THE CIRCUMCISION REFERENCE LIBRARY
J. M. ESCALA and A.M.K. RICKWOODDepartment of Urology, Royal Liverpool Children's Hospital, Liverpool
Summary—The clinical features of 100 cases of balanitis are described. The condition affects no more than 4% of boys, is commonest during pre-school years (but rare prior to toilent training) and is usually associated with a prepuce which is partly or completely non-retractable. It does not cause phimosis and no single pathogen is involved. Most boys suffer a single episode and circumcision is indicated only for those with recurrent, troublesome attacks.
Acute balanoposthitis or, more popularly, balanitis, is a common complaint of boys yet one which receives no more than cursory attention in textbooks and none in the literature otherwise. We make a modest attempt to remedy this deficiency.
We report 100 consecutive boys seen in our clinic over a 3½-year period when a diagnosis of balanitis; 32 had presented directly to the Accident and Emergency Department, when a swab of purulent discharge from the preputial orifice had been obtained for bacteriological examination. In order to assess the incidence of the condition, we questioned 200 consecutive boys aged 7 to 14 years passing through the outpatient clinic for a history of balanitis; excluded were those previously circumcised for other reasons.
Of the 200 boys questioned, 3 definitely had balanitis and 5 gave a history suggestive of the disease.
Most were aged 2 to 5 years; only 5 boys were not toilet trained. Three were under 2, 15 were either 6 or 7 and 6 were either 8 or 9.
A history of purulent discharge from the preputial orifice was regarded as pathognomonic of balanitis; in the absence of this feature, a combination of redness and swelling of the prepuce was considered compatible with the diagnosis provided there was no evidence of ammonia dermatitis, allergy or mechanical irritation of the foreskin (“foreskin fiddling”) Among the few complaining of dysuria, other symptoms of urinary tract infection were lacking.Table 1 Symptomatology
Redness 100 Swelling 91 Discharge 73 Dysuria 13 Bleeding 2 Glans Ulceration 1
One patient had true phimosis. The only other finding of note was the state of retractability of the prepuce, which was non-retractable in 30 cases, partially retractable in 57 and fully retractable in 13.
Table 2 Management
No. of episodes No. of patients Circumcision 1 64 7 2 20 13 3 or more 16 15
A single attack of balanitis was recorded in 64 boys. At the time of writing, which extends from 0.6 to 4.1 years (mean 2.3) after they had been seen, only 2 have returned with a second episode despite a general invitation to reattend if there were further problems. Only a small minority (Table 2) had suffered 3 or more episodes.
Among the 32 patients presenting acutely, culture of discharge from the preputial orifice showed no growth in 15 cases, a mixed growth in 7 and a pure growth of a single organism in 10 (5 Staph. Aureus, 4 proteus vulgaris, 1 Morganella morgagni).
The usual policy was to recommend circumcision in the event of 2 or more episodes; 6 of the 7 boys circumcised for a single attack had this performed at the parents’ request.
Although balantitis is a common complaint, the risk in any individual, uncircumcised boy appears to be no greater than 4% and even if this is appreciably more than the 1% who develop true phimosis (Oster, 1968; Rickwood et al., 1980) or the very few with paraphimosis (Gairdner, 1949). A policy of routine neonatal circumcision to avoid these preputial complains of childhood would be difficult to justify. We found no evidence that balanitis causes phimosis.
Diagnosis outside the acute stage cannot always be certain and some patients in this series may not have had true balanitis. Ammonia dermatitis is usually easy to exclude, but “foreskin fiddling”, a habit indulged in by not a few boys, may be mistaken for balanitis.
The aetiology remains unresolved. There is no single causative pathogen, nor is it proven that the suppurative process is necessarily of bacterial origin. Its rarity among boys in napkins suggests that some component of urine, or of its breakdown products (possibly) ammonia), affords protection. Beyond infancy, the age distribution corresponds with that period when the foreskin is partially or completely non-retractable due to persistence of preputial adhesions and there is logic in the proposition that this disposes to lodgement of pathogens beneath the foreskin. That said, the incidence of incomplete retractability of the foreskin in patients in this series was no greater than is normally found in young boys (Gairdner, 1949; Oster, 1968), nor is a fully retractable foreskin proof against balanitis. Poor personal hygiene would seem an obvious factor, although we are not impressed that this is the case.
As for management, once the acute episode has been treated, active measures seem unnecessary for boys with a single attack since most will will suffer no more. For those with multiple episodes, we take the idiosyncratic view that “preputial stretching” and “freeing of adhesions”, with or without general anaesthesia are wholly useless procedures. Other surgeons are of the opposite persuasion and until the improbable event of a clinical trial, this issue, like so many in surgery, must remain more a matter of faith than fact. The age distribution of our patients indicates that balanitis is ultimately a self-limiting condition and most patients could probably be managed expectantly. Nonetheless, we consider that circumcision is justified for boys with recurrent balanitis causing appreciable discomfort.
J. M. Escala, MD, Clinical and Research
A.M.K. Rickwood, FRCS, Consultant Urologist.
Requests for reprints to: A. M. K. Rickwood, Department of Urology, Royal Liverpool Children's Hospital (Alder Hey), Eaton Road, Liverpool L12 2AP.
Accepted for publication 10 March 1988
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