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Phimosis in Children

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Presentation of circumcision: clinical features, treatment, bioethical considerations

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Phimosis in Children

  1. 1. PHIMOSIS IN CHILDREN – 2016 CLINIC AND BIOETHICAL ASPECTS ABOUT CIRCUMCISION ENGLISH VERSION OF ‘FIMOSE NA CRIANÇA’ ENGLISH REVIEW BY PETER ELLIS, NEW ZEALAND Dario Palhares Pediatrician at the University Hospital of Brasilia PhD in Bioethics of the Unesco Chair of Bioethics of University of Brasília Contact: dariompm@unb.br
  2. 2. CONTENTS  Introduction/Objectives  Anthropological rite  Movements against circumcision  Techniques of circumcision  Phimosis/Excess of foreskin in adults  Ideology of circumcision  The physiological phimosis of the boy  Risks/Benefits  Conclusions
  3. 3. INTRODUCTION  There is much concern amongst medical students and residents of the Outpatients Service of General Pediatrics of University of Brasilia regarding phimosis in boys  The review of literature shows it is a topic of intense bioethical discussion
  4. 4. OBJECTIVES  To understand the differences between the physiological phimosis of boys and the phimosis of adults  To understand the therapeutical approach of children and adults  To recognize circumcision as related to many cultural rites  To recognize ideology of circumcision
  5. 5. CULTURAL RITE  Circumcision has been traditional  It appears in many different cultures in History and is a millenar practice  Today:  The Jews circumcise babies at the seventh day post-birth (in case of prematurity, birth is considered as the day of hospital discharge)  Arabs circumcise prepubescent boys  In many African countries, teenagers are circumcised in group rites (in South Africa it is a practice of certain communities; in Kenya it seems to be a generalized practice)
  6. 6. CULTURAL RITE  Traditionally for Jews, the rabbi circumcised boys; nowadays it is a medical practice  In African countries, ritual circumcision is frequently done by laymen, in terribly unhygienic conditions ( this frequently causes serious complications such as infections, septicemia, lost of the genial organ and death), turning into a problem of public health.
  7. 7. CULTURAL RITE  Circumcision as a cultural rite is ESSENTIAL for bioethical understanding  This is also essential to understand why even the medical information is confusing
  8. 8. MEDICAL PRACTICE  Clinical indications for circumcision in adults include: phimosis, excess foreskin, chronic balanitis (eczematous, fungal, lichen sclerosus, etc).  Without clear reason, in the United States it was a common practice until a few years ago the systematic circumcision of newborns.  In this same country, the movement against circumcision has become very strong  A new cultural phenomenon has appeared: the esthetical treatments of foreskin restoration!
  9. 9. CULTURAL MOVEMENT  In USA, supporters of the cultural movement against circumcision classified the foreskin regarding size (source: http://www.newforeskin.biz/CI/CIchart.htm)  At right, from Ci -1 to Ci - 4 are circumcised men  From Ci - 5 to Ci -10, intact  The candidates of foreskin restoration choose the size they want to reach.
  10. 10. CIRCUMCISION: SURGICAL TECHNIQUES  The previous picture guides the surgery of circumcision. It clarifies what is the syndrome of excess of foreskin.  At right, Dr. Mário Delgado describes the technique that results in Ci 1 to 3: the removal of a cone of foreskin. (source: http://www.youtube.com/watch?v=HD27wbqent4)
  11. 11. CIRCUMCISION: SURGICAL TECHNIQUES  In the youtube channel ‘doutorcirurgias’ of Dr. José A. Souza Costa, there is a technique that results in Ci 4 or 5. source: http://www.youtube.com/watch?v=tu_ob13twsM  At right: picture 1: cleavage of the external phimotic ring. There was eczema in the foreskin.  In picture 2, the foreskin was retracted, exposing the internal mucosa of the foreskin, from which is carried out the cleavage of the internal phimotic ring.  In picture 3, the suture of the internal mucosa with the foreskin is completed (this is the longest step of the procedure)
  12. 12. PHIMOSIS (IN ADULTS)  Phimosis is the incapacity to expose the glans  Causes: a) Idiopathic b) Secondary to chronic or recurrent balanitis c) Lichen sclerosus  Possible consequences : a) Pain during erection b) Paraphimosis (surgical emergency) c) Greater risk of penile cancer d) Adherence of foreskin to glans (to see a complicated case of a surgery of phimosis, watch http://www.youtube.com/watch?v=imbzB09sqOw)
  13. 13. PHIMOSIS: TREATMENT  Medications: one of the side effects of prolonged use of corticoids over the skin is its thinning.  Ointments of corticoids (dexamethasone, hydrocortisone, etc.) are applied inside the stenosed foreskin for 30 to 40 days; it is expected that the foreskin gets thinner hence exposing the glans.  Some ointments combine hyaluronidase to the corticoid: this seems to improve the efficacy of the treatment.  If the use of ointments doesn´t work, the surgical treatment is indicated (circumcision)
  14. 14. PHIMOSIS: REPORT OF A PATIENT  Here it follows a true report: I was 26 years-old, had a fiancée and was about to marry. I´ve always had phimosis and it bothered me during sex: the foreskin tried to retract back and I had the sensation that the skin was about to tear. Not only was I afraid of surgeries in general but also I would not like to stand with a sensitive organ such as the glans exposed all the time. By chance, a doctor prescribed me a pomade of dexamethasone. I applied it two or three times a day inside of the foreskin. After exactly 30 days, during a shower, the foreskin retracted normally, as if it always had done that. There was some white mass accumulated that I washed immediately. I noticed that throughout the day my glans got exposed several times and rubbed against the clothes. That was painful and uncomfortable. It tooks some weeks until my glans got thickened and stopped hurting. My sexual life improved a lot. Today, I think that I should have treated myself earlier, perhaps around 14 years, maybe’.
  15. 15. SYNDROME OF EXCESS FORESKIN  In men with Ci 9 or Ci 10, the glans stands always covered, which may cause the epithelium to become too thin. This provokes discomfort during the sexual act or when the glans rubs clothes. In these patients, the partial removal of foreskin can improve sexual life.  Therefore, excess foreskin is not merely anatomical fact, but a group of associated symptoms.  Being the symptoms of sexual nature, the idea of excess foreskin should not be considered during childhood, before complete genital development.
  16. 16. IDEOLOGY  Circumcision would not be questioned if it was a practice restricted to the clinical-surgical environment.  All anesthesic-surgical procedures have their risks and complications. Circumcision this is not different.  However, since it is traditional of many peoples, there are ideologies that try to use the ‘medical-scientific truths’ to validate and justify what has been a cultural practice.
  17. 17. IDEOLOGY  There are at least three ideologies about cultural circumcision a) Prevention of HIV b) Prevention of uterine cervix cancer of the female partners of circumcised men c) Prevention of urinary tract infections in babies  Let´s analyse each one.
  18. 18. IDEOLOGY: PREVENTION OF HIV  Case-control studies and also clinical essays have shown the reduction of the risk of HIV in circumcised heterosexual men.  It is a modest and variable reduction, of between 30 to 60%, in a period of up to two years of observation, with a statistically significant difference.  That doesn´t mean much: the infection rate in the studied groups was low, that is, for more than 95% of the studied men, circumcision was insignificant.
  19. 19. IDEOLOGY: PREVENTION OF HIV  From the point of view of the microbiological science, these are interesting data.  WHO was soon and quickly dominated by professionals who preach massive circumcision to face the HIV epidemics.
  20. 20. IDEOLOGY: PREVENTION OF HIV  It is only possible to understand the position of WHO under the lights of a cultural practice.  From the strict point of view of science the data simply suggest delay in the infection of heterosexual men, not complete protection.
  21. 21. IDEOLOGY: PREVENTION OF HIV  The map at right shows the prevalence of circumcsion in the world. (source: World Health Organization. Male Circumcision (2007)  Two examples of developing countries: South Africa has a high circumcision rate and more than 40% of the pregnant women are seropositive. Brazil has a low rate of circumcision and the prevalence of HIV in pregnant women is less than 1%  (in this example, the parameter of pregnant women acts as an indirect indicator of prevalence of HIV among heterosexual men, who would be supposedly protected by circumcision)
  22. 22. IDEOLOGY: PREVENTION OF HIV  What effectively protects the population against the spread of HIV is the use of condoms and early diagnosis.  Circumcision has no epidemiological significance for HIV infection.  This is an ideology that maintains cultural rites of circumcision  It affirms inept rulers in their claim to ‘fight’ HIV with circumcision.
  23. 23. IDEOLOGY: PREVENTION OF CERVICAL CANCER  It appears in the literature, but it has been overlooked by the simple fact that cervical cancer has more to do with general conditions of life and hygiene than to the removal of foreskins.
  24. 24. IDEOLOGY: PREVENTION OF URINARY TRACT INFECTION IN NEWBORNS  Since the decade of 1980s, several epidemiological studies have shown circumcised babies present a lower incidence of urinary tract infections.
  25. 25. IDEOLOGY: PREVENTION OF URINARY TRACT INFECTION IN NEWBORNS  However, there is a systematic bias in these studies: the urinary tract infection has been diagnosed on midestream urine culture!  Obviously, in clinical practice, babies with infectious symptoms and a positive urine culture will be diagnosed as urinary infected and treated.
  26. 26. IDEOLOGY: PREVENTION OF URINARY TRACT INFECTION IN NEWBORNS  To epidemiologically define the urinary tract infection, the physiological phimosis of the baby doesn´t distinguish what is urinary tract infection from balanopostitis.  Adult men are asked to retract the foreskin before collecting urine for exams. Why? Because the urinary flow, passing through the foreskin, is colonized with bacteria from the foreskin, which can give false-positive results.
  27. 27. IDEOLOGY: PREVENTION OF URINARY TRACT INFECTION IN NEWBORNS  Apart from this methodologic bias, it would be necessary 111 circumcisions in babies so 1 baby had 1 less episode of urinary tract infection.  From these 111, about 5 to 10 are expected to present complications that can go from a simple seroma to the loss of the genital organ!
  28. 28. THE PHYSIOLOGICAL PHIMOSIS OF THE BOY  Foreskin is grown and differentiated between the third and the fifth months of pregnancy  The foreskin epithelium grows adhered to the glans.  After birth, the epithelium of the glans starts to keratinize, which separates the foreskin from the glans.
  29. 29. THE PHYSIOLOGICAL PHIMOSIS OF THE BOY  At birth, less than 4% of boys expose the glans  At three years of age, 10% of the boys still don´t have a retractable foreskin.  It is not a surprise that the majority of surgeries of ‘phimosis’ in childhood are carried out before the age of 4 years...
  30. 30. THE PHYSIOLOGICAL PHIMOSIS OF THE BOY  The nomenclature of the phimosis of adults follows the phases of the evolution of the infantile foreskin.  The picture at right is a baby. The orifice of the foreskin is narrow; the foreskin is adhered to the glans.  If a pre-adolescent or an adult is found in a similar situation, he is classified as having phimosis degree 1.  In babies this phimosis is physiological, but in older children it can provoke symptoms of urinary obstruction, with indication of circumcision. http://www.youtube.com/watch?v=_lxcdtulSrA For a complex case of surgery of phimosis degree 1 in an adult man, watch also http://www.youtube.com/watch?v=imbzB09sqOw
  31. 31. THE PHYSIOLOGICAL PHIMOSIS OF THE BOY  With genital development, the foreskin starts to detach from the glans, but it is still adhered.  This stage, if persisent in adolescent/adult, is named as phimosis degree 2.  The first picture shows the beginning of the physical exam in a 3 year-old boy. The foreskin was smoothly retracted and loose for three times. After the third time it exposed part of the glans (second picture).
  32. 32. THE PHYSIOLOGICAL PHIMOSIS OF THE BOY  Adherence of foreskin to glans are common and normal and are resolved until adolescence.  At right, a 4 year-old boy with a retractable foreskin, but with a point of adherence (arrow).
  33. 33. PHIMOSIS IN CHILDREN  At right, a 6 year-old boy who had a non-retractable foreskin with an external fibrotic ring (see the whitish and fibrous aspect of the ring, probably a mild form of lichen sclerosus).  After 20 days of topical use of a cream of busonide, the foreskin retracted, evolving from the degree 1 to the degree 2 (inferior picture).
  34. 34. PHIMOSIS IN CHILDREN  A rare condition is the obstruction to urinary flow, which is an indication for circumcision as soon as possible (see picture).
  35. 35. PHIMOSIS IN CHILDREN  To see if there is obstruction to urinary flow, the foreskin must be pushed forwards to see if there is space.  The boy of the picture presented with phimosis due to lichen sclerosus, which was not resolved with 2 months of topic corticoids
  36. 36. RISKS AND BENEFITS FROM CIRCUMCISION  Risks (overall occurrence of these: 3 to 5%)  Bleeding  Deiscence of sutures  Infection of surgical wound (and in extreme cases, loss of the genital organ, sepsis)  In the newborn: narrowing of urethra  Keloid/hypertrophic scar  Hyperpigmentation of glans  Risks of local anesthesia  Risks of general anesthesia (often indicated between 1 and 10 years of age)  Benefits  To the newborn: none  To the boy: none  To the pre-adolescent: possible prevention of paraphimosis  To adolescent/adult: related to sexual life
  37. 37. CONCLUSIONS  The literature show: a) In childhood, there is no clinical indication for circumcision (except in some specific cases) b) Phimosis should not be, in general, a medical concern before pre-adolescence c) The overall surgical risks of circumcision in children is low (but not zero)
  38. 38. CONCLUSIONS  Regarding the cultural rites of circumcision in children: a) If done by people without adequate information (laymen), it is a procedure of unacceptable risks b) If done by doctors, the data don´t support the practice, but also don´t condemn it. So: in secular hospitals of secular States, it is unacceptable to circumcise boys for cultural or religious reasons. The doctors should not be a priori condemned if they carry out cultural circumcisions in boys, but they should be sanctioned in case of severe complications from surgeries that had no clinical indication.
  39. 39. REFERENCES THAT WERE NOT CITED THROUGHOUT THE PRESENTATION  Achkar M. Clinical analysis and anatomopathologic reseach on patient prepuces referred to postectomy. Anais Brasileiros de Dermatologia 2004; 79(1): 29-37.  Arie S. Circuncisão. BMJ Brasil 2010; 3(29): 532-536.  Christakis N. Isso funciona para você? BMJ Brasil 2008; 337:a2281.  Drake T. Fimose na infância. BMJ Brasil 2010; 6(62): 564-575.  Grewal S. Circumcision for the prevention of urinary tract infection in boys. Archives of Disease of Childhood 2005; 90(8): 853-858  Iasi M. Fimose. In: Sociedade Brasileira de Pediatria. Tratado de Pediatria. 2ª ed. São Paulo: Editora Manole, 2010.  Kaplan G. Complications of Circumcision. Urologic Clinics of North America 1983; 10(3): 543-549.  Krieger JN. Adult Male Circumcision Outcomes. Urologia Internationalis 2007; 78(3): 235- 240.  Palhares D, Squinca F. Ethical challenges of female genital mutilation and of male circumcision. Revista Bioética 2013; 21(3): 432-437. Disponível em http://revistabioetica.cfm.org.br/index.php/revista_bioetica  Weiss HA. Complications of circumcision in male neonates, infants and children. BMC Urology 2010; 10: 2 doi:10.1186/1471-2490-10-2

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