Foreskin development in 10 421 Chinese boys aged 0-18 years

Effectiveness of low to moderate potency topical corticosteroids for phimosis resolution in children: results of a network meta-analysis

PURPOSE

The use of topical corticosteroids (TCSs) has become an efficient, less-invasive treatment for phimosis. Whether any significant difference in efficacy exists between TCSs based on their potency is unclear.

METHODS

Electronic databases were searched up to March 2024 for randomised controlled trials (RCTs) comparing the use of any type or concentration of TCSs with placebo or no treatment in boys with any degree of physician diagnosed phimosis. A random-effects network meta-analysis (NMA) using a consistency model within a frequentist approach was employed. The primary outcome was partial or complete resolution of phimosis reported as a pooled risk ratio (RR) with 95% CI. Relative ranking was assessed with surface under the cumulative ranking curve (SUCRA) probabilities.

RESULTS

Seventeen RCTs, containing 2057 participants were identified. NMA suggested that, compared with control, the high (RR 3.19 (95% CI 1.42 to 7.16), moderate (RR 2.68 (95% CI 1.87 to 3.83) and low (RR 3.05 (95% CI 1.63 to 5.71) potency TCSs statistically significantly increased complete or partial clinical resolution of phimosis. The SUCRA plot revealed that high potency (SUCRA = 0.76) was ranked first followed by low and moderate TCSs. When we assessed comparative efficacy among TCSs based on potency, none of the classes were superior to others. The certainty of the evidence for an effect of moderate potent TCSs was that of moderate GRADE quality.

CONCLUSION

Moderate to low potency TCSs are of comparable therapeutic effect in the treatment of phimosis to that of highly potent formulations. More high-quality RCTs are warranted.

Anesthesia Analysis of Compound Lidocaine Cream Alone in Adult Male Device-Assisted Circumcision

OBJECTIVE

to evaluate the anesthetic effect among adult male patients with the single use of compound lidocaine cream in device-assisted circumcision, hoping to provide an anesthetic method for the simplification of the surgical process.

METHODS

Male adult patients undergoing device-assisted circumcision through prepuce local anesthesia using lidocaine cream in Xiangya Hospital of Central South University from December 2020 to August 2021 were selected. According to different age groups and different surgical procedures, the anesthetic effect of compound lidocaine cream was analyzed considering the aspects of anesthetic cost, anesthetic time, anesthetic duration, anesthetic effect, anesthetic side effects and anesthetic satisfaction.

RESULTS

In the study, 99.1% of 649 patients needed only 1 application of compound lidocaine cream to complete the operation. The time taken for anesthesia was short; the whole anesthesia process only required approximately 2-5 min. However, for patients with severe phimosis, the time to complete the anesthesia procedure was correspondingly longer. The pain degree caused by anesthesia was low, and the patients with a pain score of ≤3 points accounted for 96.7%. The anesthetic effect lasted for a sufficiently long period, and the time of algesia recovery from local anesthesia was almost 1 h after surgery. The anesthesia effect was sufficient, and patients with an intraoperative pain score of ≤3 accounted for 98.7%, which could meet the surgical requirements. There were few side effects of the anesthesia. The overwhelming majority of patients were pleased with the anesthesia, and 98.9% of patients had an anesthesia satisfaction score of ≥7.

CONCLUSION

The compound lidocaine cream, as a local anesthetic, is safe and effective for most adult male device-assisted circumcisions. More useful information needs to be corroborated by more advanced evidence, especially for severe phimosis.

Evaluation of topical corticosteroids in children with phimosis through morphological and immunohistochemical analyses of the foreskin

INTRODUCTION

Histopathological analysis of the foreskin has become more common in the last two decades.

OBJECTIVES

This study aims to analyze the morphology of the foreskin and determine the effects of topical corticosteroid therapy on this tissue.

MATERIALS AND METHODS

We retrospectively evaluated forty foreskin samples from children aged from 2 years to 15 years with phimosis undergoing circumcision at our institution over a 2-year period. In the foreskin samples, we analyzed the elastic fibers (Verhoeff), epidermal thickness (hematoxylin and eosin), and Annexin 1 and Langerhans cells (LCs) (immunohistochemistry).

RESULTS

In the present study, 18 (45%) patients made use of topical corticosteroids, and 22 (55%) did not, while 4 (10%) had a history of balanoposthitis as previous complication. Forty patients were divided according to the parameter analyzed: with or without previous complication and with or without previous topical corticotherapy. Annexin 1 expression was significantly higher in group with a history of complications when compared with group without complications (P = 0.024) and lower in the group of those who used corticosteroids when compared with those who did not used corticosteroids (P = 0.364). In the analysis of all samples, the density of mature LCs was significantly higher when compared with immature LCs (P < 0.0001). The density of immature LCs was significantly higher in patients without previous complications when compared with group with complications (P = 0.028).

CONCLUSIONS

These findings contribute to a better understanding of the histopathological aspects of previous complications and of treatment with corticosteroids in children with phimosis.

Phimosis in a 10-yr-old Boy Without Urinary Infection-How to Inform Parents: For Circumcision

Circumcision can be a viable option for phimosis in a 10-yr-old boy, also if asymptomatic, in the presence of skin alterations or if the parents prefer avoid observation. Morbidity is minimal if the procedure is performed in a hospital setting.

Phimosis in a 10-yr-old Boy Without Urinary Infection-How to Inform Parents: Against Circumcision

In a 10-yr-old boy with no abnormalities or symptoms other than nonretractability of the foreskin, the foreskin should be preserved. If treatment is needed, local corticoid application should be used as first-line therapy, as it gives excellent results in up to 90% of cases, before removing this sensitive part of the body.

Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy

AIM

To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.

METHODS

Articles in 2005 through 2015 were retrieved from PubMed using the keyword "circumcision" together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.

RESULTS

Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and "ballooning" during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.

CONCLUSION

Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.

2D:4D indicates phimosis risk: A study on digit ratio and early foreskin development

BACKGROUND

Many researchers have adopted 2D:4D (second to fourth finger length ratio) as a noninvasive retrospective biomarker for prenatal androgen exposure in recent years. It is thought to be related to diverse traits including behavioral phenotypes, disease susceptibility, and development of urogenital system.

OBJECTIVE

To examine the relationship between 2D:4D and early foreskin development.

METHODS

We analyzed the digit ratio and foreskin condition in 176 cases (range 0-6years). The boys were divided into four groups according to their ages: group 1, neonates (below 28days, n=13); group 2, infants (1-12months, n=45); group 3, toddlers (1-2years old, n=42); group 4, preschool children (3-6years old, n=76). We measured the lengths of the second and fourth digits of the left and right hands. The foreskin status was classified into 4 types. Type I (phimosis), type II (partial phimosis), type III (adhesion of prepuce), type IV (normal).

RESULTS

The phimosis rate was 92.3%, 82.2%, 45.2%, and 38.7% in group 1 to group 4. In contrast, the proportion of normal foreskin increased from 0% in neonates to 13.2% in preschool children. The percentage of higher level of foreskin development shows a downward trend with the increase of digits ratio, and as the age grows, the percentage of normal foreskin cases also increases.

CONCLUSIONS

These results suggest that a higher R2D:4D (right hand 2D:4D) is a risk factor for phimosis in the early human development. Age is also a significant influence factor of foreskin conditions. Additional research is required to identify pathophysiologic mechanisms and to determine clinical significance.

Estimation of country-specific and global prevalence of male circumcision

BACKGROUND

Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence.

METHODS

MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15-64 years.

RESULTS

The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries.

CONCLUSIONS

The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37-39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.

Benign penile skin anomalies in children: a primer for pediatricians

BACKGROUND

Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern.

DATA SOURCES

The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions.

RESULTS

Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age.

CONCLUSION

This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

It is not "Just Circumcision"

OBJECTIVE

Circumcision is one of the most commonly performed operations during childhood. The procedure is often underestimated in areas where it is frequently executed due to social and religion-based indications. In fact it might be an opportunity to detect and to correct any existing penile anomaly. The aim of the study was to retrospectively evaluate the boys who were admitted to a hospital for circumcision and the outcome of the procedure.

METHODS

The boys who were brought to outpatient clinics for circumcision between 2009-2015, were retrospectively evaluated. The indications for hospital admission and the presence of associated penile anomalies were searched. All the boys were examined and operated by a single surgeon of the institution.

RESULTS

Nine hundred forty four boys were brought to pediatric surgery outpatient clinics in order to be circumcised. The operation was performed in 318 of them. The physical examination revealed penile anomalies in 29 of the 318 cases. The detected anomalies were webbed penis, penile torsion, hypospadias, chordee without hypospadias and meatal stenosis.

CONCLUSIONS

The proper examination of the boys by a physician prior to circumcision provides the detection of penile anomalies which can be corrected at the same session. The arrangements for performing circumcision in hospitals by the medical staff should be favored. The misleading perception of underestimation of the procedure where it is ritually performed, should be corrected.

Circumcisions for medical reasons in the Brazilian public health system: epidemiology and trends

OBJECTIVE

To evaluate the epidemiological factors associated to medical circumcision, based on data from the Brazilian public health system.

METHODS

Using the Unified Health System public database between 1984 and 2010, hospital admissions associated with surgical treatment of phimosis were searched. A total of 668,818 men admitted to public hospitals who underwent circumcision were identified and included in the present study.

RESULTS

A mean±standard deviation of 47.8±13.4 circumcisions/100,000 men/year was performed through the Unified Health System for medical reasons. During the 27-year period evaluated, 1.3% of the male population required circumcision for medical reasons. Total number of circumcisions and circumcision rate increased in childhood, declined progressively after 5 years of age and rose again progressively after the sixth decade of life. In the regions of the country with better access to healthcare, 5.8% of boys aged 1 to 9 years old required circumcisions. From 1992 to 2010 there were 63 deaths associated with circumcisions (mortality rate of 0.013%).

CONCLUSION

In conclusion, yearly circumcision rates could be estimated in Brazil, and a very low mortality rate was associated with this procedures. Circumcision is mostly performed in children in the first decade of life and a second peak of incidence of penile foreskin diseases occurs after the sixth decade of life, when circumcision is progressively performed again.