Glans penis and prepuce colonisation of yeast fungi in a paediatric population: pre- and postcircumcision results

Candidiasis presenting as pseudocircinate balanitis in a preschooler

Candidal balanitis typically affects sexually active adult males and may present as eroded papules, pustules, whitish discharge or erythema with dry glazed appearance. We report an unusual presentation of this common infection in an uncommon demographic, candidal balanitis presenting as coalescent vesicles and erosions arranged in an arcuate pattern in a pre-school child.

MalaSelect: A Selective Culture Medium for Malassezia Species

Malassezia species are fastidious and slow-growing yeasts in which isolation from polymicrobial samples is hampered by fast-growing microorganisms. Malassezia selective culture media are needed. Although cycloheximide is often used, some fungi, including the chief human commensal Candida albicans, are resistant to this compound. This study aimed to test whether the macrolide rapamycin could be used in combination with cycloheximide to develop a Malassezia-selective culture medium. Rapamycin susceptibility testing was performed via microdilution assays in modified Dixon against two M. furfur and five Candida spp. The MIC was the lowest concentration that reduced growth by a minimum of 90%. Rapamycin ± cycloheximide 500 mg/L was also added to FastFung solid, and yeast suspensions were inoculated and incubated for 72 h. Rapamycin MICs for Candida spp. ranged from 0.5 to 2 mg/L, except for C. krusei, for which the MIC was >32 mg/L. M. furfur stains were rapamycin-resistant. Rapamycin and cycloheximide supplementation of the FastFung medium effectively inhibited the growth of non-Malassezia yeast, including cycloheximide-resistant C. albicans and C. tropicalis. Based on our findings, this “MalaSelect” medium should be further evaluated on polymicrobial samples for Malassezia isolation and culture.

Estimated burden of serious human fungal diseases in Turkey

The current number of fungal infections occurring each year in Turkey is unknown. We estimated the burden of serious human fungal diseases based on the population at risk, existing epidemiological data from 1920 to 2017 and modelling previously described by the LIFE program (http://www.LIFE-worldwide.org). Among the population of Turkey (80.8 million in 2017), approximately 1 785 811 (2.21%) people are estimated to suffer from a serious fungal infection each year. The model used predicts high prevalences of allergic fungal rhinosinusitis episodes (312 994 cases) (392/100 000), of severe asthma with fungal sensitisation (42 989 cases) (53.20 cases/100 000 adults per year), of allergic bronchopulmonary aspergillosis (32 594 cases) (40.33/100 000), of fungal keratitis (26 671 cases) (33/100 000) and of chronic pulmonary aspergillosis (5890 cases) (7.29/100 000). The estimated annual incidence for invasive aspergillosis is lower (3911 cases) (4.84/100 000 annually). Among about 22.5 million women aged 15-50 years, recurrent vulvovaginal candidiasis is estimated to occur in 1 350 371 (3342/100 000) females. The burden of three superficial fungal infections was also estimated: tinea pedis (1.79 million), tinea capitis (43 900) and onychomycosis (1.73 million). Given that the modelling estimates reported in the current study might be substantially under- or overestimated, formal epidemiological and comprehensive surveillance studies are required to validate or modify these estimates.

Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision

Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently in medical consultations. We conducted a systematic review of the medical literature on PubMed, EMBASE, and Cohrane databases using keywords "balanitis," "posthitis," "balanoposthitis," "lichen sclerosus," "penile inflammation," and "inflammation penis," along with "circumcision," "circumcised," and "uncircumcised." Balanitis is the most common inflammatory disease of the penis. The accumulation of yeasts and other microorganisms under the foreskin contributes to inflammation of the surrounding penile tissue. The clinical presentation of inflammatory penile conditions includes itching, tenderness, and pain. Penile inflammation is responsible for significant morbidity, including acquired phimosis, balanoposthitis, and lichen sclerosus. Medical treatment can be challenging and a cost burden to the health system. Reducing prevalence is therefore important. While topical antifungal creams can be used, usually accompanied by advice on hygiene, the definitive treatment is circumcision. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer. Because of the high prevalence and morbidity of penile inflammation, especially in immunocompromised and diabetic patients, circumcision should be more widely adopted globally and is best performed early in infancy.

Pediatric Urology for the General Surgeon

Pediatric urology spans the neonatal period through the transition into early adulthood. There are a variety of common pediatric urologic conditions that overlap significantly with pediatric surgery. This article reviews the pertinent pathophysiology of a few key disease processes, including the pediatric inguinal hernia and/or hydrocele, cryptorchidism, and circumcision. General surgeons may find themselves in the position of managing these problems primarily, particularly in rural areas that may lack pediatric subspecialization. An understanding of the fundamentals can guide appropriate initial management. Additional focus is devoted to the management of genitourinary trauma to guide the general surgeon in more acute, emergent settings.

[Male circumcision from an infectiological point of view]

BACKGROUND

In May 2012 a German regional court (Cologne) declared circumcision on religious grounds in minor boys an illegitimate bodily harm. This led to substantial political and religious discussions, because Jews as well as Muslims consider circumcision as an indispensable element of their religion. Still in 2012 a "circumcision law" was passed by the Federal Council of Germany, which continues to allow circumcision in boys "performed under strict medical conditions".

OBJECTIVE

How male circumcision is assessed in terms of infectiology (pros and cons)?

METHOD

Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, treponema pallidum, chlamydia, hemophilus ducrey and Neisseria gonorrhoeae.

RESULTS

Contra circumcision: The highest risk of neonatal circumcision is hemorrhage (35 %). Among infections surgical wound infection (10 %), meatitis urethrae (8-20 %) and urinary tract infections (2 %) are frequent (depending on the surgical technique). Severe complications like penile necrosis or lethal sepsis are rare (1:20,000). Pro circumcision: Circumcised boys have a reduced risk for urinary tract infections in childhood (1:10). Compared to uncircumcised men circumcised adults have a 50-60 % reduced risk of becoming infected with viral sexually transmitted infections (STIs; HIV, HPV and HSV). This advantage of circumcision is also discussed for the transmission of bacterial STIs (e.g. syphilis and chancroid), but the analysis of different clinical studies is still controversial.

DISCUSSION AND CONCLUSION

Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual, medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self-determined young men only. In adolescents and adults circumcision reduces the risk of the transmission of viral STIs (HIV, HSV, HPV) and there is also probably some effect on the sexual transmission of treponema pallidum and hemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behavior (e.g. unprotected sexual intercourse, promiscuity) have a strong influence on STI epidemiology.

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.