximal processus vaginalis allows bowel (and, in girls, the ovary as well) to enter the inguinal canal, producing a reducible lump in the groin called an indirect inguinal hernia (Fig. 9.1.5). This occurs in about 2% of infant boys but is less frequent in girls. The greatest incidence is in the first year of life.

Fig. 9.1.5 Large bilateral inguinal herniae.

The usual presentation is that of an intermittent swelling, overlying the external inguinal ring, that has been noticed by a parent. At times it may appear to cause discomfort. It is most likely to be obvious during an episode of crying or straining, and in infants may be seen during nappy changes. Inguinal herniae should be repaired as soon as practicable.

Strangulation of inguinal herniae is common, particularly during the first 6 months of life. Strangulation can be recognized when the groin swelling becomes irreducible. If left untreated, a strangulated hernia may damage the trapped bowel and, occasionally, by compressing the testicular vessels, may lead to testicular atrophy. For this reason, an immediate attempt should be made to reduce the hernia manually. This is done by first manoeuvring the hernial contents through the external inguinal ring, and then reducing them along the line of the inguinal canal. Fortunately, most herniae that become stuck can be reduced manually; the hernia can then be repaired as an elective procedure within a few days. This is best done in a specialist paediatric surgical centre.

Hydrocele

A hydrocele presents as a painless cystic swelling around the testis in the scrotum (Fig. 9.1.6). It contains peritoneal fluid that has tracked down a narrow but patent processus vaginalis. It transilluminates brilliantly. When the hydrocele is lax, the testis can be felt within it. The upper limit of the hydrocele can be demonstrated distal to the external inguinal ring, distinguishing it from an inguinal hernia where the swelling extends through the external inguinal ring. There is no impulse on crying or straining.

Fig. 9.1.6 Right hydrocele.

Hydroceles are common in the first few months of life, do not cause discomfort and usually disappear spontaneously within a year. Surgery involves an inguinal herniotomy and is indicated only if the hydrocele persists beyond 2 years of age.

Undescended testis

Undescended testis (or cryptorchidism) is a term used to describe the testis that does not reside spontaneously in the scrotum. Cryptorchidism occurs in about 2% of boys, being more common in premature infants. Spontaneous descent of the testis is unlikely beyond 3 months post-term. Cryptorchidism is important to detect because it can result in reduced fertility if left untreated. It is suspected that the higher temperature to which an undescended testis is subject impairs spermatogenesis.

The diagnosis is made by examining the inguinoscrotal region. Normally, the testis should be found within the scrotal sac. In cryptorchidism the scrotum looks empty (Fig. 9.1.7). The testis is ‘milked’ down the line of the inguinal canal towards the scrotum with the left hand and pulled gently towards the scrotum with the right hand. If the testis cannot be brought into the scrotum, or will not remain there spontaneously, it is considered undescended.

Fig. 9.1.7 Right undescended testis.

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