Doodle, wee-wee, boy bits, ding-dong, pee-pee, knob…

So many names for a such troublesome appendage!

We often joke that boys are unduly fascinated by their genitalia and that it “gets them into trouble” but medically speaking, male genitalia really CAN get into lots of trouble and these problems are more common than…  ummmm…  forgetting your “reusable bags” when you go to the supermarket (face palm).

I wrote a post about medical issues with girl-bits last year – so my apologies to all the mums of boys out there that this instalment has taken so long!

In the next couple of blog posts I hope to address common medical issues of little-boy-bits that can be problematic, and what to do if they occur!

Issue list:

This week:

1. Phimosis and paraphimosis (and ballooning of the foreskin)
2. Balanitis
3. Undescended testes and retractile testes

Next Monday 18/11/2018:

4. Circumcision
5. Testicular torsion (torted testis)
6. Hydrocoele
7. Hypospadias

So lots to talk about – let’s get to it!

1. Phimosis/paraphimosis

Phimosis is a condition in which the foreskin cannot be pulled back to expose the glans (the “head” of the penis).  In the first few years of life, the glans and the foreskin are actually connected, meaning that in most uncircumcised babies and toddlers a non-retractable foreskin is normal and needs no intervention. The reason for this is thought to be because it is meant to guard the urethra (the tube through which the urine flows out) against entry of dirt and protects the glans from irritation by urine, faeces and abrasion. It starts to separate naturally between the ages of 2-6 years of age (with a range of 1-10 years) but the incidence of this at different ages varies depending on the source of the information.   Generally however, most sources agree that about 90% of boys between the ages of 3-4 years will have a separated, retractable foreskin.

Severe phimosis can be associated with voiding problems, balanitis and urinary tract infections.  Topical steroid creams have become the mainstay of conservative treatment of phimosis (instead of circumcision).  Reports about how effective it is to treat phimosis range between 75-88% success.

Paraphimosis is when the foreskin has been retracted back past the glans but gets stuck there and cannot be brought down to cover it again.  In younger boys, the most common cause is trying to retract the foreskin too early – which is why paediatricians will advise you against trying to retract the foreskin.  In most cases, gentle squeezing/compression of the glans with a compression bandage for about 15 minutes starting at the tip (+/- an ice pack) and then unwrapping to allow the foreskin to slip forward again will solve the problem.  Less commonly (when the problem has been present for some time, the glans and foreskin can become swollen and can cut off circulation to the penis.  In these cases, urgent medical (surgical) attention is needed.

 

Ballooning

Ballooning is exactly as the term suggests.  The foreskin balloons out during urination causing urine trapping.  It may or may not cause problems, but can be associated with an increased risk of balanitis, urinary tract infections and urine spotting in the underpants. As above with phimosis, the mainstay of conservative treatment is topical steroid creams or ointments – you will need to see your doctor for a prescription for this. This treatment is generally very effective (success rate of more than 9 out of 10 cases, but it can recur in about 17% of children treated).

 

2. Balanitis

Balanitis is when the head of the penis (glans) gets red, inflamed and sore.  There are a number of common things that can cause balanitis, but by far the most common reason for mild redness and soreness of the tip of the penis is hygiene reasons – either not washing well enough, or washing with something that might leave a residue to irritate the skin (eg soap). Minor irritation can be managed with frequent washing with warm water and avoidance of the irritant.

Other more significant irritation can be caused by

• Trauma caused by forcible retraction of the forskin
• Nappy rash in babies
• Other chemical irritation eg soap, faeces or urine

You should take your child to see your GP or pharmacist if he has balanitis.  Soaking in warm salty water can soothe the discomfort

• Your GP recommend a steroid cream (that you can get over the counter at the chemist) and/or a barrier cream (like zinc oxide, Sudocream etc)
• If there are signs of a fungal infection, an antifungal cream might be recommended (eg Canesten, Nilstat etc) or a combination cream (eg steroid+antifungal or antifungal+barrier)
• If your little person is really sore and distressed, oral paracetamol or ibuprofen can also help.

 

3. Undescended testes (note the terminology is “testicle” for one, “testes” for two)

About 1 in every 20 boy babies are born with one or both testes that are not in their scrotum.  Usually the testes move down the inguinal canal (a tube that runs the length of the groin) into the scrotum during the 7-8^th month of pregnancy.

A baby can be born with an undescended testicle or testes (this is called an “congenital” undescended testicle) or, they can be born with the testes in the scrotum, but as the child grows, the spermatic cord attached to the testicle (or testes) does not and it is pulled back up into the groin (this is called “acquired” undescended testes).

The general rule is that if the testes (one or both) are not down in the scrotum by the time the child is 6 months old, then an operation (called an “orchidopexy”) is needed to bring them down into the scrotum and secure them there. If the testes have not descended by 6 months of age, then it is unlikely they will come down without medical intervention.

If undescended testes are not treated (ie brought down into the scrotum), it increases the risk of a whole lot of OTHER boy bit problems (yes there are more!) such as:

• Increased risk of testicular cancer – the testes are meant to hang outside the body in the scrotum so that they are a few degrees lower than the rest of the body. If they stay up, then the increased temperature over a long time increases cancer risk.
• Hernia
• Testicular torsion (where the testicle twists upon the spermatic cord and cuts off blood supply)
• Impaired fertility (reduced ability of the testicular cells to produce sperm)

If your child does eventually need an operation, the operation itself is called an “orchidopexy”

• It is usually just a day procedure
• A small incision is made in the groin area, and the cord that is attached to the testicle is gently stretched.
• Another cut is made in the scrotum to pull the testicle down, and then it is secured there so it cannot rise back up again.

Retractile testes

A testicle that can spontaneously move out of and back into the scrotum (with or without manual manipulation) is called a retractile testicle.  By definition, the testicle should be easily manipulated into the scrotum and remain there until a reflex (called the cremasteric reflex – which pulls the testicle upwards) is triggered.  Historically, such testicles were thought to be a variant of a normal testicle, but this idea has now changed.  In a study by Agarwal et al (Agarwal P, Diaz M, Elder J. Retractile testis – is it really a normal variant? J Urol. 2006;175:1496-1499) boys 7 years or older, the testicle had a 19% chance of remaining retractile compared to 44% in boys less than 7 years. Hence, boys with retractile testes need long-term follow up – the study demonstrated that 32% of these retractile testes become ascending testes.

Stay tuned for the next exciting article about ‘what can go wrong with ding-dongs.’

Catch you soon!

 

xxDr Megs