KULSHRESTHA: CARE OFTHE UNCIRCUMCISEDPENIS 17. Grossman E, Posner NA. Surgical circumcision of neonates. A history of its development. Obstet Gynaecol 1981; 58 : 241-246. 18. Felman YM. Letter to the editor; NY
291
StateJMed 1979; 79: 1964. 19. Expectant Parents Information Kit (1982) 241-2811, pp. 22 Distributed by Pampers, Proctor and Gamble Co., Cincinnati, Ohio.
Care of the Uncircumcised Penis The prepuce or foreskin is firmly adherent to glans at birth. Its separation from the glans starts after the age of 3-6 months. 90% of the children have fully retractable prepuce at the age of 2-3 years, only 10% may still have an adherent prepuce. The separation initiates as a result of shedding of the cells from both the prepuce and glans. These discarded cells accumulate as whitish, cheesy material between the glans and prepuce, and is called as smegma. This is different from the adult smegma, which is due to mixing of shed cells with oily substance produced by sebaceous glands called Tyson's glands, located on the glans. These glans are largely inactive in childhood. The baby should be given bath daily and the genitalia should be cleaned with water and baby's bathing soap only. This is more than sufficient to maintain proper hygiene of the genitals. No antiseptic solution viz Dettol or Savlon etc. should be added in the water as they are not necessary and can be detrimental, leading to allergic reactions or dermatitis. No attempt should be made to forcibly retract or manipulate the prepuce in the infant. Forceful retraction leads to tears in the prepucial skin which bleeds and heals by fibrosis causing dense adhesions, ob-
structing the natural process of the separation of prepuce. Mothers also tend to put a drop of oil in the prepucial opening, anticipating that it will expedite the process of separation. The oil does not in any way help in the separation of the prepuce and may lead to infection or dermatitis. Prepuce may retract spontaneously with erection of penis, which occurs normally in the child from birth onwards. Also as the child grows they 'discover' their body, specially genitalia, and may retract the prepuce themselves. If the prepuce does not retract spontaneously, retraction should be attempted after the age of 172 years only. The glans is held between the thumb and index finger of the left hand. Right hand supports the shaft of the penis. The prepuce is gently pushed back away from the glans towards the shaft, after dilating the prepucial opening. There may be flimsy adhesions which can be gently separated by soft wet gauze piece or separated by small artery clamp under direct vision. The prepuce is pushed upto coronal sulcus. Once the prepuce is fully retracted, glans is cleaned of all the smegma by a wet saline gauze piece. Small amount of any antibiotic cream is applied on the glans and the prepuce is pushed again to its original position, otherwise it will lead to Paraphimosis.
292
THE INDIANJOURNALOF PEDIATRICS
The first retraction is done by the attending pediatrician or by the pediatric surgeon. Subsequent retraction is done by the parents after being fully instructed, while giving bath to the child. After the first retraction, usually there is some swelling and pain. This is easily taken care of by giving more fluids orally, warm compresses of the prepuce and paracetamol. No attempt should be made to blindly probe the space between prepuce and glans. In the first few years, retraction and cleaning of the prepuce and glans should be done once or twice a week only. Later the penile hygiene becomes part of the child's everyday total body care. Approximately 1-2% of male children require circumcision later in life for phimosis, paraphimosis or recurrent attacks of balanitis. Phimosis is confirmed if (a) the prepucial opening is very tight and the retraction is very difficult, (b) the prepuce balloons out duringvoiding and (c) there is tight fibrous ring at prepucial opening. Circumcision is also indicated if the prepuce is excessively long. Setting aside surgical indications circumcision is a controversial matter with differing opinions and is widely practised for reasons of culture and traditions. However, there is a general consensus now that circumcision in the newborn
Vol.57, No. 3 period is undesirable. In s u m m a r y :
(a) The care of the uncircumcised penis is very easy. It requires external cleaning by bhby's bathing soap and water only. (b) Prepuce is firmly adherent to glans in the new born periods. (c) Separation of the prepuce starts at the age of 3-6 months and is usually complete by 2-3 years of age. (d) Forceful retraction, manipulation or blind probing should not be attempted in the infant as it leads to pain, tears in the prepucial skin, bleeding and dense adhesions. (e) Spontaneous retraction is possible. (f) First retraction should be done by the attending pediatrician or pediatric surgeon after the age of 2years. (g) In the initial years cleaning is done once or twice a week only after retraction. Later at puberty it becomes part of everyday body care. R. Kulshrestha Senior Pediatric Surgeon, Department of Pediatric Surgery, Safdarjung Hospital, New DelhL
How to Read a Journal Article The later part of the 20th century is identified for the explosion of information both in scientific and non-scientific world. Medicine, in particular the field of pediatrics is no exception. Unless, the reader becomes
very discriminating the scientific information may be overwhelming, sometimes too good and other times confusing. It is these characteristics of the information flow which may sometimes overtake the reader
291
StateJMed 1979; 79: 1964. 19. Expectant Parents Information Kit (1982) 241-2811, pp. 22 Distributed by Pampers, Proctor and Gamble Co., Cincinnati, Ohio.
Care of the Uncircumcised Penis The prepuce or foreskin is firmly adherent to glans at birth. Its separation from the glans starts after the age of 3-6 months. 90% of the children have fully retractable prepuce at the age of 2-3 years, only 10% may still have an adherent prepuce. The separation initiates as a result of shedding of the cells from both the prepuce and glans. These discarded cells accumulate as whitish, cheesy material between the glans and prepuce, and is called as smegma. This is different from the adult smegma, which is due to mixing of shed cells with oily substance produced by sebaceous glands called Tyson's glands, located on the glans. These glans are largely inactive in childhood. The baby should be given bath daily and the genitalia should be cleaned with water and baby's bathing soap only. This is more than sufficient to maintain proper hygiene of the genitals. No antiseptic solution viz Dettol or Savlon etc. should be added in the water as they are not necessary and can be detrimental, leading to allergic reactions or dermatitis. No attempt should be made to forcibly retract or manipulate the prepuce in the infant. Forceful retraction leads to tears in the prepucial skin which bleeds and heals by fibrosis causing dense adhesions, ob-
structing the natural process of the separation of prepuce. Mothers also tend to put a drop of oil in the prepucial opening, anticipating that it will expedite the process of separation. The oil does not in any way help in the separation of the prepuce and may lead to infection or dermatitis. Prepuce may retract spontaneously with erection of penis, which occurs normally in the child from birth onwards. Also as the child grows they 'discover' their body, specially genitalia, and may retract the prepuce themselves. If the prepuce does not retract spontaneously, retraction should be attempted after the age of 172 years only. The glans is held between the thumb and index finger of the left hand. Right hand supports the shaft of the penis. The prepuce is gently pushed back away from the glans towards the shaft, after dilating the prepucial opening. There may be flimsy adhesions which can be gently separated by soft wet gauze piece or separated by small artery clamp under direct vision. The prepuce is pushed upto coronal sulcus. Once the prepuce is fully retracted, glans is cleaned of all the smegma by a wet saline gauze piece. Small amount of any antibiotic cream is applied on the glans and the prepuce is pushed again to its original position, otherwise it will lead to Paraphimosis.
292
THE INDIANJOURNALOF PEDIATRICS
The first retraction is done by the attending pediatrician or by the pediatric surgeon. Subsequent retraction is done by the parents after being fully instructed, while giving bath to the child. After the first retraction, usually there is some swelling and pain. This is easily taken care of by giving more fluids orally, warm compresses of the prepuce and paracetamol. No attempt should be made to blindly probe the space between prepuce and glans. In the first few years, retraction and cleaning of the prepuce and glans should be done once or twice a week only. Later the penile hygiene becomes part of the child's everyday total body care. Approximately 1-2% of male children require circumcision later in life for phimosis, paraphimosis or recurrent attacks of balanitis. Phimosis is confirmed if (a) the prepucial opening is very tight and the retraction is very difficult, (b) the prepuce balloons out duringvoiding and (c) there is tight fibrous ring at prepucial opening. Circumcision is also indicated if the prepuce is excessively long. Setting aside surgical indications circumcision is a controversial matter with differing opinions and is widely practised for reasons of culture and traditions. However, there is a general consensus now that circumcision in the newborn
Vol.57, No. 3 period is undesirable. In s u m m a r y :
(a) The care of the uncircumcised penis is very easy. It requires external cleaning by bhby's bathing soap and water only. (b) Prepuce is firmly adherent to glans in the new born periods. (c) Separation of the prepuce starts at the age of 3-6 months and is usually complete by 2-3 years of age. (d) Forceful retraction, manipulation or blind probing should not be attempted in the infant as it leads to pain, tears in the prepucial skin, bleeding and dense adhesions. (e) Spontaneous retraction is possible. (f) First retraction should be done by the attending pediatrician or pediatric surgeon after the age of 2years. (g) In the initial years cleaning is done once or twice a week only after retraction. Later at puberty it becomes part of everyday body care. R. Kulshrestha Senior Pediatric Surgeon, Department of Pediatric Surgery, Safdarjung Hospital, New DelhL
How to Read a Journal Article The later part of the 20th century is identified for the explosion of information both in scientific and non-scientific world. Medicine, in particular the field of pediatrics is no exception. Unless, the reader becomes
very discriminating the scientific information may be overwhelming, sometimes too good and other times confusing. It is these characteristics of the information flow which may sometimes overtake the reader
