THE CIRCUMCISION REFERENCE LIBRARY


CHINESE MEDICAL JOURNAL 1991: Volume 104, Number 6: Pages 491-493.



      BALLOON DILATION TREATMENT OF PHIMOSIS IN BOYS

                    Report of 512 cases

                By He Ying* and Zhou Xiu-hua* *

Changzheng Hospital
Second Military Medical College
Shanghai 200003
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Abstract:
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          Five hundred and twelve boys, aged from 5 months
to 12 years, with phimosis were treated by application of a
specially designed balloon catheter (patented). 1% dicaine
topical anesthesia was used. 3-6 months follow-up showed
that all patients were cured.  The procedure is simple, safe
and much less traumatizing than the conventional
circumcision.  The mechanisms of balloon dilation, the
age-specificity and the anesthesia were [sic] discussed.

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          Phimosis is not uncommon in young boys,[1] and
surgical circumcision is usually advised.[2]  Many of them
have consequent urinary tract infection, frequent
micturition or bradyuria but their parents are reluctant to
agree to surgery because of fear and other concerns.  We
therefore developed a non-surgical treatment with a balloon
catheter designed for pediatric use (patented in China),
which was first applied to a 4-year-old boy in September
1987.  Since then we have treated 512 patients aged from 5
months to 12 years at Changzheng Hospital, with satisfactory
results as those of conventional methods.  We report herein
our clinical experience in 512 male children and discuss the
mechanisms of balloon dilation, the age-specificity, the
anesthesia and the cautions.

                   MATERIAL AND METHODS

     APPLIANCE.  The balloon dilation technique for treating
phimosis in boys includes a balloon catheter, an inflator, a
valve clip and two curved retractors, which are all made of
disposable plastics.

     ANESTHESIA.  It was given topically with 1% of dicaine.

     CRITERIA OF DIAGNOSIS.  Balloon dilation treatment is
indicated for boy patients with a constricted preputial
orifice impeding retraction of the prepuce over the glans
penis and/or a history of either urinary tract infection,
frequent micturition or bradyuria due to phimosis before the
age of three years.

     EVALUATION OF CURATIVE EFFECT.  Success.  Subsidence of
edema of prepuce in 2 weeks and free retraction of prepuce
over the coronary sulcus.  Failure.  The tip of the prepuce
remains constricted and the prepuce cannot be retracted
freely over the glans penis.

     CLINICAL DATA.  The age of the 512 phimotic boys ranged
from 5 months to 12 years.  Phimosis was severe in 397
(77.6%). 93 (18.2%) were under the age of 3 and all had
complications.  65 (25.1%) of 259 between 4 to 7 years, and
29 of 160 aged from 8 to 12 years, had the same sufferings.

     METHODS.  The patient was kept in supine position.  The
preputial orifice was pulled slightly open with two curved
retractors and 2-3 drops of 1% dicaine were dripped in
After two minutes or so the balloon catheter was inserted in
place, and the retractors removed.  The balloon was inflated
gradually, and the tip of the foreskin was adjusted to the
middle part of the balloon, which was further inflated until
the balloon waist disappeared or the preputial orifice was
about 3-5mm greater than the maximal diameter of the glans
penis.  The balloon remained adequately inflated for 20-30
seconds by closing the valve clip.  Dilation was repeated
2-3 times before the balloon was removed.  By now the
foreskin should be retractable freely over the coronary
sulcus if there are no adhesions.  Smegma was cleaned if
any.  The prepuce was drawn back and forth several times
after dripping 2-3 drops of parogen in the orifice and
finally restored to the original position.  If any adhesions
exist, blunt decollement should be made before dilation.
Thereafter, the prepuce was retracted fully 2-3 times daily
and cleaned with warm water.  A few drops of parogen were
applied to the prepuce once a day (Figs 1-3).
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| a photograph     | a photograph     | a photograph    |
|                  |                  |                 |
| Before           | During           | After           |
| operation        | operation        | operation       |
| Fig 1            | Fig 2            | Fig 3           |
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                          RESULTS

          All patients over 4 years of age cooperated well
during the treatment and no forced position was needed,
indicating that anesthesia used in the process was effective
and acceptable.  Follow-up and correspondence investigations
showed that 509 out of the 512 patients were completely
cured after a single balloon dilation.  Only three patients
(0.06%) required 2-3 times of dilation, once every other
week.  The complicating urinary tract infection, frequent
micturition or bradyuria in 187 children with phimosis,
disappeared in in 169 (90.4% and alleviated in 18 (9.6%).

          The following illustrative cases are noteworthy.

          Case 1.  An 11-year-old boy complained of tight
phimosis, diabetes nervous bladder, uroschesis and
ureterohydronephrosis, and had to use urinary catheter
because of dribbling of urine and enuresis nocturna.  He
preferred balloon dilation to circumcision for fear of
infection.  As a result, the patient was freed from
mechanical urethophraxis, frequent micturition and enuresis
nocturna.  Ureschesis and ureterohydronephrosis were
significantly relieved.

          Case 2.  A 3-year-old boy with tight phimosis and
persistent hematuria, had been admitted to hospital because
of repeated urinary tract infections (five times in 2
years).  The follow-up 14 months after balloon dilation
showed he was cured.

                        DISCUSSION

     MECHANISMS OF BALLOON DILATION.  Generally,
circumcision is accepted as the treatment of phimosis for
penis hygiene and elimination of smegma bacilli,
inflammation and other complications.  It is also considered
as an effective way of preventing carcinoma of the penis.[3]
 However, it is traumatic so that not few patients and their
parents are often reluctant to accept this treatment.
Knowing that balloon dilation is helpful in managing the
constrictions of blood vessels, esophaguses, urinary tracts
and ureters,[4-6] we have applied this method in treating
phimosis in 512 boys since 1987.  The prepuce of young boy
(sic) is soft and free of fat and is extensible both
anatomically and mechanically.[7]  Besides, the procedure is
simple and safe requiring no sophisticated skill and
equipment.  Even a junior physician can do it with brief
training.  It carries only a little discomfort and psychic
stress to the patient.  The success rate is as high as 99%
according to our experience.

     AGE SPECIFICITY FOR BALLOON DILATION.  Almost every
male infant or baby has congenital phimosis.  However in
most children the prepuce becomes spontaneously retractable
with the growth and erection of the penis during the first
two years of life.  It has been reported that at 4 years of
age phimosis occurrence is 32%.  They are often brought to
pediatricians for care of inflammation and infection, which
occurred in 36.5% in our series.  The preputial orifice
often became thicker and a fibrous ring made the foreskin
less elastic and extensible.  Dilation by one attempt in
such cases often resulted in failure.  Our experience
suggests that the optimum age for balloon dilation is 2-4 years.

     ANESTHESIA.  Balloon dilation is almost nontraumatic
and time to accomplish the treatment is relatively short.
In our practice, we used 1% dicaine topical anesthesia with
satisfactory results in all cases.  Almost every patient
cooperated well, and no allergic reaction has been found so far.

     CAUTIONS.

     1. Balloon dilation should not be carried
out if there is inflammation.

     2.  Dilation of the prepuce should be terminated if the
balloon waist disappears or when the balloon diameter is
3-5mm greater than that of glans penis.  The prepuce is
retracted 3-3 times daily for two weeks.  Parogen should be
applied to prevent secondary adhesion or paraphimosis.

     3.  In acquired phimosis with preputial pachynsis,
dilation and adhesion detachment should not be done in one
attempt to avoid tearing and bleeding.

     4. Circumcision is still a necessity when detachment of
adhesion is not possible by balloon dilation technique.

                        REFERENCES

     1.  Shen SX. Investigations of the external organs in
         583 boys. Shanxi Med J. 1988:17(4):218. (in
         Chinese)

     2.  Shi SE, et al. Urinary Surgery. 2nh ed. Beijing:
         People's Publishing House, 1978:117. (in Chinese)

     3.  Yu MS. Practical urinary surgery. 1st ed. Beijing:
         Soldier Publishing House, 1980:219. (ins Chinese)

     4.  Zhang WM, et al. Balloon catheter dilation in the
         treatment of uterostenosis. J Clin Uri Surg
         1988;3(1):34. (in Chinese)

     5.  Lu ZB, et al.  Balloon catheter dilation in the
         treatment of cardia achalasaia.  Tianjin Med
         1989:1:18. (in Chinese)

     6.  Chen CZ, et al.  Intercavitary balloon dilation in
         the treatment of ureterostenosis.  Chin J Uri Surg
         1989:9(5):276. (in Chinese)

     7.  Zheng SJ. Human Anatomy. 2nd ed. Beijing: People's
         Health Publishing House. 1987:174. (in Chinese)
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     * Department of Pediatrics

     * * Department of Nursing Care

CIRP Note: Non-retractile foreskin is the normal condition in pre-pubescent boys. It is not a disease and seldom, if ever, requires treatment. The treatment of this non-disease in young boys by these Chinese doctors reveal their ignorance of the normal development of retractile foreskin in boys. Nevertheless, balloon dilation of the prepuce is preferable to circumcision.





(File revised 4 October 2007)

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