Disclosure. The Pediatric Penis: A maintenance guide from birth through puberty. The Newborn Genital Exam 9/16/2015

Transcription

1 The Pediatric Penis: A maintenance guide from birth through puberty John Gatti, MD Pediatric Urology Disclosure I have no financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. The Newborn Genital Exam Scrotum/Inguinal Canal Well formed Palpable testes Hernia or hydrocele 1

2 The Newborn Genital Exam Penis Foreskin configuration deficient? Meatus Visible Orthotopic large?, figure of 8 Chordee (curvature) Ignore the Raphe The Circumcision Debate Yes UTI risk 23% lifetime 10-fold first year of life STD Risk HIV (50% reduction) HPV (40% reduction) Penile Cancer Cost/Risk if done later Morris, J Urol, 2013 Cultural Preferences No Comp Risk (1%) Sensation/ Function Insurance Coverage? Circumcision Debate Revised AAP Policy Statement of 2012 Inform parents in non-biased manner Support parental choice Decision remains in parents hands Pediatrics,

3 Contraindications to Newborn Circumcision Hypospadias Severe Chordee Epispadias EPISPADIAS HYPOSPADIAS CHORDEE Relative Contraindications to Newborn Circumcision Large Pre-pubic Fat Pad Penoscrotal Webbing Prematurity/ Micropenis Large Hernia/Hydrocele Mayer 2003 Dilemma - MIP Variant MIP = Megameatus Intact Prepuce Glanular Hypospadias with Normal Foreskin MIP Variant Generally Discovered After the Dorsal Slit 3

4 MIP What to do? AAP says STOP! Gatti says, Circ away, my friend! Why the discrepancy? Pediatric guidelines recommend aborting any planned circumcision and to refer to a pediatric urologist for repair between the ages of 6-12 months. Timing: complications increase as children age Accurate diagnosis: increased cost of a free-hand circumcision versus neonatal circumcision. 10-fold + cost increase Risk of General Anesthesia in Infancy 1. Elder, J. Nelson Textbook of Pediatrics 19 th Edition. Saunders, Schoen EJ, et al. J Urol 175: , Hypospadias Referrals 2011 Diagnosis 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60.58% 26.92% 12.50% Hypospadias Other Normal Diagnosis 4

5 So what? 40% of patients had NO hypospadias 8 of 11 with hypospadias had been circ d Uneventful operative hypospadias repair 12 of 14 normal required OR circ Increased cost General instead of local anesthetic Hypospadias repair in the setting of distal hypospadias was not affected by prior neonatal circumcision 12 with Congenital Chordee/Torsion OR repair, but did they need it? Recommendations Within Reason: Hooded foreskin and obvious hypospadias Refer Normal foreskin and questionable hypospadias Finish the circumcision Megameatus discovered after dorsal slit Dealer s choice Circumcision Complications Hematoma 5

6 Circumcision Complications Concealed Penis Circumcision Complications Webbed Penis Circumcision Complications Glans Amputation with Clamp Device Circumcision Injury Glans is an excellent graft bed Performed primary anastomosis with catheter 6

7 Circumcision Complications Thermal Injury from Cauterization of Clamp Ultimately Resulted In Penile Necrosis Circumcision Complications Glans Prolapse Through Plastibell Ring Cutter to Remove Plastibell 7

8 Foreskin Care: Prepuce 101 Gently retract foreskin to limit when cleaning Majority of foreskin retracts by age 5 Use Betamethasone for Pathologic Phimosis 0.05% 2-3x/day x 1-2 months If fails or recurrs Repeat or consider circumcision Adhesions Can be lysed in office using topical anesthetic Dense skin bridges: Clamped and lysed using topical anesthetic Skin tags left by loose plastibell string handled similarly Compress base of penis Apply abx ointment to subcoronal sulcus 3x/d x 7d Can see the purple hue of the coronal margin? leave these filmy adhesions alone Penile Trauma Common Injuries Falling toilet seat Supportive mgt Zipper trauma Break median bar Strangulation by human hair Nair 8

9 Penile Trauma Uncommon Injuries 17 y/o M with GSW to penis Urethra debrided with EE anastomosis Testis & Cord intact Scrotal Trauma Intentional scrotal trauma on the rise! Intentional scrotal injuries Number of reported incidences Year Arther, 2011 Intentional Scrotal Trauma 17 yr old Hit in groin by brother with a Timberland boot Presents to ED 4 days later 9

10 Meatal Stenosis: The Over-diagnosis Does the meatus look small? Most do! Parents will describe Dorsally (or transversely) deviated, pinpoint stream Has to stand on his head to hit the toilet Must point it straight down Without these, explore voiding/stooling pattern Usually seen at time of toilet training Only s/p circumcision (abrasion vs. ischemic) Treatment- meatotomy (OR vs. Office) Priapism Rare in absence of Sickle Cell Disease Painful erection lasting > 4 hours Surgical Emergency: Team approach with Hematology Hydration, oxygenation, pain/anxiety management Surgical therapy with corporal irrigation, vasoconstrictors, shunt Despite treatment, long-term erectile dysfunction is common Can see with hypercoagulable states Lymphoma, leukemia Priapism High Flow Priapism (Non-Emergent) Usually after trauma Arterovenous Fistula Painless Treatment: None Vasoconstrictors (chronic) Embolization Concerns for erectile dysfunction 10

11 Erectile Dysfunction Rare in Pediatrics Large Psychogenic Component Evaluation Deferred into Adulthood with Adult Urologists Non-invasive imaging (Doppler US) Treatments: Phosphodiesterase Inhibitors Penile Prostheses Miscellaneous Penile Pain Largely associated with voiding dysfunction Chordee Late presenting followed through puberty Various Skin Lesions Suture Sinus Tracts Inclusion Cysts at Circumcision Scar or Meatus Pearls at raphe or glans margin GOMCO CIRC: Assessment 11

12 GOMCO CIRC: Technique Take down the Frenulum SST Deformity GOMCO CIRC: Technique Mark the Incision Important! GOMCO CIRC: Technique Dorsal Slit 12

13 GOMCO CIRC: Technique Size to cover 2/3+ of glans Most newborns Clamp and bell MUST match GOMCO CIRC: Technique GOMCO CIRC: Technique Personal fan of Skin Glue 13

14 Thank You! Questions? 14