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Phimosis

• Physiologic at birth, separates over time due to smegma production and intermittent erections
• Foreskin easily retractable in 90% by 3yo and > 99% by 17yo
• Avoid forceful foreskin retraction, can cause scarring and pathologic phimosis
• Circumcision indications: persistent or secondary phimosis, balanitis, posthitis, BXO, recurrent UTIs
• Balanitis Xerotica Obliterans (BXO): can treat with steroids or circumcision, may require reconstruction if meatus involved, 20% meatal recurrence
• Steroids: apply topical betamethasone 0.05% BID-TID with gentle manual retraction, usually responds within 2-8 weeks (50-90% success) but often regress once treatment stopped
• For details on circumcision technique and considerations, see separate section

Paraphimosis

• Can cause glans gangrene if not reduced
• Conservative treatments: manual compression (with coban), iced glove for 5 minutes
• Next steps: perform penile block, consider puncturing holes in edematous foreskin
• Last steps: may require dorsal slit or circumcision for treatment

Hypospadias

Evaluation/Considerations

• Exam Triad: ectopic ventrally located meatus, ventral penile curvaturee, incomplete dorsally hooded foreskin
• Associated conditions: hydrocele/hernia (9%), and cryptorchidism (9-30%)
• DSD testing: obtain US, karyotype, hormone labs if undescended testis or micropenis in the setting of proximal hypospadias
• Megameatus intact prepuce: <1% hypospadias, normal foreskin, meatus anomaly only noted when attempting circumcision, does not require repair (but can be offered)
• Prostatic utricle: often enlarged, can make catheterization difficult, may need coude
• Imaging: usually not required, but renal/bladder US recommended if multiple other congenital anomalies

The Inconspicuous Penis

• Buried penis: normal penis hidden under fat pad, due to obesity/scarring, can treat depending on cause with weight loss or scar repair, avoid reconstruction until puberty due to potential normal loss of fat pad during puberty
• Webbed penis: scrotal skin extends onto ventral penis, can repair by fixing skin to ventral penile base, occasionally may require ventral repair of hypoplastic distal urethra
• Micropenis: > 2.5 SD below average stretched length for age, obtain karyotype and serum T if diagnosed at birth, can attempt treatment with short course of testosterone

Penile Masses

• Evaluation: assess duration, location, prior surgeries, and changes in size to help determine origin
• Parameatal urethral cyst: rare, excise cyst, avoid meatal stenosis
• Median raphe cyst: epidermal cyst, can observe if asymptomatic, otherwise can resect
• Inclusion cyst: occur due to epithelium within subQ tissue, seen after penile surgery
• Congenital nevus: superficial and benign, but should be removed
• Juvenile xanthogranulomas: benign and self-limiting, pigmented nodules 2-20mm, firm/rubbery, can observe to avoid surgery

Miscellaneous

• Aphallia: rare (1 per 10-30mil), absent penile shaft with anteriorly displaced anus, usually associated with other GU abnormalities, assess karyotype
• Diphallia: rare (1 per 5mil), spectrum of presentation and associated GU conditions, obtain RUS and VCUG
• Lymphedema: can observe, but may require removal of all affected tissue and placement of graft/flap
• Neonatal priapism: spontaneously resolves in 2-6 days without treatment
• Balanoposthitis: inflammation usually from fungal or irritative source, treat with topical steroid and antifungal cream, usually no PO meds required, consider further workup if symptoms persist
• Hypospadias, chordee, and torsion: see separate surgery page