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Konoma Svetlana Mursalovna. Physiological and pathological changes in the prepuceal sac in children - diagnostics, management tactics: dissertation... Candidate of Medical Sciences: 14.00.35 / Konoma Svetlana Mursalovna; [Place of defense: State Educational Institution "Russian Medical Academy of Postgraduate Education"]. - Moscow, 2008. - 111 p. : 68 ill. RSL OD,
Introduction
CHAPTER 1. Current state of the issue (literature review) 15
1.1. Background 15
1.2. Embryogenesis of the preputial sac 18
1.3. Anatomical and physiological aspects of the development of the preputial sac 23
1.4. Modern directions, methods of treatment of pathological changes in the preputial sac in children 29
1.5. Types of surgical interventions on the preputial sac 49
CHAPTER 2. Materials and research methods 54
2.1. Study design and data collection methods 54
2.2. Research materials 56
2.3. Research methods 60
2.3.1. Mandatory examination methods 60
2.3.2. Additional examination methods: 63
CHAPTER 3. Physiological changes in the preputial sac in children 68
3.1. Congenital physiological phimosis. Comparative results of using two different management tactics. Complications and preventive measures 68
3.2. Physiological synechiae of the preputial sac in children. Research on the feasibility of dividing synechia, comparative groups. Lead tactics 81
3.3. Physiological accumulations of smegma. Research on the feasibility of removing smegma accumulations, comparative groups. Lead tactics 89
CHAPTER 4. Pathological changes in the trepputial sac in children 97
4.1. Congenital hypertrophic phimosis. Comparative results of conservative and surgical treatment. Complications of surgical treatment and methods of their prevention 97
4.2. Paraphimosis. Clinic. Reasons for development. Treatment 106
4.3. Acquired cicatricial phimosis (complicated, uncomplicated). Etiology. Clinical manifestations. Surgical treatment. Complications and measures to prevent them 109
4.4. Inflammatory changes in the preputial sac 118
4.4.1. Balanoposthitis of coccobacillary etiology, clinic. Comparative results of treatment of balanoposthitis
in groups using two different techniques 119
4.4.2. Balanoposthitis of fungal etiology, clinical features, treatment 123
4.4.3. Allergic changes in the preputial sac. Clinical manifestations, treatment 124
4.5. Benign volumetric formations of the preputial sac and congenital malformations of its development. Treatment methods 126
4.6. Working classification and differential diagnostic algorithm of physiological and pathological changes in the preputial sac in children 128
CHAPTER 5. Long-term results of treatment of forms of phimosis and inflammatory changes in the preputial sac in children 133
5.1. Long-term results of treatment of forms of phimosis in children 133
5.2. Long-term results of treatment of inflammatory changes in the preputial sac in children 135
Conclusion 137
Bibliography
Introduction to the work
Relevance of the topic. The issues of early diagnosis and treatment of phimosis in children have not yet received their final resolution. Assessment of the condition of the preputial sac (IM) in pediatric practice remains the subject of discussion among pediatricians, pediatric surgeons, and pediatric urologists in Russia and abroad (Dukhanov A.Ya. 1968, Isakov Yu.F. 1970, Lopatkin N.A. 1986, Pugachev A. G. 1986, Graham G. 1983, Duckett J. 1988, Walker J. 1989, Mac-Kinlay G. 1988, Soloviev A.E. 1995, DewamP:, Tieu H. 1996, Rudin Yu:E: 1999, Orsola A., Caffaratti J., Garat J. 2000). Experts have different opinions and offer diametrically opposed recommendations for the treatment and prevention of diseases TIM". When conducting preventive examinations, doctors at children's clinics do not pay due attention to the age-related characteristics of PM. There is no single point of view 1 in the definition of the concept * physiological phimosis (FF), there is no pathological classification of the preputial sac convenient for practical “application”, the boundaries between the norm 1 and pathology are not clearly defined. There are differences of opinion regarding accumulations of smegma and the presence of synechiae (fusion of the head with the inner leaf of the PM), consider these conditions normal or pathological? How dangerous is the presence of smegma for the occurrence of balanoposthitis? Is it necessary to separate synechiae in children under 10 years of age? Do you need active tactics or is it advisable to take a wait-and-see approach? Can recommendations for immediate removal of the head be considered justified? boys with physiological phimosis? How often do iatrogenic damage to the PM, cicatricial phimosis (RF) and paraphimosis occur after these manipulations? There are different points of view on treatment tactics and the scope of surgical care for patients with purulent-inflammatory diseases of the PM. Practical recommendations on methods of hygienic care for the genitals of a boy in the younger age group are often compiled by non-specialists, people far from practice, without
7 assessment of long-term results, confirmed by large clinical material with the reliability of statistical indicators.
Thus, the identification and treatment of pathological conditions of the preputial sac is considered an urgent problem in pediatric surgery and pediatric urology-andrology. Our study was devoted to solving all these issues.
GOAL OF THE WORK
Qualitative improvement of diagnosis and determination of treatment tactics for various forms of phimosis and changes in the preputial sac in children.
RESEARCH OBJECTIVES
To identify variants of physiological and pathological changes in the preputial sac and to determine the characteristics of the forms of phimosis in childhood. To create a working classification of physiological and pathological changes in the preputial sac and a differential diagnostic algorithm.
To develop rational tactics for the management of children with physiological and hypertrophic phimosis (HF). To establish the effectiveness of gradual stretching of the preputial ring (PR) in comparison with traumatic one-step removal of the glans penis.
31 Determine the tactics for managing children with synechiae and smegma accumulations in the preputial sac in age groups. To prove the unjustifiedness of surgical separation of synechiae. To evaluate the effectiveness of delayed circumference of the glans penis (PG). To identify the connection between smegmal accumulations and inflammatory changes in the preputial sac:
To analyze the results of surgical treatment of cicatricial and hypertrophic phimosis*. Clarify the causes of complications and propose basic preventive measures. To develop optimal treatment methods for children with hypertrophic phimosis.
To clarify the scope of surgical care in the treatment of purulent-inflammatory diseases of the preputial sac (acute, balanoposthitis, fungal infections). To prove that local drainage of the preputial sac is a rational conservative tactic in children with balanoposthitis.
SCIENTIFIC NOVELTY
For the first time, using large clinical material, the main variants of physiological and pathological conditions of the preputial sac, leading to difficulty in excretion, have been described in detail. \ glans penis.
Clear definitions of the forms of phimosis are given. Proposed working I classification and differential diagnostic algorithm
physiological and pathological changes in the preputial sac
based on an analysis of the variety of clinical manifestations, with
taking into account the age-related characteristics of the PM condition, allowing for a clear
determine the tactics and method of treating prepuce pathology.
1 3. Method of gradual, gentle stretching of the pretrial sac
allows you to achieve elimination-narrowing in 1 2-3 months. for the majority. (93%) children with physiological and (91.3%) with hypertrophic phimosis for 4-6 months.
4. It has been established that the method of treating phimosis by one-step
complete removal of the glans penis 1 has no medical
indications is erroneous, especially in younger age groups,
I because it leads to injury and scarring of the preputial sac.
5. For the first time it has been proven that synechiae are stages of development
preputial sac. Separation of synechia in young children
age group not shown. In the absence of inflammation
preputial sac, their existence is permissible up to 12-13 years.
6. It has been revealed that accumulations of smegma by themselves do not lead to
1 inflammation of the preputial sac, are not the main cause
, balanoposthitis and do not require removal, since gradually
migrate and independently evacuate from the preputial sac.
PRACTICAL SIGNIFICANCE
The applied method of gradual, gentle stretching of the narrow preputial ring after warm hygienic baths with a decoction of herbs (chamomile, string, celandine) 1-2 times a week allows achieving removal of the head in 93% of cases within 1 to 3 months. Long-term results confirm the effectiveness of this method.
It is important to achieve free removal of the head of the penis by the prepubertal period (12-13 years), in order to teach a teenager the rules of hygiene and prepare the young man for upcoming sexual activity. Before prepubertal age, there are no medical indications for separating synechiae and completely removing the head, since complete free removal of the head is necessary for painless sexual intercourse.
Actively limiting the use of the technique of simultaneous complete removal of the head in case of phimosis makes it possible to reduce the number of iatrogenic damage to the preputial ring and its cicatricial changes.
Waiting tactics allows you to eliminate unnecessary painful manipulations to eliminate phimosis, separate synechiae and remove accumulations of smegma and prevent possible complications.
Constant use of antiseptics for hygiene purposes can lead to dysbacteriosis and fungal infections of the preputial sac.
The proposed differential diagnostic algorithm allows the doctor, during an outpatient examination, to identify groups of children: those requiring general supervision, those at risk and those in need of strict outpatient monitoring or surgical treatment.
Sanitary educational work among parents on compliance with the proposed boy hygiene rules helps reduce the number
chronic inflammatory changes in the preputial sac, and, as a consequence, cicatricial phimosis.
BASIC PROVISIONS OF THE DISSERTATION SUBMITTED FOR DEFENSE
The reasons for the narrowing of the preputial sac in boys are associated with age-related characteristics of the formation of the preputial ring and are qualitatively different from phimosis in an adult man.
Children with physiological phimosis, especially the younger age group, do not require surgical intervention, since conservative tactics are effective in 93% of cases.
The method of simultaneous removal of the glans penis should be limited, since in physiological and hypertrophic phimosis in 43.7% of cases it leads to iatrogenic damage to the prepuce and the development of cicatricial phimosis, in 14.6% it is ineffective (phimosis persists).
Synechiae are stages of development of the preputial sac; they are most recorded in younger age groups. The formation of the preputial space is completed during puberty. Simultaneous separation of synechiae is a painful, ineffective procedure and is accompanied by relapse (80.6%) in children under 3 years of age.
Removal of accumulations of smegma of the preputial sac is not indicated, since they recur in 77.1% of cases. Accumulations of smegma are not the main cause of balanoposthitis. Infection most often occurs during various manipulations and procedures with the preputial sac.
Simultaneous removal of the head of the penis during acute inflammatory diseases of the preputial sac leads to deep tears and scar changes, which requires circumcision in 25% of cases. Drainage of the preputial sac without removing the head of the penis is a more effective and less traumatic method of treatment.
Conservative tactics for hypertrophic phimosis are effective in 91.3% of cases. Circumcision for hypertrophic cicatricial phimosis in children with increased body weight is dangerous due to recurrence of phimosis or hidden sexual intercourse
13 member The operation of choice may be economical resection of the preputial sac with the formation of the contour of the penis.
The presented working classification and differential diagnostic algorithm of physiological and pathological changes in the preputial sac help in choosing tactics for managing the child.
APPROBATION OF THE WORK
The dissertation research materials were presented and discussed at: the symposium “New Technologies in Pediatrics and Pediatric Surgery” (Moscow, 2005), the 4th Russian Scientific Forum “Men’s Health and Longevity” (Moscow, 2006).
The main provisions of the dissertation were reported and discussed at a joint scientific and practical conference of the Department of Pediatric Surgery of the Russian Medical Academy of Postgraduate Education and the Children's Clinical Hospital of St. Vladimir, 02/01/2008; (protocol No. 228). The results of the work were reported at a meeting of the Scientific Council of the Russian Medical Academy of Postgraduate Education in Moscow.
PUBLICATIONS
20 published works were published, 8 on the topic of the dissertation, including one article in the central press (Urology magazine, 2007); article in the collection of materials of the 4th Russian Scientific Forum “Men’s Health and Longevity” (Moscow 2006); in the collection of materials of the scientific and practical conference dedicated to the 50th anniversary of the Department of Children's Infectious Diseases Rost State Medical University, 2006 - 2 articles; in the collection of materials of the annual joint scientific and practical conference of departments of surgical diseases* No. 2 and 4 of the State Educational Institution of Higher Professional Education Rost State Medical University of Roszdrav, Rostov-on-Don, 2007 - 1 article. A textbook for doctors “Pathology of the foreskin. Methods of treatment in childhood" (RMAPO, Moscow, 2006).
This work was carried out at the Department of Pediatric Surgery (Head of the Department - Doctor of Medical Sciences, Professor Sokolov Yu.Yu.) RMAPO (Rector, Academician
14 RAMS, Professor Moshetova L.K.), on the basis of the State Children's Clinical Hospital of St. Vladimir (chief physician Kasyanov P.P.) in Moscow and the Children's City Hospital of Taganrog (chief physician Kuvikov V.F.).
SCOPE AND STRUCTURE OF THE DISSERTATION
The dissertation is presented on 179 pages of typewritten text and consists of an introduction, a literature review, 5 chapters of own research, a conclusion, conclusions, practical recommendations, a literature index and an appendix.
The work is illustrated with 6 tables and 59 drawings. The bibliography contains 90 sources, of which 23 are works by domestic authors and 67 works by foreign authors.
The PM, covering the head of the penis, is an important natural anatomical part of the external genitalia in humans. The outer epithelium has a protective function, covering the glans penis, meatus and inner preputial epithelium, which reduces the risk of irritation and contamination. PM is a special connective mucocutaneous tissue that forms the boundary between the mucous membrane and the skin; it is similar to the skin of the eyelids, labia minora, anus, and lips. In addition, the PM in men provides sufficient mucocutaneous coverage of the entire penis during erection. The unique innervation of the PM also performs an erogenous function.
According to A. Orsola, the CP is a specialized mucocutaneous connective tissue, equipped with nerves, that forms the anatomical membrane of the head of the penis. At the birth of a child, it is usually unretractable, because the inner epithelial surface is connected to the head of the penis; this normal anatomical condition in infants is very often mistaken for phimosis. Over the course of 2-3 years, the PM is separated from the head of the penis due to the formation of keratinized epithelial nodules. As a result of this, as well as periodic erection, the PM is separated, which ultimately leads to its complete physiological retraction. In 80-90% of children who did not undergo circumcision, the PM can be retracted by 3 years. True “phimosis” is extremely rare before age 3 years. To date, the etiology of “phimosis” has been little studied.
The PM has somatosensory innervation through the dorsal penile nerve and branches of the perineal nerves (including the posterior scrotal nerves). The autonomic innervation of the PM begins in the pelvic plexus. The parasympathetic visceral adductor nerve and afferent fibers begin from the sacral center, and the sympathetic preganglionic nerve and visceral adductor fibers begin in the thoracolumbar center. The parasympathetic nerves are located along the membranous wall of the urethra and penetrate it. Although most operations are performed in neonates and children without anesthesia, the complex innervation of the PM explains why dorsal penile nerve blockade provides partial pain relief during circumcision in infants. Likewise, blocking the IF ring cannot block the visceral adductor fibers from the cavernous nerve, as well as the posterior scrotal somatosensory branches of the perineal nerve. Sensory receptors can be classified as mechanoreceptors, such as sensory Meissner corpuscles (Figure 8), lamellar corpuscles of Vater-Pacini (Figure 9), and Merkel discs/cells (Figure 10), as well as nociceptors (free nerve endings). A variety of terms are used to refer to these encapsulated, encysted receptors, such as iron/Krause receptor, Dogiel receptor, sex sensory corpuscles, Endcalpsen receptor, and mucocutaneous cell receptors. placental membrane. The head of the penis is supplied with nerves, mainly through free nerve endings, and has tactile sensitivity with narrowly localized sensations (including pain, temperature and certain sensations from mechanical contact). In the glans penis (Fig. 11), cellular receptors are scattered, and are mainly found along the crown of the glans and frenulum. The ridge-shaped strip of the PM in men at the site of the mucocutaneous junction has a high degree of concentration of these receptors. The difference in the degree of innervation of the IF head from the ridge-shaped strip of the IF, rich in corpuscular receptors, is a natural additional part of the erogenous tissue of the IF. The mucous epithelium of the PM and the head have the same structure. It does not separate until hormonal factors appear. The epithelium of the fetal PM, adherent and tightly adjacent, has intraepithelial nerves and, according to some studies, Langerhans cells. The native PM is well vascularized, which explains the presence of common hemorrhagic complications during circumcision. The IM contains more free collagen than the native fascia of the IM head.
The smooth, fleshy membrane of the scrotum is characteristic exclusively of the male external genitalia and most of this membrane. is within the PM. It consists of smooth muscle cells surrounded by elastic fibers (Fig. 12); thin, tender from the PM surrounds the shaft of the penis to the scrotal membrane. The fleshy membrane of the intestinal tract is sensitive to changes in temperature and is responsible for changes in the volume required for an erection, and its loss during circumcision explains the decrease in temperature sensitivity of the penis. In infants, the muscle fibers are intertwined and arranged in a mosaic pattern, causing the distal portion of the PM to fold into folds and end like a one-way valve. This explains why, during examination, the distal part of the infant's PM is folded, a. in an adult it is freer. An increase in the mass of elastic fibers may be necessary for simple eversion of the glans penis in an adult. Although the etiology of this transformation is still unknown, steroid hormones may have an effect because their local use can accelerate PM retractability in boys; have not reached puberty.
The skin of the PM consists of connective tissue, blood vessels, nerve trunks, sensitive bodies in the area of the tubercles, scattered sebaceous glands, and elastic fibers. The difference between the elastic fibers in the preputial fascia and the skin contributes to the formation of a “muzzle”-like structure around the head of the penis. The elastic tissue of the skin of the midsection, along with the scrotal flesh and frenulum, limits the midsection and helps it return to its anatomically correct position after deployment during erection or after manual retraction. The outer layer of the PM has sparse sebaceous and sweat glands.
Congenital physiological phimosis (FP) is considered to be a narrowing of the preputial sac, in which there are no scar changes in the skin of the preputial ring area. The skin of the preputial ring is soft, stretches well, and when you try to remove the head, you can see part of the meatus (Fig. 19). The preputial sac in FF is pink, has a normal length, and there are no signs of inflammation.
This condition can be considered as one of the manifestations of functional immaturity, disproportion in the growth of the PM and preputial ring. According to our observations, under the influence of hormonal changes in boys during puberty, there is a particularly rapid and easy expansion of the skin of the preputial ring and, as a result, more free removal of the head. A similar effect was observed in boys after treatment of the head of the intestinal tract and the ulcer with testosterone ointment during a test for sensitivity to testosterone. It is generally accepted that FF or (unstretched preputial ring) can be observed in boys up to 2-5 years of age. However, our research has proven that the concept of physiological phimosis has no age limits and can occur at any age (from a newborn to a 17-year-old boy). We observed signs of FF in 15 adolescents aged 16 years, who had never tried to open the head slightly and were not observed by a pediatric surgeon (Fig. 20). The graph shows a clear trend towards a decrease in the number of children with FF as their age increases.
The degree of PC narrowing varied. In cases of moderate narrowing of the PC, it was possible to examine the meatus and partially the head of the PC. This prepuce ring can be stretched quite easily. In cases of pronounced narrowing, when it was often impossible to visualize even the meatus, we noted diagnostically significant ischemia of the SC tissues (“ischemia ring”), the appearance of which was seen in rigid, difficult to stretch and easily injured skin of the PM.
Distribution of children with physiological phimosis by age groups Of 1512 (88.3%) cases of congenital FF identified during a one-time study, up to 5 years of age, narrowing of the PC was in 855 (49.9%) cases, and a significant decline in these changes can be traced to 15 years - 327 (25%) people, as can be seen in the graph presented in Fig. 20.
In 1406 (92.9%) cases, the skin of the PM was elastic, easily extensible, in 106 cases (7.1%) it was rigid, “tight”, easily vulnerable and was more common between the ages of 5 days and 6 years (Fig. 21, A). The inverter head was partially removed in 1141 (75.4%) cases, and was not removed in 320 (21.1%) cases (Fig. 21, b). Moderate narrowing of the PC was observed in 1263 (83.5%) people, severe narrowing in 249 (16.5%), while the meatus could not be visualized in 123 (49.4%) cases (Fig. 21, c).
General characteristics of observations in congenital physiological phimosis
The skin of the preputial sac in FF has no scar changes, is soft, and stretches well. However, when trying to quickly or roughly remove the head, radial cracks appear in the area of the transition of the inner and outer sheets of the PM. The deepest ruptures can be observed during simultaneous removal of the head in boys with FF.
It is difficult to explain why, but in many manuals of past years, the procedure for complete simultaneous removal of the head is considered as the main method of treating FF, which ceases to be considered as such after 6 years (Lopatkin A.N., Lyulko A.V. 1987). Therefore, doctors of all specialties - neonatologists, pediatricians, surgeons, urologists and even orthopedists, consider it their duty to perform the procedure of simultaneous removal of the IF head, with a narrow PM. Most importantly, without knowing the peculiarities of the physiological development of the boy’s PM, doctors carry out the above manipulation, without taking into account the age of the child and the condition of the PM! The sad thing is that even among neonatologists in the maternity hospital there are doctors who perform similar manipulations on boys and give recommendations to parents to continue them at home, explaining this by the need to perform hygienic care for the foreskin.
It is important to remember that immediate removal of the head is not a harmless procedure for all children. These manipulations are accompanied by episodes of bleeding, severe swelling of the bladder, pain and difficulty urinating, up to acute urinary retention. Significant ruptures of the PM often heal with the formation of rough scars and lead to the formation of cicatricial phimosis (Fig. 22, a, b, c). That is why we consider the attempts to carry out this to be erroneous; simultaneous removal of the head. In order to assess the degree of narrowing: and the condition of the skin of the PM, it is absolutely not necessary to completely remove the head (retract the PM beyond the coronary sulcus). Moreover, this manipulation is meaningless (has no medical indications), is sharply painful and very harmful. Advice to parents is even more dangerous; Carry out a one-step procedure: removing the head yourself, at home. The tendency of the PM to edema, the traumatic and painful nature of manipulation predisposes to the development of paraphimosis.
For the last 10 years we have; abandoned any attempts at immediate withdrawal; head of the PN, and used the method of gradual gentle stretching of the PM developed in the clinic (St. Vladimir Hospital): The method is based on two principles.
The first principle is a slow impact on the narrowed area of the MI; treatment continues for months, hurry up; no reason. Head PN; should be open by prepubertal age (12-15 years). Data: the timing is determined by hormonal changes in the boy’s body.. Important; remember that the head is freely removed; necessary only - for; painless performance of sexual intercourse. The second principle is that EQV1 stretching should occur as gently as possible, even minimal injury is not allowed; narrowed area (rupture, cracks). After each procedure; and they were carried out 2 times a week, it is necessary to achieve stretching (displacement) of the preputial sac by 1-2 mm from the original position, no more. For; improvement, stretching: PM before manipulation, it is recommended to perform a hygienic bath with decoctions of medicinal herbs (chamomile, string, celandine) for 10-15 minutes. Skin steamed in warm water, stretches easier and less; gets injured. After the procedure. THEM? It is advisable to treat with baby cream or solcoseryl for: better epithelization, occasionally occurring micro tears of the skin.
This group of patients consisted of boys with cicatricial phimosis (73 (4.3%). Based on anamnestic data, we tried to find out the reasons for the occurrence of scar changes in the PM. In the majority of children, 31 (42.4%) cicatricial narrowing of the PC occurred against the background of complete health. Signs of balanoposthitis shortly before the appearance of a preputial scar were observed in 25 (34.2%) patients. Traumatic simultaneous removal of the head preceded cicatricial phimosis in 17 (23.3%) children. Depending on the clinical manifestations, we conditionally divided all patients with cicatricial phimosis into 2 subgroups. The percentage of causes of scar changes in the PC is presented in the diagram (Fig. 43). it is not possible to remove it due to cicatricial narrowing of the preputial ring. The diameter of the PC can be narrowed to a point, or remain wide enough to 1.0 cm in diameter. If the PC is significantly narrowed, it is not possible to examine the meatus, and urination is impaired. Dense, difficult to separate fusions of the PM and the head often occur, often accompanied by moderate or severe inflammation of the prepuce.
For the period of time 1996-2006. In the department, 179 children were operated on for cicatricial changes in the skin of the PM. To analyze the results of surgical treatment of RF, we used a retrospective analysis of a group of children (106 people) operated on during the period 1996-2003. and a prospective analysis of a group of children operated on during the period 2003-2006 (73 people).
The study included patients with signs of changes in the intestinal tract characteristic of the Russian Federation: the color of the skin of the intestinal tract, scar changes and the degree of narrowing of the intestinal tract, the possibility of removing the meatus and head of the intestinal tract, the presence and nature of synechiae, signs of inflammation of the intestinal tract, and urinary disorders.
Carrying out a prospective analysis of a group of children operated on during the period 2003-2006, depending on the clinical manifestations, we conditionally divided all patients with RF into 2 subgroups: those with signs of inflammation of the bladder and urination disorders against the background of cicatricial changes in the bladder and those without the above mentioned signs .
The first subgroup consisted of 62 (84.9%) boys with uncomplicated cicatricial phimosis. Visually, the PM was changed slightly; there were no obvious signs of inflammation (edema, hyperemia, tissue infiltration). All children urinated freely, painlessly, in a wide stream. When trying to remove the head, a dense scar ring was detected, which did not allow examining the head. The diameter of the PM scar ring significantly exceeded the external opening of the urethra, so there were no signs of urination problems. In Fig. 44 (a, b, c) shows photos of boys with signs of uncomplicated cicatricial phimosis, a wide diameter of the cicatricial ring. opening of the PC), the separation of these synechiae was accompanied by the formation of a large erosive surface on the glans penis with diapides bleeding. It was in these children (17 people - 9.3%) that in the postoperative period the phenomena of severe balanitis, fibrin deposits, and painful urination were observed. Healing of erosions on the head was slow, lasting from 2 to 3 weeks. In Fig. 50 shows the infarction of an 8-year-old child, with signs of severe postoperative balanitis, after dividing the adhesions into operations.
Signs of postoperative balanitis with cicatricial phimosis The following surgical techniques were used: traditional circular excision of the preputial sac (circumcisio), plastic surgery according to Roser. Circumcision during RF was carried out according to the generally accepted method; first, brilliant green markings were applied to the skin of the outer leaf to determine the level of scar tissue excision. Next, after cutting off the scarred prepuce, hemostasis was performed. Bleeding vessels were coagulated during the operation using bipolar forceps. The outer and inner sheets of the PM were compared with interrupted sutures using chrome-plated catgut (4-0, 6-0). At the end of the operation, a circular, pressure bandage was applied to the IF, which was abundantly soaked in glycerin. This dressing prevented the development of edema and served as a method of preventing residual secondary bleeding from the postoperative wound. The bandage was removed on the 3rd day, after which baths with a 0.5% solution of potassium permanganate were prescribed. With the development of postoperative balanitis, the head was treated with 5% syntomycin emulsion, levomekol or solcoseryl ointment until complete epithelialization. Roser's operation was performed with a narrow PC, which prevented the free removal of the head of the intestinal tract during erection, a narrow PC with an elongated CP, and at the insistence of the parents. In case of a short frenulum of the intestinal tract and scarring of the midsection, the technique of 2 incisions was used in order not to damage the vessels of the frenulum of the intestinal tract. To carry out surgical interventions on the PM, modern methods of pain relief (penial, caudal block) have been introduced and used, which facilitates the course of the postoperative period.
Analysis of the results of surgical treatment of RF and HF, as well as conditions associated with them (paraphimosis), showed that out of 179 operated children, the following complications were noted in 4 (2.2%) cases. We observed an unsatisfactory cosmetic result in the form of long-term lymphostasis of preserved PM in 1 boy with MF during preputial plasty according to Roser, as a result of making a fairly long dorsal incision and violating the integrity of the lymphatic collectors located in this area. For a long time, the CP remained edematous, but gradually the lymph flow began to be restored and the edema decreased. In Fig. 51 (a, b) shows the PM of a 9-year-old child, with signs of severe lymphostasis of preserved PM during GP (a consequence of an extended dorsal incision and disruption of the integrity of the lymphatic pathways), 4 months later. after Roser's operation.
The results of treatment of boys with all forms of phimosis were assessed from 6 months. up to 4 years. In the group of patients with physiological phimosis (185 people), after conservative treatment (using the technique of gradual gentle stretching of the PM), 162 (93%) boys recovered. Recurrence of physiological phimosis was not observed. In 13 people (7%) phimosis persisted, although positive dynamics from the initial data were noted. Among them, children of younger age groups predominated. It was recommended to continue observation and conservative treatment. In 3 (1.6%) cases, after 6 months. the effect of conservative therapy was not obtained, possibly due to the structural features of the preputial ring or incomplete implementation of recommendations for conservative treatment. These children (3 people) were operated on and circumcised.
In the comparison group (103 people), where children with FF underwent simultaneous removal of the head, a positive effect of the manipulation (recovery) was achieved in 43 (41.7%) children. No recurrence of phimosis was observed. In 15 (14.6%) boys, the effect of treatment by simultaneous removal of the head was not achieved, signs of narrowing of the PC remained. Moderate narrowing of the PC currently persists in 7 (6.8%) young children; it was decided to continue conservative1 therapy. Significant ruptures of the prepuce after immediate removal of the head were observed in 60 (58.3%) boys. In 15 (14.6%) cases, radially located, non-extended PM scars were noted, occupying 1/4 of the PM diameter. We treated these children with contractubex. Twice a day for 2 weeks, the PM was lubricated with anti-scar ointment, rubbing it into the scar area. The next step was gradual stretching of the PM according to the standard method. The duration of treatment was up to 6-8 months. 9 (8.7%) boys managed to stretch the preputial ring and eliminate phimosis. 6 (5.8%) people continue treatment and are under observation. There are currently no indications for surgery (circumcision). The final decision on tactics will be made in the prepubertal period. If phimosis persists, surgery will be recommended. An unsatisfactory result of the use of simultaneous removal of the head of the intestinal tract during FF was observed in 45 (43.7%) boys, all of them had signs of gross cicatricial narrowing of the intestinal tract; they underwent scar excision with a positive result.
Thus, the technique of gradual gentle stretching of the PM is effective in 93% of patients with FF and in the long term there is no relapse of FF. The use of simultaneous removal of the head for phimosis allows one to achieve correction of phimosis only in 41.7% of cases, no effect was noted in 14.6% of patients, and an unsatisfactory result with scarring of the PM, requiring surgery (circumcision) was detected in 45 (43.7%) patients.
In the group of patients with hypertrophic phimosis (69 people), after gradual stretching of the PM, restoration of the narrowing of the PM was not observed. Cicatricial phimosis, after a previously obtained satisfactory result, was identified in 2 children (2.9%), and circumcision was performed.
In children with hypertrophic phimosis (21 people), who underwent simultaneous removal of the head, 9 (42.9%) boys developed a cervical scar, which required surgical treatment.
In the group of patients with cicatricial phimosis (179 people), only 1 (0.6%) case required a repeat! surgery to excise the scar after PM plastic surgery without radical excision of scar tissue. In the case of lymphostasis after Roser's operation, long-lasting swelling of the prepuce tissue was noted; the result was considered cosmetically unsatisfactory, however, positive dynamics were noted and it was decided to continue observation.
The male body is designed by nature in such a way that the intimate area requires special attention in terms of cleanliness. The development of bacteria occurs without proper hygiene. The place where unpleasant inflammation occurs is located under the foreskin of the penis and is called the preputial sac.
Men develop various diseases when exposed to bacteria: phimosis, balanoposthitis, paraphimosis. At a young age, the problem becomes especially acute, since children are less likely to think about the hygiene of their organs.
The prepuce sac in boys can cause inflammation of the head of the penis and the skin around it. There are two types of disease development:
Diagnosis of problems consists of determining the patient’s condition through a survey and testing to determine the type of disease. When determining the source of the problems, a visual inspection of the head is carried out, and the foreskin is checked for inflammation. To exclude infectious development of the disease, appropriate studies are prescribed.
Symptoms of inflammation affecting the preputial sac:
The pain goes away after some time, but recurs periodically. Severe conditions require prompt solution to the problem. Minor irritations can be relieved with the right ointment. It is important to establish the cause that caused the inflammation of the preputial sac.
With your problem, you can contact the following doctors:
After the rinsing procedures, use Levomekol ointment, which is injected into the preputial sac with a syringe. For children, warm herbal baths are used as a preventive measure.
Problems of the preputial sac caused by phimosis in boys are eliminated using presurgical methods:
The listed methods should be used only after examination in the clinic. In the case of infections, you can harm the child’s delicate skin and trigger the disease. It is impossible to achieve results using independent measures if there are scars on the flesh.
In medical practice, non-medicinal methods of tightening the foreskin are used. Through daily exercise, you can achieve gradual stretching while showering and after urinating. The duration is determined by the moment when the pain began.
The second method is to stretch the preputial sac with your fingers. Using these methods you can get rid of congenital pathology. In 7 out of 10 patients, complete cure of phimosis was observed.
It is recommended to begin physiological treatment no earlier than the onset of puberty. In 70% of children this phenomenon goes away over time. If there are no serious complications, preventive measures are taken to reduce inflammatory processes in the foreskin using traditional methods.
The exception is infectious and bacterial problems. It is not recommended to delay dealing with this type of disease. Visiting a doctor will be the best decision for parents. Constant monitoring of the ongoing inflammatory process will be required. Particular attention is paid in cases where the foreskin has already expanded, but at some point in time narrowed again. Here we are talking about the pathological development of the organ.
Balanoposthitis in children is an inflammatory process that affects the head of the penis (lat. penis) and foreskin (lat. prepucium). Children are very often susceptible to this disease. Statistics show that every male child suffered from balanoposthitis at least once during his life. If balanitis is diagnosed in children, only the head of the genital organ is affected.
Collapse
The genitals of all males have a very complex anatomical structure. A fold of skin covers the delicate head of the genital organ, covering and protecting it. Even in the womb, a dense fusion of these tissues occurs. At birth, in infant boys, a physiological condition is observed, in which the prepucium is narrowed, so the head of the penis does not extend beyond the foreskin. This condition is natural in infants. By about 2 years of age, this temporary condition goes away on its own. As a rule, the head gradually opens at primary school age.
As the boy grows, the prepucium, together with the head of the penis, forms the preputial sac. It is a small cavity in the groin. In this pocket, the secretion of the preputial glands, urethral secretions, and dead cells of the desquamated epithelium are deposited. A mixture of these biological substances is formed - smegma. It is impossible to carry out full hygienic measures inside the preputial sac. However, normally this cavity self-cleanses.
Different microflora live on a child’s skin. Under certain conditions, in such a specific pocket, streptococci (streptococcus), E. coli (Escherichia coli), staphylococcus (staphylococcus) and other pathogenic bacteria and fungi rapidly multiply. Under the influence of several factors, a boy may develop balanoposthitis. Even in infancy, an inflammatory process can develop in the tissues of the foreskin.
Extensive infection develops if favorable conditions for the development of infection arise in the area of the head of the penis. A wide variety of reasons can cause inflammatory processes in the genitals. Balanoposthitis in a boy occurs due to infection of the smegma by pathogenic microorganisms. As a rule, due to poor hygiene, such an inflammatory process can begin in a baby if he is in dirty diapers for a long time. The specialist must establish the etiology of the disease.
Various disorders can provoke balanoposthitis in a boy:
The acute form of the disease lasts less than 3 months. A severe form of acute disease is considered to be erosive balanoposthitis in a child, which is characterized by deep inflammation. This form is extremely dangerous, since natural blood flow can be disrupted due to pinching of the prepucium. When ulcers and ulcerative spots appear, the epithelium begins to die.
Balanoposthitis of the simple type is the easiest to treat. As a rule, violation of hygiene rules becomes the cause of this disease. The allergic form of balanoposthitis is much less common. As a rule, herpes viruses cause viral infectious urethritis. The most dangerous type of acute inflammation is the gangrenous form. It has been statistically proven that boys most often suffer from acute purulent form of balanitis.
As a rule, chronic balanoposthitis continues for many years. Less severe symptoms are characteristic of the chronic form of the disease. Exacerbations of the disease occur at irregular intervals. From time to time, the tissues of the penis begin to become inflamed. This pathology develops in indurative and ulcerative-hypertrophic forms. Hypertrophic balanoposthitis has more pronounced symptoms and longer duration. Wrinkling of the affected areas is observed with indurative inflammation of the penis tissue. Chronic inflammation of the foreskin in a child is very dangerous.
Symptoms of damage to the skin of the penis manifest themselves differently at different stages of the disease. Initially, the disease develops in a subacute form. In the acute form of balanoposthitis, smegma cannot flow out on its own, since this yellowish ointment-like substance has an excessively thick consistency and large volume.
In the first 5 days, the following symptoms of balanoposthitis develop:
With adequate treatment of inflammation of the foreskin in boys, the symptoms of balanoposthitis disease, as a rule, disappear if spontaneous clearance of the preputial sac from smegma occurs within 5 days. Acute purulent balanitis quickly becomes chronic if there is no prompt qualified medical intervention.
In the chronic form of balanoposthitis, the patient's condition is assessed as satisfactory. However, a lot of problems arise with painful urination. The prepucium tissues are slightly swollen. The patient is bothered by itching in the head and redness of the penis. Whitish deposits cover the affected organ. Periods of improvement alternate with phases of exacerbation. The child suffers for months.
Untimely treatment of balanoposthitis can cause serious complications. A serious consequence of balanoposthitis is enuresis. Inflammation of the walls of the urethra occurs. There is a cicatricial change in the tissues of the foreskin. The extremely small opening in the prepucium excludes the possibility of normal urination.
Without therapeutic help, the infection develops very quickly and can affect other parts of the body. The receptor apparatus of the penis completely atrophies. There is a threat of partial loss of sensitivity of the head of the genital organ. If bacteria enter the bloodstream, extremely dangerous sepsis can quickly develop.
Accurate diagnosis is required before treatment. If symptoms of damage to the tissue of the penis appear, you should immediately take your child to a surgeon or pediatrician. In the prepucium cavity, the doctor takes a smear to analyze the microflora. Microbiological examination allows you to clarify the diagnosis. The sensitivity of the balanoposthitis pathogen to certain groups of medications is revealed. Based on the results of the diagnostic study, the doctor will determine the nature, genesis and area of the lesion.
As a rule, hospitalization for this pathology is not required. Damaged penile tissue requires specific therapy. Taking into account the type of infection and the severity of the disease, the doctor prescribes a course of treatment. Only under the supervision of a doctor can conservative treatment be carried out at home. In the early stages of balanoposthitis, disinfectants are needed for therapy.
Usually he prescribes sitz baths with a very weak solution of potassium permanganate. After taking a bath, the genitals should be carefully dried with soft gauze. Levomekol ointment, which contains antibiotics, gives a good effect. Usually the affected area is treated with an antiseptic. A weak solution of furatsilin or chlorhexidine is used. Powders with talc and tannin have a therapeutic effect. After the inflammation subsides, the penis must be cleaned with hydrogen peroxide, furatsilin ointment, and soapy water.
When the disease is advanced, antibacterial therapy is carried out. Self-use of antibiotics is unacceptable. Fungal infections cannot be treated with antibacterial agents. Antimycotic ointment Clotrimazole is used to identify yeast fungi. The patient requires careful hygienic care.
In most cases, balanoposthitis can be cured with medication. Surgery is performed in severe cases. If, with pathological phimosis, epithelial gluing is observed in the preputial sac, a button-shaped probe with spherical thickenings is used for mechanical separation. An experienced specialist usually recommends circumcising the child if infantile balanoposthitis progresses. Symptoms of the disease disappear after this operation.
Baths with medicinal herbs and proper toileting of the genitals will help avoid illness. Baby moisturizer is applied before changing the diaper. You should wash your child after each bowel movement and dry the skin thoroughly.
If symptoms of balanoposthitis are detected in children, measures must be taken. You should begin treatment as quickly as possible if the doctor has diagnosed balanoposthitis, since this disease is dangerous. In the initial stage of the pathology, such an inflammatory process can be easily treated.
Phimosis– a condition characterized by narrowness of the foreskin, which leads to limited mobility. Thus, the first, and often the only, sign of phimosis is the inability to expose the head of the penis at rest and/or during erection.
The foreskin or prepuce in men is the fold of skin covering the head of the penis. The preputium is a specialized tissue, the structure of which is in many ways similar to the structure of the eyelids and labia in women. 
The foreskin consists of two sheets that are attached to coronal sulcus located at the base of the head of the penis. The outer leaf is lined with thin skin epithelium, and the surface of the inner leaf is a mucous membrane.
Provides additional fixation of the preputium bridle, located on the underside of the glans and limiting the movement of the foreskin towards the base of the penis. The structure of the frenulum of the foreskin is in many ways similar to the structure of the frenulum of the tongue.
Typically, during an erection, the foreskin moves towards the base of the penis and exposes the head of the penis. In its normal state, the prepuce completely covers the head, so that the inner surface of the foreskin forms a preputial cavity (preputial sac) - a narrow gap between the head and the foreskin.
Thus, the foreskin performs a protective function, protecting the mucous membrane of the glans penis from drying out and adverse external influences. It is for this reason that when treating phimosis, doctors try to preserve this anatomical formation and resort to circumcision (removal of the foreskin) only in extreme cases.
How common is phimosis?
It should be noted right away that phimosis is a very common phenomenon and in many cases does not cause much concern to patients.
This is due to the fact that the head and foreskin are formed from the same tissue during intrauterine development. The development of the external genitalia continues until the end of puberty, so congenital physiological phimosis is observed in more than 95% of newborn male infants.
By the beginning of the second year of life, the head of the penis opens in only 20% of infants, and by the beginning of the third - in 50%. As a rule, spontaneous elimination of physiological phimosis occurs in preschool age (3-6 years).
However, it is far from unique that the head of the penis opens for the first time already during puberty, due to an increase in the level of sex hormones that help soften and stretch the skin of the foreskin.
Many peoples of the world have a common gene for predisposition to the persistence of physiological childhood phimosis into adulthood. So, for example, in some countries of Southeast Asia, phimosis in adult men is considered normal, except in cases where narrowing of the foreskin leads to painful symptoms.
And in the culture of Ancient Greece, a long and narrow foreskin was not only not considered a pathology, but was also perceived as a sign of beauty and masculinity. The exposed head of the penis was considered obscene because it was reminiscent of circumcision. Ancient frescoes depict the custom of artificially gradually lengthening the foreskin.
To do this, ancient Greek youths used a special leather tape - kinodesma, one end of which was attached to the foreskin, and the other was tied around the waist. Wearing a kinodesma was seen as a manifestation of special modesty and decency.
According to the mechanism of development, hypertrophic and atrophic phimosis are distinguished.
Hypertrophic phimosis characterized by significant elongation of the foreskin (due to its very characteristic appearance, it is also called proboscis phimosis).
Statistically, hypertrophic phimosis is more common in obese boys, which is associated both with metabolic disorders and with the accumulation of fatty tissue in the pubic area.
About atrophic form of phimosis they say in cases where the foreskin, on the contrary, is reduced in volume and tightly fits the head of the penis. In this case, the preputial opening is narrowed and does not allow the head to pass through. 
The reasons for this anomaly have not yet been studied. The fact that phimosis occurs more often in some peoples than in others indicates the existence of a genetic predisposition to congenital phimosis.
Clinical studies have shown that congenital phimosis is often combined with other structural abnormalities of the connective tissue and musculoskeletal system, such as flat feet, scoliosis, and heart defects.
In children, a common cause of the development of pathological phimosis is injuries, including those received during grossly violent attempts by parents to “correct” physiological phimosis in little boys.
In such cases, adhesions form between the mucous membranes of the glans penis and the foreskin, leading to a narrowing of the preputial cavity and the development of secondary pathological phimosis.
And finally, a fairly common cause of phimosis in children and adults are infectious and inflammatory processes in the preputial sac, leading to the formation of a characteristic cicatricial phimosis.
For phimosis first degree It is possible to freely remove the head of the penis in a calm state, but during an erection, exposure of the head is difficult or painful.
ABOUT second degree phimosis is said to occur when difficulty exposing the head occurs even at rest. During an erection, the head is either completely hidden under the foreskin, or only a small part of it is exposed, often swelling in the form of a ball. 
At third degree phimosis, it is no longer possible to move the head of the penis beyond the preputial ring. 
Fourth degree phimosis is characterized by such a sharp narrowing of the foreskin that it causes difficulty urinating.
It should be noted that it is customary to talk about the first to third degrees of pathological phimosis when the patients are adults or adolescents. As for the fourth degree, normally in childhood physiological phimosis the preputial cavity has an opening sufficient for the free passage of urine.
Therefore, signs such as filling of the preputial sac during urination and/or narrowing of the urine stream, even if they occur in early infancy, clearly indicate pathology and require emergency medical intervention.
At the same time, it is not uncommon for men with severe phimosis to experience absolutely no problems sexually.
Unfortunately, phimosis poses a significant threat to the health of an adult man. The fact is that the cells of the mucous membrane of the inner leaf of the prepuce secrete a special secretion that has a rather complex composition (fats, bactericidal substances, pheromones (exciting substances), etc.). This secretion is the main part of smegma (translated from Greek as “sebum”), which also includes dead epithelial cells and microorganisms.
The activity of cells of the glandular epithelium of the foreskin increases during puberty (maximum smegma formation occurs at the age of 17-25 years) and progressively decreases in older men.
Normally, smegma protects the mucous membranes of the glans penis and the inner surface of the foreskin from drying out, and also acts as a natural lubricant during sexual intercourse.
However, the secretion of the glands of the mucous membrane of the inner layer of the foreskin is an excellent living environment for many pathogens. Therefore, stagnation of smegma in the preputial sac can cause the development of infectious and inflammatory diseases, such as balanitis (inflammation of the mucous membrane of the glans penis) and balanoposthitis (combined inflammation of the mucous membranes of the glans penis and the inner layer of the foreskin).
In addition, according to many studies, with prolonged stagnation of smegma, carcinogenic substances are formed and accumulate in it, which contributes to the development of cancer in men (papillomas of the glans penis, penile cancer) and their sexual partners (cervical cancer).
In childhood, cleansing of the preputial sac occurs independently, since the amount of smegma secreted is small. To prevent the development of complications, adult men must follow the rules of hygiene, that is, perform a daily toilet routine, which consists of washing the foreskin and glans penis with warm water and soap.
With phimosis, this procedure is usually difficult. Thus, the narrowing of the foreskin in adults contributes to the accumulation of smegma in the preputial sac.
Even in cases where phimosis does not manifest itself with any unpleasant symptoms, doctors advise taking care of eliminating the pathology, since, in addition to the danger of developing infectious-inflammatory and oncological diseases, one should also take into account the possibility of developing such a serious complication as paraphimosis.
Paraphimosis refers to a complication of phimosis when the withdrawn head of the penis is pinched in the shifted foreskin. The head, caught in a tight ring of narrowed foreskin, swells, and the pressure of the ring increases. Thus, a vicious circle is created: the circulatory disturbance caused by strong compression increases the swelling of the head, and the swelling increases the pressure on the head of the foreskin ring.
In adult men and adolescents, paraphimosis most often occurs during sexual intercourse or masturbation. It should be noted that this complication is typical only for phimosis of the first or second degree, since more severe forms of phimosis simply do not allow the possibility of exposing the glans penis.
Clinically, paraphimosis is manifested by acute pain, the head of the penis swells and becomes bluish. Over time, the intensity of the pain syndrome decreases due to severe circulatory disorders. In advanced cases, the strangulated head becomes purple or black.
Severe and prolonged circulatory disorders can lead to deep necrosis (death) of the tissues of the foreskin and glans penis. Therefore, paraphimosis is an extremely dangerous complication that requires immediate help.
First aid for paraphimosis in men is to immediately seek specialized medical help. In the early stages of the development of paraphimosis, doctors can perform manual reposition of the glans penis (this manipulation is very painful, so it is performed after the administration of narcotic analgesics). In more severe cases, they resort to cutting the foreskin ring.
First of all, it should be noted an essential feature of physiological phimosis in infants: the lack of mobility of the foreskin is not at all due to the narrowness of its opening. At such a tender age, for most boys, the inner layer of the foreskin is fused to the head of the penis. It is for this reason that you should never try to forcibly expose the head - this will lead to erosion of the inner surface of the preputial cavity, the development of an inflammatory process and the occurrence of secondary pathological phimosis.
The well-known children's doctor Komarovsky rightly asserts that in 99 cases out of 100, complications of physiological phimosis in children are associated with rude and illiterate intervention carried out by the parents themselves on the advice of relatives, neighbors and even, sadly, doctors.
If nothing bothers the boy (no problems with urination, pain, itching, etc.), no additional measures should be taken to correct phimosis. It is only necessary to perform a regular toilet every day, washing the perineum and genitals with water. It is best to use soap no more than once every three to four days, avoiding it getting into the preputial sac.
Separation of the mucous membranes of the glans penis and the inner layer of the foreskin occurs due to the gradual desquamation of epithelial cells. This is a fairly slow process that should not be artificially stimulated.
The exfoliated epithelial cells form the basis of the so-called children's smegma, which, accumulating, slowly moves towards the exit and is excreted in the form of grains along with urine. Unlike adult smegma, children's smegma does not pose a risk for the development of infections and cancer.
Physiological phimosis itself performs an important protective function; it protects the delicate, unformed epithelium of the glans penis and the inner layer of the foreskin from external aggressive agents.
If we focus on clinical data, then the probability of self-elimination of physiological phimosis in a five-year-old boy is 90%, at the age of 10 years - 83%, and by the age of thirteen it decreases to 33%.
Many pediatricians advise parents to take a wait-and-see attitude before reaching puberty: if there are no alarming symptoms, it is best to wait, since phimosis can be treated at an older age.
It should be noted that the persistence of phimosis by the age of 11-13 may be associated with a low level of male sex hormones in the blood, which have a beneficial effect on the process of softening and stretching of the foreskin.
In addition, it is necessary to distinguish congenital physiological phimosis from secondary phimosis resulting from any infectious and inflammatory diseases.
Of course, only a specialist can make such a diagnosis. But in cases where the child has already experienced an opening of the head of the penis, and then a narrowing of the foreskin occurs, we are most likely talking about pathological phimosis.
In cases where the severity of unpleasant symptoms is insignificant (itching, slight redness, restlessness of the child), you can try to eliminate the problem yourself. Many pediatricians recommend washing the preputial cavity with a warm solution of furatsilin using a regular ten-millimeter syringe.
The procedure is as follows:
If a child has an increased tendency to allergic reactions (exudative diathesis, atopic dermatitis, etc.), unpleasant symptoms may be associated with exposure to allergen substances excreted in the urine or with their contact effect on the skin.
Even in cases where phimosis in a boy was unconditionally recognized as physiological, you should immediately consult a doctor if the following alarming symptoms appear:
Balanitis called inflammation of the glans penis, postitom- inflammation of the foreskin. Balanoposthitis– combined infectious and inflammatory lesion of the glans penis and foreskin.
These diseases occur several times more often in boys than in adult men. The latter circumstance is connected precisely with the physiological characteristics of the structure of the child’s male genital organ.
In addition to physiological phimosis, important predisposing factors to the development of inflammatory processes in the area of the glans penis in children are:
The symptoms of the disease are quite characteristic:
If you suspect an infectious inflammation of the glans penis and/or foreskin, you should immediately consult a doctor who will prescribe the necessary treatment.
With relapses of the disease, as well as in the case of secondary phimosis, the question of surgical treatment may arise.
In young boys, this pathology most often occurs as a result of a violent attempt to expose the head of the penis, made by inept parents in the course of “correcting” physiological phimosis. The clinical picture and complications of phimosis in boys are the same as in adult men. Characterized by very severe pain, redness and rapidly progressing swelling of the glans penis. Untimely or inadequate medical care can lead to irreparable consequences in the form of necrosis of areas of the foreskin and penis.
First aid for paraphimosis in children. There are a lot of tips online for how to straighten the head on your own (applying cold to reduce swelling, using oil, etc.). Of course, a lot depends on the severity of paraphimosis (severity of swelling and pain) and the child’s mental state.
But it is wiser not to follow such advice. Reduction of the glans penis in case of paraphimosis is a very painful procedure, which in medical institutions is performed under anesthesia (in pediatric practice, intravenous anesthesia is used, which implies a short-term but complete loss of consciousness).
So it is best not to waste precious time and not to abuse the child, but to seek medical help as soon as possible. In such cases, patients are transported in a supine position with legs apart.
Difficulty urinating occurs when the opening of the foreskin is very narrow. In such cases, a very characteristic symptom is observed: swelling of the preputial sac with urine during urination. The stream of urine becomes thin and intermittent, and sometimes urine is released in drops. In addition, in such cases, children often complain of pain and discomfort during urination. They begin to avoid going to the toilet, which leads to the development of secondary enuresis (daytime and nighttime).
Difficulty urinating in infants is manifested by restlessness, crying and severe straining when urinating.
This pathology leads to increased pressure in the urinary tract, which is fraught with serious complications. Therefore, difficulty urinating is an indication for emergency elimination of phimosis.
This disdainful attitude was greatly facilitated by the fact that many patients self-medicate without consultation with professionals and often make gross mistakes leading to serious complications (paraphimosis, infectious and inflammatory diseases of the foreskin).
In addition, it is often not taken into account that cicatricial forms of phimosis are an absolute contraindication to the use of conservative methods. The fact is that scar tissue does not stretch, so all attempts to eliminate phimosis are doomed to failure.
Meanwhile, there is evidence of the effectiveness of conservative methods in many patients, even with the second or third degree of congenital phimosis.
An important positive aspect of all non-surgical methods of treating phimosis is the “naturalness” of their effects, since they actually repeat the mechanism of physiological self-elimination of age-related phimosis.
In addition, conservative methods of treating phimosis make it possible to fully preserve the absolutely important functions of the foreskin and avoid unpleasant side effects and complications.
Thus, in the absence of contraindications, conservative methods may well be used as a useful alternative. Of course, treatment should be carried out after consultation with a specialist and under the supervision of a doctor.
However, in cases where it is necessary to achieve rapid and radical elimination of phimosis for medical reasons (for example, with phimosis of the fourth degree) or for personal reasons, it is better to give preference to surgical intervention.
As a result, a hypothesis was put forward about the possibility of eliminating congenital phimosis by gradually stretching the foreskin and special methods for conservatively eliminating the pathology were developed.
The general rules of these techniques are:
There is evidence that it is possible to eliminate phimosis of the first or second degree with the help of exercises to expose the head in just three to four weeks.
Method foreskin stretching consists of daily pulling the foreskin onto the head of the penis during the morning shower, as well as after urination until pain appears.
This method is often used when the self-elimination of phimosis in childhood is delayed. In such cases, it is quite effective, but the duration of treatment largely depends on the type of phimosis and can reach 3-4 months for hypertrophic (proboscis) phimosis.
Method finger sprain consists of carefully inserting the fingers into the preputial cavity and gradually spreading them apart.
According to some data, the effectiveness of the methods described above for congenital phimosis reaches 75%.
Drug therapy is especially indicated for children and adolescents (recommended by the American Association of Pediatrics), since it is at this age that there is the greatest chance of eliminating congenital phimosis using conservative methods.
However, it should be borne in mind that such ointments are not suitable for everyone. So, for example, a contraindication to the local use of corticosteroid drugs is the presence of a bacterial, viral or fungal infection - both acute and chronic.
Long-term use of drugs can cause unpleasant side effects (thinning of the skin, hyperpigmentation, disruption of the structure of superficial vessels), and with uncontrolled use, the systemic effect of corticosteroids may occur, which is fraught with dangerous complications.
Therefore, ointments with corticosteroids can be used only after a thorough examination and consultation with a specialist who has sufficient experience in treating congenital phimosis with this method.
Of course, individual selection of the drug and dose of the drug is necessary, as well as constant medical monitoring of the results of therapy.
However, some favorite remedies of traditional healers are widely used as an aid. We are talking about herbal decoctions that have anti-inflammatory, bactericidal and softening effects, such as:
Steaming the skin of the foreskin in a bath with a decoction of medicinal herbs for 15-20 minutes promotes effective, painless and safe stretching.
This kind of preliminary procedures is especially recommended for children and adolescents.
During the treatment of phimosis, you can alternate decoctions of various medicinal herbs or use a collection of medicinal plants for decoction.
The only contraindication to the use of traditional medicine as an adjuvant in the treatment of phimosis may be individual intolerance or allergies (which are extremely rare).
This surgical procedure is most often used in children; its undeniable advantage is minimal intervention and preservation of the functions of the foreskin. First, a special probe is inserted into the prepuce cavity, which is used to separate the synechiae (adhesions) formed between the head of the penis and the inner layer of the foreskin. To do this, carefully move the probe inward to the coronary sulcus and make slow movements clockwise.
Then the opening of the foreskin is expanded using a Pean clamp: the ends of the clamp are inserted into the hole and the jaws are separated.
Often two or three such manipulations are enough to completely eliminate phimosis. In cases where no positive dynamics are observed, more invasive surgical intervention is indicated.
After sessions of bloodless elimination of phimosis, it is necessary to follow all the surgeon’s recommendations in order to prevent fusion of the mucous membranes of the foreskin and the head of the penis.
Anti-relapse measures are indicated for a month: daily manual opening of the foreskin and washing of the preputial cavity with a weak solution of potassium permanganate. If this manipulation is too painful or unpleasant for the child, it can be performed once every two to three days, but not less often.
Surgical interventions for phimosis are most often performed under local anesthesia; indications for the use of general anesthesia may be:
After surgery, you may experience discomfort in the area of the surgical wound for several days, but, as a rule, you can manage without taking additional painkillers.
In cases where there is a need to remove sutures, this manipulation is performed 7-10 days after surgery. Before removing the sutures, it is necessary to change the dressings every other day and ensure that urine does not come into contact with the postoperative wound.
As a rule, the patient can have sex within two weeks after the operation. Until this time, it is advisable to wear tight underwear that provides additional support for the penis.
Circular excision of the foreskin, which in medicine is more often called circumcision, and “in the world” - circumcision, is the most common operation to eliminate pathological phimosis.
Important positive aspects of this surgical intervention are the speed of elimination of all unpleasant symptoms and the absence of relapses (this is the only surgical intervention for phimosis that provides 100% effectiveness).
The only but significant drawback of the method is the complete elimination of the foreskin, and, consequently, the irreversible loss of all the functions it performs. However, it should be taken into account that millions of men in the world undergo circumcision every year for religious reasons and do not suffer at all.
Circumcision is the only method for cicatricial phimosis, as well as for the fourth degree of phimosis, paraphimosis and recurrent balanoposthitis (the operation is performed after the elimination of the acute process).
An alternative to circumcision is plastic surgery aimed at eliminating phimosis in combination with partial preservation of the foreskin. So, with prepucioplasty, unlike circular excision of the foreskin, the foreskin is not completely removed, since a much smaller incision is made.
Another common method of foreskin plastic surgery is called the Schloffer method. During the operation, the surgeon makes not a straight, but a zigzag incision, and then stitches the edges in such a way as to significantly widen the hole while preserving the foreskin. 
In addition, methods of foreskin plastic surgery according to Roser, spiral foreskin plastic surgery, etc. are quite widely used.
The general disadvantages of this type of operation include a longer recovery period, the possibility of relapses and a relatively short list of indications. So, for example, operations with partial preservation of the foreskin cannot be performed on patients with severe cicatricial forms of phimosis.
With the help of a laser, it is possible to perform both operations for circular excision of the foreskin (laser circumcision) and plastic surgeries that preserve the foreskin.
Laser surgery is characterized by high precision incisions, so that damage to surrounding tissue is minimal.
In addition, laser beams cut tissue, simultaneously cauterizing blood vessels, and have a bactericidal effect.
Thus, laser surgery has the following advantages:
Compared to conventional surgery, the postoperative period with laser correction of phimosis is more comfortable (there is virtually no tissue swelling, there is no need for dressings, suture removal, etc.) and lasts only three to four days. However, doctors do not advise starting sexual activity earlier than two weeks after the operation.
The inability to expose the head of the penis at rest or during an erection, limited mobility of the foreskin due to its excessive narrowness.
This is a fairly common condition and usually does not cause much discomfort.
This birth defect is observed in almost 90% of newborns in the second year of life.
This is due to the formation of the head and foreskin from the same connective tissue.
Occurs in 50% of children aged 3-6 years.
Physiological phimosis in children, as a rule, disappears spontaneously and without a trace by the age of 5. But there are cases when the head at a given age in boys cannot freely come out of the narrow opening of the foreskin. According to doctors, deviations from the norm are possible in some cases in children under 12 years of age.
If the head does not come out with age and the problem remains in boys during puberty, then it requires eradication, and sometimes surgery. Although, of course, everything is at the discretion of the doctor. There are other more gentle non-drug methods for treating phimosis in boys.
Everyone knows that the sexual organ of future men begins to form in the womb in the second or third month of pregnancy. With such a pathology, when the organ remains in an underdeveloped state at birth, the reasons may be different.
Doctors today do not consider it a pathology, even if, due to the narrowness of the foreskin, the organ cannot come out freely in boys under 5-6 years of age. A delay of this kind is possible until puberty, and the problem can be solved with simple manipulations by performing a light massage to stretch the muscles in the part of the narrow opening, which helps release the organ outward.
Many newborns experience this phenomenon and in 5-10% of cases it persists up to 1 year. Typically, by age 6, the separation of the glans and foreskin occurs on its own.
Some mothers, in an attempt to speed up this physiological process, resort to unauthorized stretching of the flesh, not realizing that incorrect manipulations can only cause harm, injure delicate tissues and aggravate the situation. This is where the inflammatory process begins and is one of the reasons for the development of already acquired phimosis.
Congenital physiological phimosis in boys due to the failure of the glans penis to emerge from the foreskin has not been fully studied.
There are suggestions that this could be due to:
It is worth understanding that physiological phimosis in a child is a normal condition in boys up to a certain age.
Pathological phimosis can result from:
Regardless of the cause of its appearance, phimosis requires close attention. If the condition does not go away when boys reach 5 years of age, then you need to consult a doctor.
Video: "What happens if phimosis is not treated?"
Congenital physiological phimosis is a condition when the head of the penis is soldered to the inner layer of the foreskin.
Doctors under no circumstances advise separating the genital organ from the tissue by violent means. This can only lead to erosion, the development of inflammation, and the transition of physiological phimosis into a pathological state. Illiteracy of parents can lead to sad consequences for a boy in the future.
Phimosis usually does not bother children and does not cause much discomfort. There is no pain or problems with urination. The main thing is to regularly wash the perineum, genitals and the cavity of the preputial sac with water without detergents.
Physiological phimosis in itself is not dangerous. On the contrary, it protects the delicate epithelium of the glans penis and the inner part of the foreskin from aggressive external influences. It is possible that only in the absence of hygiene rules, due to the bending of the leaf from the inside of the flesh or allergic reactions, minor symptoms appear in the form of itching and redness.
But this can be easily eliminated by rinsing the preputial sac with water and Furacilin (warm solution) by inserting a syringe (10 mm). Unpleasant symptoms will pass quickly.
If babies are prone to allergies or if exudate appears along with urine, you should contact a pediatrician or pediatric urologist. These are already alarming symptoms. Especially when urination becomes painful, difficult, with a thin stream coming out, the area of the foreskin and the head of the penis is red, swollen, hyperemic.
It is the accumulation of urine in the preputial sac that leads to pain when urinating. The discharge of purulent exudate, an increase in temperature and a pronounced enlargement of the lymph nodes - all this indicates the development of inflammation. In addition, there is a blue discoloration of the foreskin and an increase in the size of the genital organ.
These are all suspicious signs and most likely require surgery. Although the questions and prescription of the treatment course are dealt with exclusively by the doctor on the basis of a visual examination and test results.
In children, characteristic signs of phimosis:
Mothers need to be more attentive to their sons. If you suspect phimosis in boys and the symptoms appear unpleasant, then you need to contact experienced specialists. A diagnosis will be made and the correct treatment will be prescribed.
Parents concerned about their health are wondering: what to do?
If phimosis is physiological, then the most likely cause is lack of personal hygiene. The problem can be eliminated by rinsing with Furacilin and inserting a syringe with a solution into the area of the preputial sac.
Children under 1 year of age do not need any manipulations. If the head opens poorly, then this is the physiological norm for up to 3 years.
If at 4-5 years the head does not partially come out of the flesh, smegma is released from the opening of the foreskin, enuresis and pain when urinating appear, then you should sound the alarm and consult a doctor.
Video: "Phimosis in boys and what to do?"
Boys can usually expose the head of the penis on their own when urinating. But some older children experience residual adhesions and a decrease in the elasticity of the foreskin. Usually in such cases, children under 10 years of age are prescribed medication.
Drug treatment of phimosis in children Betamethasole, Clobetasol, wound healing ointments, glucocorticosteroids are usually prescribed to increase the elasticity of the epithelium, activate and heal microcracks, relieve inflammation, and reduce the manifestations of phimosis.
If the problem of phimosis in boys is not eliminated after 11-12 years and cicatricial phimosis is diagnosed, then surgery is indicated.
Doctors do not try to resort to surgical intervention; they perform it only in advanced cases. Rarely, but there are complications after the doctor’s manipulations, rough insertion of instruments for the purpose of separation 
adhesions.
Surgical intervention consists of removing accumulations of pus from the preputial sac, separating the foreskin and from the glans through small incisions. Next, wash the genitals with Furacilin.
Baths with the addition of potassium permanganate or chamomile decoction will be prescribed for the home. Additionally, antibacterial ointments for urination problems and painkillers are prescribed. It is possible to insert a catheter into the urethra if the outflow of urine worsens after surgery.
Carrying out an operation or circumcision of the foreskin is fraught with complications or the development of balanoposthitis. There may be difficulty urinating with cicatricial phimosis.
There is no specific age for the operation. If at the initial stage conservative treatment at home does not bring tangible results, then a step-by-step operation under anesthesia to excise the foreskin, cut the skin around, without affecting the frenulum, is prescribed regardless of age.
The method usually used is to regularly stretch the flesh with your hands., slowly pulling the flesh over the head until moderate pain appears. In just a month, you can achieve positive results in this way.
A manual method is also used to insert 2 fingers into the preputial sac and move them apart until pain appears.
Prevention of phimosis in boys involves regular hygiene procedures, rinsing the genitals with a solution of potassium permanganate and chamomile infusion.
Only a specialist knows how to treat phimosis. You cannot engage in treatment or carry out manipulations on your own, which can only lead to a worsening of the condition. If phimosis is detected in boys, treatment is prescribed by a urologist or surgeon.
Andrologist, Urologist
Conducts examination and treatment of men with infertility. Engaged in the treatment, prevention and diagnosis of diseases such as urolithiasis, cystitis, pyelonephritis, chronic renal failure, etc.
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