Preputial adhesions--a misunderstood entity
Prasanna Kumar1, Mainak Deb, Kanishka Das
1Department of Paediatric Surgery, St. John's Medical College Hospital, Johnnagara, Bangalore 560034, India.
Insights
Most boys referred for circumcision due to phimosis actually have preputial adhesions. Outpatient adhesiolysis is effective, highlighting a need for better physician awareness to prevent unnecessary infant circumcisions.
Area of Science:
- Pediatric Surgery
- Urology
Background:
- Phimosis is a common concern in pediatric surgical referrals.
- Distinguishing true phimosis from physiologic preputial adhesions is crucial for appropriate management.
Purpose of the Study:
- To evaluate referral trends and outcomes for 'phimosis for circumcision' at a tertiary pediatric surgical department.
- To assess the diagnostic accuracy and treatment efficacy for presumed phimosis in children.
Main Methods:
- Prospective study of 100 children referred for circumcision due to presumed phimosis.
- Classification of cases into preputial adhesions or true phimosis by a senior surgeon.
- Treatment involved outpatient preputial adhesiolysis for adhesions and circumcision for phimosis, with follow-up.
Main Results:
- Of 100 referrals, 92 had preputial adhesions and 8 had phimosis.
- Preputial adhesions were successfully managed with outpatient adhesiolysis in most cases (95.5%).
- Only 4.5% of those with adhesions required circumcision after failing adhesiolysis, indicating high efficacy of the non-surgical approach.
Conclusions:
- The majority of referrals for phimosis are misdiagnosed physiologic preputial adhesions.
- Outpatient preputial adhesiolysis is an effective treatment for preputial adhesions.
- Improved awareness among primary care physicians is needed to reduce unnecessary circumcisions in pediatric patients.
Objective:
To assess the trends and outcomes in referrals of 'phimosis for circumcision' to a tertiary care pediatric surgical department.
Methods:
This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution.
Results:
All 100 were referred with a non-retractile prepuce and an additional reason - preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age -58 months, referred for preputial ballooning at voiding -6/8 and dysuria -2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age - 22 months, referred for preputial ballooning at voiding -52/92, dysuria -28/92 and suspect UTI -12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 -4 sittings and 4(4.5%) required 5-8 sittings over a follow up period of 1 -24 months (median -3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later.
Conclusion:
The majority of children referred with 'phimosis for circumcision' to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.
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