Physiological and pathological changes in the prepuce sac in children - diagnostics, tactics of conducting konoma svetlana mursalovna. Inflammation of the foreskin - the "male" problem of a small child

This article is addressed primarily to the parents of boys, because it will focus on one of the anomalies in the development of the male genital organ, the narrowness of the foreskin, and the complications with which it is fraught. But first, let's give some anatomical information.

The head of the penis is covered by the foreskin, which consists of inner and outer sheets. This skin forms the so-called preputial sac. In the first time after the birth of a child, it is usually closed, the inner sheet of the foreskin is, as it were, glued to the surface of the glans penis. Such a condition, called physiological phimosis, should not inspire concern. As the child grows, the anatomical structure of his organs improves, and in the second or third year of life, the foreskin spontaneously separates from the glans penis. This is also facilitated by the accumulation in the preputial sac of a wetting fat-like substance similar to a white ointment - smegma. If you try to move the separated foreskin back, the head, as a rule, is easily exposed.

However, in some children, the opening of the preputial sac and exposure of the head is prevented by a too narrow opening of the foreskin. This is true congenital phimosis (compared to physiological, it is rare).

The foreskin in these cases, as a rule, is elongated and has the shape of a proboscis. This structure makes it difficult to drain urine. Pouring out of the urethra, it first enters the preputial sac (at the same time it swells spherically), and then it comes out in a thin stream or drop by drop. Attentive parents may notice that during urination, the child behaves restlessly - pushes, cries, blushes, and then calms down.

You can create normal conditions for the outflow of urine by eliminating phimosis with a simple operation - dissection or excision of the foreskin. If this is not done in a timely manner, complications develop. In young children, for example, the constant tension of the abdominals during urination can contribute to the occurrence of a hernia, dropsy of the testicle, prolapse of the rectum.

Urine pouring into the preputial sac partially lingers in it, mixes with accumulated smegma and, decomposing, often causes balanoposthitis - inflammation of the skin of the glans penis and the inner layer of the foreskin. The disease is accompanied by redness and even swelling of the foreskin, especially around its opening, the release of purulent fluid, increased urination. The child becomes capricious, tends to touch the penis with a pen, because he constantly experiences itching, burning and other unpleasant sensations.

Balanoposthitis can be not only a consequence of congenital phimosis, but also the cause of an acquired one. If for some reason an inflammatory process occurs in the preputial sac and lasts for a long time, cicatricial changes form in the tissues and the inner layer of the foreskin fuses with the glans penis.

Acquired phimosis is most often observed in children of preschool and school age. It can also occur in adult men. The inflammatory process usually acquires a persistent course in cases where the foreskin is elongated and, moreover, the rules of hygiene are not observed.

As well as congenital, acquired phimosis must be eliminated surgically. Moreover, doctors usually recommend not to postpone the operation for a long time, fearing complications.

Phimosis and balanoposthitis often cause bedwetting.

One of the most serious complications of phimosis can be inflammatory diseases of the urinary tract and kidneys, caused by a violation of the normal outflow of urine.

Initially, such a violation and stagnation of urine lead to the expansion of the bladder, infection and inflammation of its mucous membrane, that is, to cystitis. These congestion and inflammation often also lead to the formation of bladder stones. In addition, the stagnation of urine in the bladder, in turn, contributes to its retention in the ureters, renal pelvis, calyx, and this causes their expansion and contributes to the development of hydronephrosis.

The figure shows possible complications of phimosis: narrowing of the urethra (1), cancer of the glans penis (2), smegmolitis (3), inflammation of the bladder - cystitis (4), stones (5) in the bladder, progressively increasing expansion of the kidney cavities - hydronephrosis (6), inflammatory process in the renal pelvis, calyces and parenchyma of the kidney - pyelonephritis (7).

All this creates the prerequisites for the occurrence of pyelonephritis - one of the most serious kidney diseases.

Leukoplakia can be the result of phimosis and the associated prolonged inflammatory process. This disease, accompanied by keratinization of the inner layer of the foreskin, the appearance of whitish spots on it in the form of thickenings, painful and long-term healing cracks and sores, creates a fertile ground for the development of cancer.

A special role in the occurrence of a malignant tumor can be played by prolonged stagnation and decomposition of smegma, which, as shown by some studies, contains carcinogenic substances. Observations indicate that almost all patients with penile cancer suffered from congenital or acquired phimosis.

As a result of the accumulation of smegma in the preputial sac, smegmolites are often formed - soft stones resembling hardened curd mass. Their sizes sometimes reach one centimeter, they are easily palpable, are visible under the skin (parents even take them for a tumor) and, of course, cause constant anxiety to the child.

Sometimes, experiencing discomfort and trying to somehow get rid of them, children forcibly push back the narrow foreskin behind the head of the penis. As a result, the head is pinched (paraphimosis), and it can become dead if not urgently seek medical help.

In the first hours, doctors usually manage to set the strangulated head into the preputial sac. If this is not possible, the operation is performed immediately.

The most reliable prevention of all possible complications is the early elimination of phimosis by surgery. If phimosis is complicated by an inflammatory process, treatment is preliminarily prescribed. In addition, it is usually recommended to make warm baths from a pale pink solution of potassium permanganate, to wash the cavity of the preputial sac with some kind of disinfectant solution. These recommendations must be strictly followed so that the inflammatory phenomena pass faster.

Careful implementation of hygiene requirements throughout life helps to prevent the development of secondary, or acquired, phimosis.

When bathing a small child, push back the foreskin, wash with warm soapy water, rinse and be sure to dry with a towel.

In the future, each boy must certainly be taught to remove smegma daily, washing it off with warm water and soap.

If inflammation occurs or you notice signs of any other trouble in the boy, consult a doctor without delay. Timely measures taken will help prevent possible serious complications.

Phimosis (from the Greek. "Contract") is a condition in which it is impossible to completely withdraw the head from the foreskin due to its narrowing. It occurs in 90% of boys before the onset of puberty and is a manifestation of the physiological maturation of the penis. Phimosis in men is a pathological condition. It develops in 2-3% of adults and leads to a number of serious complications, impoverishes the sensations of sexual intercourse. In the early stages, phimosis can be successfully treated with conservative methods, so it is important to notice the pathology in time and consult a doctor.

Development mechanism

The penis is the external genital organ of a man, the main function of which is to introduce sperm into the woman's vagina. The most sensitive part of it is called the head, it contains the largest number of nerve endings. It is covered with a thin delicate epithelium, which is similar in structure to the red border of the lips. At the top of the head, a slit-like opening opens the urethra - the male seminal and urinary tract. With its lower part, it fuses with the cavernous bodies of the penis, which form its trunk. In this place, the penis has a thickening - the coronal groove, it can be felt immediately under the head.

The skin fold - the foreskin (prepuce) protects the delicate skin of the head from damage. It consists of 2 sheets:

External - identical in structure to the epidermis of the skin, has an upper stratum corneum;
Internal - covered with thin epithelium, similar to mucous membranes. It has a large number of modified sebaceous glands that produce a waxy substance - smegma. Their secret serves to moisturize the head and facilitate sliding during sexual intercourse.

The foreskin starts from the coronal sulcus and tightly covers the entire head, forming a slit-like preputial cavity. In front, it opens with a hole that easily stretches and releases the head out. Normally, in a mature man, the foreskin is easily displaced, completely exposing the upper part of the penis. In the back of the head, the inner sheet of the prepuce is tightly fused with its tissues in the form of a frenulum. A huge number of nerve endings and capillaries lie in the thickness of the frenulum, so stimulating it during intercourse gives a man pleasure.

The foreskin performs the following functions:

Protects the urethra from the penetration of pathogens, covering its opening;
Prevents mechanical irritation and damage to the thin epithelium on the surface of the head, while maintaining its sensitivity;
Facilitates sliding during sexual intercourse due to the production of smegma and a smooth inner leaf;
Increases the pleasure received in the process of intercourse by stimulating the nerve endings of the head and frenulum. This is an important factor in evolutionary terms: without strong positive emotions, people would refuse sex and have less chance of procreation.

Phimosis, as a pathological condition, develops after inflammation or injury of the foreskin. As a result of exposure, tissues are destroyed and the inflammatory process starts. It goes through certain stages and necessarily ends with the organization - the restoration of the integrity of the body. Deep damage is replaced with the formation of coarse connective tissue, which significantly reduces the elasticity of the foreskin. High activity of recovery processes leads to the formation of synechia - connective tissue partitions between the inner leaf of the prepuce and the glans penis. They firmly hold them together and prevent the upper part of the penis from being exposed.

Classification

It should be understood that phimosis is not a disease, but a special condition that is associated with the physiological characteristics of the body (age), heredity and damage to the tissue of the foreskin. Concerning the following forms of phimosis are distinguished:

Physiological - occurs in most boys before the onset of puberty, is associated with the functional maturation of the preputial cavity. It is not a pathology and resolves on its own after 7 years.
Pathological - occurs as a result of inflammation, trauma, metabolic disorders and requires treatment:
Hypertrophic (proboscis);
atrophic;
Cicatricial.

The frequency of occurrence of one form or another of phimosis directly depends on age. In children, in the vast majority of cases, it is physiological in nature, and in men it is due to cicatricial changes.

According to the severity of the process, 4 degrees of phimosis are distinguished:

In a calm state, the head is released completely, with an erection, its removal is difficult and painful;
At rest, the head of the penis is difficult to withdraw, during an erection it is completely covered by the foreskin and is not released;
The head can only be partially withdrawn at rest;
The head is constantly hidden by the foreskin, it is not displayed. At the same time, during urination, urine first fills the preputial sac and only after that is released drop by drop.

Physiological phimosis

The genital organs of a boy begin to form after 11-12 weeks of intrauterine development. The head of the penis and the foreskin are formed from a common germ in the third trimester of pregnancy, their separation occurs at the site of the coronal sulcus. The cells of the prepuce begin to actively divide, significantly outpacing the growth of the tissues of the penis. As a result, they surround the head in the form of a cup and close it with a cavity. The anatomical proximity and commonality of the tissue lead to the formation of delicate epithelial septa between the inner layer of the foreskin and the skin of the head.

The development of the penis during the growth of the child. Up to ~10 years, fused glans and foreskin are normal

In a newborn child, the preputial cavity is completely delimited from the environment by such cords, which excludes the ingress of pathogenic microflora into it. By 3-4 months of life, the sebaceous glands of the foreskin begin to function. They produce smegma, which accumulates in a small amount in the preputial cavity. Its infection and the development of the inflammatory process are prevented by epithelial septa in the region of the opening of the foreskin. Gradually, these thin strands are destroyed, the smegma is displaced towards the exit and is released through the formed free spaces. It can be seen as small white waxy flakes on the baby's underwear.

By the time of puberty, the septa are completely or partially reduced and the mobility of the foreskin increases. During masturbation or after the onset of sexual activity, the head begins to be completely released, although the process may be painful at first. In this way, Physiological phimosis resolves spontaneously during puberty and does not require treatment.

Treatment for inflammation

Despite the naturalness of phimosis, in some cases there is a need for medical care. With insufficient care for the boy or his non-compliance with personal hygiene, pathogenic microflora enters the preputial sac from the skin and an inflammatory process develops. Clinically, this is manifested by redness along the edge of the opening of the prepuce, local soreness and an unpleasant odor from the penis. Subsequently, inflammation leads to the formation of cicatricial phimosis, which will require surgical treatment.

If such symptoms are found in a child, parents should contact a pediatric urologist or pediatric andrologist. Previously, the technique of simultaneous opening of the foreskin with a sharp jerky movement was widely practiced. Such a procedure is extremely painful for the boy and can cause psychological trauma. In addition, a single opening damages the foreskin and can cause cicatricial phimosis in the future.

To date, doctors recommend a gradual opening of the head by 1-2 mm. It is carried out after a warm bath, preferably with the addition of antiseptics: a weak solution of potassium permanganate, a decoction of chamomile, calendula, sage. It should be taken 2 times a week for 10-15 minutes. After the water procedure, the foreskin is treated with a healing ointment (bepanten, solcoseryl) or baby cream to increase its elasticity and prevent rupture. The skin is retracted no more than 2 mm in one procedure. In this way, phimosis can be treated at home for several months.

If the method described above is ineffective, the surgeon or urologist dissects the adhesions formed with a probe. He performs the procedure on an outpatient basis without anesthesia or under local anesthesia. The doctor inserts a thin metal rod with a rounded end into the preputial sac and runs it along the circumference of the glans penis. Subsequently, the boy's penis should be washed daily using antiseptic solutions.

Video: phimosis - norm and pathology, Dr. Komarovsky

Pathological phimosis

The causes of pathological phimosis are:

Genetic defect of connective tissue;
Metabolic disease;
Inflammatory diseases of the foreskin and head of the penis;
penis trauma;
sexually transmitted infections;
Age changes.

hypertrophic

Hypertrophic phimosis in terms of frequency of occurrence in children is the next place after the physiological one. It is an overdevelopment of the foreskin, which hangs down from the penis with a long proboscis. At its end, the "proboscis" narrows and opens with a dense ring, the removal of the head through which is not always possible. As a rule, such a condition is due to the obesity of the child - excessively developed subcutaneous fat pulls the foreskin and reduces its elasticity.

A long proboscis lengthens the path for the excretion of urine and smegma, resulting in favorable conditions for the growth of pathogenic microflora. The increased moisture in the preputial sac and the accumulated secret of the sebaceous glands is an ideal breeding ground for bacteria. They damage the epithelium of the head and the inner leaf of the foreskin with the development of an inflammatory reaction -. In children with diabetes, yeast fungi often multiply in the preputial sac, which is manifested by unbearable itching of the genital organs and white curdled discharge. Balanoposthitis often ends with the formation of a cicatricial form of phimosis.

Another reason for the pathology is the underdevelopment of the penis against the background of the normal size of the foreskin. It comes to light in the course of puberty of the boy and is connected usually with insufficient production of testosterone by testicles (hypogonadism). In this case, phimosis is combined with short stature, lack of muscle mass, female-type hair growth, lack of facial hair growth, high voice, and depression. Treatment of this condition is carried out jointly by a urologist and an endocrinologist or andrologist.

cicatricial

Cicatricial phimosis is the most common form of the disease among adult men. Its causes are any conditions that lead to inflammation in the area of the foreskin or head. Among genital infections, the most common cause of balanoposthitis with cicatricial phimosis in the outcome is pale treponema - the causative agent and. Virus, and also often cause inflammation of the head. In children, cicatricial phimosis is rare and in about a third of cases it is not possible to find out the cause of the disease.

The disease progresses gradually. In the first weeks after inflammation, thin connective tissue bridges are formed, which slightly limit the mobility of the foreskin. In just a few months, they thicken significantly, become dense and rough. The mobility of the foreskin is reduced, the head remains closed even during erection, and attempts to bring it out are accompanied by severe pain. Forcible exposure of the head leads to small tears, bleeding and the formation of new scars.

The last degrees of phimosis violate the self-cleaning of the preputial cavity and the process of urination. Urine bathes the glans, mixes with the infected smegma, and flows back into the urethra after the man stops urinating. As a result, the patient develops urinary tract infections: cystitis, pyelonephritis. In addition, cicatricial phimosis prevents the normal course of sexual intercourse. There is a need for additional lubrication, the man receives insufficient stimulation and feels sore when the foreskin is stretched.

Treatment of pathological forms

Diagnosis and treatment of phimosis is carried out by a urologist, surgeon or andrologist. If the cause of the disease was a sexual infection, then the patient is additionally observed by a dermatovenereologist, who prescribes antibiotic therapy. Both partners should be treated in this case.

Treatment with a conservative method is carried out with the first two degrees of phimosis, if the adhesions are thin and have arisen no more than a month ago. In such cases, the patient is advised to gradually stretch the foreskin after a hot bath. An anti-inflammatory ointment containing glucocorticoids (locoid, hydrocortisone) and absorbable ointment contratubex are applied to the glans penis. Open the head carefully, avoiding injury to the foreskin. After the procedure, healing preparations (solcoseryl, bepanthen, panthenol) are indicated locally.

The surgical method of treatment is circumcision or circumcision. The operation implies the complete removal of the foreskin, the head after it remains permanently open. The intervention is performed under general anesthesia in children and under local anesthesia in adults. The surgeon first cuts and folds back the outer sheet of the foreskin, then carefully excised the adhesions in the preputial sac. After both leaves are selected, he cuts them off along the coronal sulcus. The surgeon sutures the resulting wound with absorbable suture material, that is, the removal of sutures after the operation is not required. In the postoperative period, 1-2 dressings are performed and the patient is discharged home. Complete healing of tissues occurs within 2-3 weeks and after this period, you can resume sexual activity.

surgery for phimosis

Complications and prevention

The most common complications of phimosis are:

Infringement of the head (paraphimosis) - develops when trying to forcibly remove the head of the penis from the preputial cavity. A dense ring of the foreskin compresses the tissue of the head, it swells and increases in size. As a result, its reverse reduction becomes impossible, the blood supply to the tissue is disrupted, and without urgent medical care, the situation ends with necrosis - necrosis of the strangulated part of the head.
Balanoposthitis - inflammation of the foreskin and head of the penis.
Urethritis, cystitis, pyelonephritis - develop at the 4th degree of phimosis due to a violation of the flow of urine.
The increment of the foreskin to the head - the most damaged areas, due to their tight adhesion to each other, heal with a single scar, which is not always possible to excise.

The most important preventive measures are:

Careful hygiene of the genitals, daily washing of the child and timely change of diapers or diapers;
Use of barrier methods of contraception (condom) during casual sexual intercourse;
Treatment of underlying diseases (diabetes mellitus).

Video: doctor about phimosis in men

The male body is arranged by nature in such a way that an intimate place requires special attention in terms of cleanliness. The development of bacteria occurs without proper hygiene. The place of formation of unpleasant inflammation is under the foreskin of the penis and is called the preputial sac.

Men earn various diseases when bacteria enter: phimosis, balanoposthitis, paraphimosis. At a young age, the problem is especially acute, as children are less likely to think about the hygiene of their body.

Diseases of the foreskin

The preputial sac in boys can cause inflammation of the very head of the penis and the skin around it. There are two types of disease development:

Diagnosis of problems consists in determining the patient's condition through a survey and testing to determine the type of disease. When determining the source of the problems, a visual inspection of the head is carried out, the foreskin is checked for inflammation. To exclude the infectious development of malaise, appropriate studies are prescribed.

How to identify foreskin problems?

Symptoms of inflammation affecting the preputial sac:

Constant itching of the head of the penis.
There is a slight burning sensation of the foreskin.
Rarely, a boy can detect purulent components.
Slight swelling of the skin around the preputial sac.
Flesh redness.
Eruptions on the head.
It is difficult to go to the toilet in a small way.
Pain when trying to move the flesh, as well as when the organ is enlarged.

Pain disappears after a while, but recurs periodically. Severe conditions require prompt resolution of the problem. Small irritations can be removed with the right ointment. It is important to establish the cause that caused the inflammation of the preputial sac.

Who can help?

With your problem, you can contact the following doctors:

therapist
surgeon
urologist.

Why does the skin around the head become inflamed?

After washing procedures, Levomekol ointment is used, which is injected into the preputial sac with a syringe. For children, herbal warm baths are used as a prophylaxis.

Medical methods

Problems of the preputial sac caused by phimosis in boys are eliminated by pre-surgical methods:

These methods should be used only after examination in the clinic. In the case of infections, you can harm the delicate skin of the child and start the disease. It is impossible to achieve a result by independent measures if there are scars on the flesh.

Non-medical practice

In medical practice, non-drug methods of foreskin tension are used. With daily exercises, you can achieve a gradual stretch during the shower and after urination. Duration is determined by the moment when the pain began.

The second way is to stretch the preputial sac with your fingers. In the listed ways, you can get rid of congenital pathology. In 7 out of 10 patients, a complete cure of phimosis was observed.

It is recommended to start treatment of physiological phimosis in boys no earlier than the onset of puberty. In 70% of children, this phenomenon disappears with time. If there are no serious complications, preventive measures are taken to reduce the inflammatory processes of the foreskin by folk methods.

The exceptions are infectious problems and bacterial. It is not recommended to delay this type of illness. A visit to the doctor will be the best solution for parents. Constant monitoring of the current inflammatory process will be required. Particular attention is paid in cases where the foreskin has already expanded, but at some point in time narrowed again. Here we are talking about the pathological development of the body.

Balanoposthitis is an inflammation of the glans penis and foreskin. It is found in children 3 times more often than in adult men. This is due to the anatomical features of the structure of the penis in boys. In childhood, there are adhesions between the foreskin and the head of the penis that do not allow the head to be opened. This condition is called physiological phimosis.

As a result of adhesions of the foreskin with the head, pockets are formed in which secretions stagnate - smegma. Getting into such a pocket of a bacterial infection causes inflammation. Redness and swelling appear on the head, it becomes painful, the child experiences itching and burning, difficulty urinating. Therefore, this process must be treated.

Reasons for the development of balanoposthitis

The direct cause of inflammation in the head and foreskin is the penetration of a bacterial infection into the preputial sac. Infectious agents can be:

conditionally pathogenic microflora: staphylococci, streptococci, proteus, E. coli;
gonococcus, while gonorrhea develops;
trichomonas causing trichomoniasis;
fungi of the genus Candida;
herpes virus;
human papilloma virus;
pale treponema causing syphilis;
gardnerella.

The most common cause is the activation of opportunistic microflora with neglect of the rules of personal hygiene, dermatitis and reduced immunity.

The main causes of the disease:

1. Non-compliance with the personal hygiene of the child.

Rare washing and insufficient care of the boy's external genitalia leads to the accumulation of secretions and urine in the preputial sac. This stagnation serves as a good breeding ground for bacteria. Too frequent washing with detergents irritates the delicate skin of the penis and contributes to the development of inflammation. Tight rubbing underwear, oversized diapers, poor-quality synthetic detergents for washing children's clothes can provoke a disease.

2. Allergic reaction.

The appearance of allergic rashes, due to which microcracks and sores are formed, make the skin more vulnerable. In the genital area, children often develop diaper dermatitis. The reason for its development is tight and synthetic underwear, diapers, household and cosmetic chemicals, cream, powder. Simple contact dermatitis may also develop.

3. Reduced immunity.

Endocrine diseases, such as diabetes and obesity, weaken the protective properties of the body. Diabetes mellitus is an important risk factor due to the high concentration of glucose in the urine, which serves as a favorable environment for microbes. Improper nutrition, hypothermia, beriberi have a bad effect on immunity.

4. Chronic infections.

From the focus of chronic infection, microorganisms enter the genital organ with the blood stream.

5. Infections of the genitourinary system.

Cystitis, urethritis, prostatitis.

6. Traumatization.

Forced opening of the glans penis in phimosis.

Treatment

An important aspect in the treatment of balanoposthitis is the observance of the personal hygiene of the baby. Wash the child should be 2 times a day, as well as after bowel movements. The diaper needs to be selected according to size and changed on time. Before putting on a diaper, you need to cleanse and moisturize the skin. Air baths will be useful.

Do not use force to push back the foreskin of the penis. In children, this narrowing is physiological and disappears by 3-5 years.

In the treatment of balanoposthitis in children, conservative and surgical methods are used. A mild form of the disease can be cured at home.

Conservative therapy

Treatment consists in sitz baths with antiseptic solutions, washing the preputial sac with these solutions using a syringe.

480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Thesis - 480 rubles, shipping 10 minutes 24 hours a day, seven days a week and holidays

Konoma Svetlana Mursalovna Physiological and pathological changes in the prepuce sac in children - diagnostics, management tactics: dissertation ... candidate of medical sciences: 14.00.35 / Svetlana Mursalovna Konoma; [Place of defense: GOUDPO "Russian Medical Academy of Postgraduate Education"]. - Moscow, 2008. - 111 p. : 68 ill. RSL OD,

Introduction

CHAPTER 1. Current state of the issue (literature review) 15

1.1. Background 15

1.2. Embryogenesis of the preputial sac 18

1.3. Anatomical and physiological aspects of the development of the preputial sac 23

1.4. Modern directions, methods of treatment of pathological changes in the preputial sac in children 29

1.5. Types of surgical interventions on the preputial sac 49

CHAPTER 2. Materials and methods of research 54

2.1. Study design and data collection methods 54

2.2. Study materials 56

2.3. Research methods 60

2.3.1. Mandatory examination methods 60

2.3.2. Additional examination methods: 63

CHAPTER 3 Physiological changes in the preputial sac in children 68

3.1. Congenital physiological phimosis. Comparative results of two different management tactics. Complications and preventive measures 68

3.2. Physiological synechia of the preputial sac in children. Studies on the feasibility of separating synechia, comparative groups. Leading tactics 81

3.3. Physiological accumulations of smegma. Studies on the feasibility of removing smegma accumulations, comparative groups. Leading tactics 89

CHAPTER 4 Pathological changes in the greputial sac in children 97

4.1. Congenital hypertrophic phimosis. Comparative results of conservative and surgical treatment. Complications of surgical treatment and methods of their prevention 97

4.2. Paraphimosis. Clinic. Reasons for development. Treatment 106

4.3. Acquired cicatricial phimosis (complicated, uncomplicated). Etiology. Clinical manifestations. Operative treatment. Complications and measures for their prevention 109

4.4. Inflammatory changes in the preputial sac 118

4.4.1. Balanoposthitis of coccobacillary etiology, clinic. Comparative results of treatment of balanoposthitis

in groups using two different methods 119

4.4.2. Balanoposthitis of fungal etiology, clinical features, treatment 123

4.4.3. Allergic changes in the preputial sac. Clinical manifestations, treatment 124

4.5. Benign volumetric formations of the preputial sac and congenital malformations of its development. Methods of treatment 126

4.6. Working classification and differential diagnostic algorithm of physiological and pathological changes in the preputial sac in children 128

CHAPTER 5 Long-term results of treatment of forms of phimosis and inflammatory changes in the preputial sac in children 133

5.1. Long-term results of treatment of forms of phimosis in children 133

5.2. Long-term results of treatment of inflammatory changes in the preputial sac in children 135

Conclusion 137

Bibliography

Introduction to work

Relevance of the topic. The issues of early diagnosis and treatment of phimosis in children have not yet received their final resolution. Assessment of the state of the preputial sac (MI) in pediatric practice remains the subject of discussion among pediatricians, pediatric surgeons, pediatric urologists in Russia and abroad (Dukhanov A.Ya. 1968, Isakov Yu.F. 1970, Lopatkin N.A. 1986, Pugachev A. G. 1986, Graham G. 1983, Duckett J. 1988, Walker J. 1989, Mac-Kinlay G. 1988, Solovyov A. E. 1995, DewamP:, Tieu H. 1996, Rudin Yu:E: 1999, Orsola A., Caffaratti J., Garat J. 2000). Experts have different opinions and offer diametrically opposed recommendations for the treatment and prevention of diseases. TIM". Doctors of children's polyclinics during preventive examinations do not pay due attention to the age-related features of PM. There is no single point of view 1 in the definition of the concept * physiological phimosis (FF), there is no convenient for practical "application" classification pathology "of the preputial sac, the boundaries between the norm 1 and pathology are not clearly defined. There are disagreements regarding smegma accumulations and the presence of synechia with an internal leaflet of the PM), consider these conditions as a norm or pathology? How dangerous is the presence of smegma for the occurrence of balanoposthitis? Is it necessary to separate synechiae in children under 10 years old? Is an active tactic necessary or it is advisable to take a wait-and-see attitude? boys with physiological phimosis? There are different points of view on the tactics of treatment and the volume of surgical care for patients with purulent-inflammatory diseases of the PM. Practical recommendations on the methods of hygienic care for the genital organs of a boy in the younger age group are often compiled by non-specialists, people far from practice, without

7 evaluation of long-term results, confirmed by a large clinical material with the reliability of statistical indicators.

Thus, the detection and treatment of pathological conditions of the preputial sac is considered an urgent problem in pediatric surgery and pediatric urology-andrology. All of these questions were addressed in our study.

PURPOSE OF THE WORK

Qualitative improvement of diagnosis and determination of tactics for the treatment of various forms of phimosis and changes in the preputial sac in children.

OBJECTIVES OF THE RESEARCH

To identify variants of physiological and pathological changes in the preputial sac and to determine the features of the forms of phimosis in childhood. Create a working classification of physiological and pathological changes in the preputial sac and a differential diagnostic algorithm.

To develop rational tactics for managing children with physiological and hypertrophic phimosis (HF). Establish the effectiveness of gradual "stretching of the preputial ring (PC) in comparison with the traumatic simultaneous removal of the glans penis.

31 To determine the tactics of managing children with synechia and accumulations of smegma in the preputial sac in age groups. To prove the groundlessness of the surgical division of synechiae. Evaluate the effectiveness of delayed tracing of the glans penis (PC). To reveal the relationship of smegmal accumulations with inflammatory changes in the preputial sac:

To analyze the results of surgical treatment of cicatricial and hypertrophic phimosis*. Clarify the causes of complications and suggest basic preventive measures. To develop optimal methods of treatment of children with hypertrophic phimosis.

Clarify the scope of surgical care in the treatment of purulent-inflammatory diseases of the preputial sac (acute, balanoposthitis, fungal infections). To prove that local drainage of the preputial sac is a rational conservative tactic in children with balanoposthitis.

SCIENTIFIC NOVELTY

For the first time on a large clinical material, the main variants of physiological and pathological conditions of the I preputial sac, leading to difficulty in excretion, are described in detail. \ head of the penis.

Clear definitions of phimosis forms are given. Proposed working I classification and differential diagnostic algorithm

physiological and pathological changes in the preputial sac
based on the analysis of the variety of clinical manifestations, with
taking into account the age characteristics of the state of the PM, allowing clearly
to determine the tactics and method of treatment of prepuce pathology.
1 3. Technique of gradual, gentle stretching of the pressure bag

allows you to achieve elimination-narrowing in 1 2-3 months. the majority. (93%) of children with physiological and (91.3%) with hypertrophic phimosis for 4-6 months.

4. It has been established that the method of treatment of phimosis by one-stage
complete removal of the glans penis 1 has no medical
indications, is erroneous, especially in younger age groups,

I because it leads to injury and scarring of the preputial sac.

5. For the first time it has been proven that synechia are stages of development
preputial sac. Separation of synechia in younger children
age group not shown. In the absence of inflammation
preputial sac, their existence is permissible up to 12-13 years.

6. It was found that accumulations of smegma by themselves do not lead to
1 inflammation of the preputial sac, not the main cause
, balanoposthitis and do not require removal, because gradually

migrate and independently evacuate from the preputial sac.

PRACTICAL SIGNIFICANCE

The applied method of gradual, gentle stretching of the narrow prepuce ring after warm hygienic baths with a decoction of herbs (chamomile, string, celandine) 1-2 times a week makes it possible to achieve head removal in 93% of cases within 1 to 3 months. Long-term results confirm the effectiveness of this method.

Free removal of the glans penis is important to achieve by the prepubertal period (12-13 years), in order to teach the teenager the rules of hygiene and prepare the young man for the upcoming sexual life. Before prepubertal age, there are no medical indications for separation of synechia and complete removal of the head, since complete free removal of the head is necessary for painless intercourse.

Active restriction of the use of the technique of simultaneous complete removal of the head in phimosis can reduce the number of iatrogenic damage to the preputial ring and its scarring.

Expectant tactics allow you to exclude unnecessary painful manipulations - to eliminate phimosis, separate synechiae and remove accumulations of smegma and prevent possible complications.

The constant use of antiseptics, for hygiene purposes, can lead to dysbacteriosis and fungal infections of the preputial sac.

The proposed differential diagnostic algorithm allows the doctor to identify groups of children during an outpatient examination: those requiring general observation, those at risk and in need of strict outpatient monitoring or surgical treatment.

Sanitary education among parents on compliance with the proposed hygiene rules for the boy helps to reduce the number

chronic inflammatory changes in the preputial sac, and, as a result, cicatricial phimosis.

MAIN PROVISIONS OF THE THESIS TO BE DEFENDED

The reasons for the narrowing of the preputial sac in boys are associated with age-related features of the formation of the preputial ring and are qualitatively different from phimosis in an adult male.

Children with physiological phimosis, especially of the younger age group, do not require surgical intervention, since conservative tactics are effective in 93% of cases.

The technique of simultaneous removal of the glans penis should be limited, since in physiological and hypertrophic phimosis in 43.7% of cases it leads to iatrogenic damage to the prepuce and the development of cicatricial phimosis, in 14.6% it is ineffective (phimosis persists).

Synechias are the stages of development of the preputial sac; they are maximally recorded in the younger age groups. The formation of the preputial space is completed in the pubertal period. Simultaneous separation of synechiae is a painful, ineffective procedure and is accompanied by a relapse (80.6%) in children under 3 years of age.

Removal of accumulations of smegma of the preputial sac is not indicated, since they recur in 77.1% of cases. Accumulations of smegma are not the main cause of balanoposthitis. Infection often occurs during various manipulations and procedures with the preputial sac.

Simultaneous removal of the glans penis in acute inflammatory diseases of the preputial sac leads to deep ruptures and cicatricial changes, which require circumcision in 25% of cases. Drainage of the preputial sac without removing the glans penis is a more effective and less traumatic method of treatment.

Conservative tactics in hypertrophic phimosis is effective in 91.3% of cases. Circumcision for hypertrophic cicatricial phimosis in children with increased body weight is dangerous due to recurrence of phimosis or latent sexual

13 member. The operation of choice may be an economical resection of the preputial sac with the formation of the contour of the penis.

The presented working classification and differential diagnostic algorithm of physiological and pathological changes in the preputial sac help in choosing the tactics of managing a child.

WORK APPROBATION

The materials of the dissertation research were presented and discussed at: symposium "New Technologies in Pediatrics and Pediatric Surgery" (Moscow, 2005), 4th Russian Scientific Forum "Men's Health and Longevity" (Moscow, 2006).

The main provisions of the dissertation were reported and discussed at a joint scientific-practical conference of the Department of Pediatric Surgery of the Russian Academy of Postgraduate Education and the Children's Clinical Hospital of St. Vladimir, 01.02.2008; (protocol No. 228). The results of the work were reported at a meeting of the Scientist, Council of the RMAPE of Moscow.

PUBLICATIONS

Published 20 publications, 8 on the topic of the dissertation, including one article in the central press (Journal "Urology", 2007); an article in the collection of materials of the 4th Russian Scientific Forum "Men's Health and Longevity" (Moscow, 2006); in the collection of materials of the scientific and practical conference dedicated to the 50th anniversary of the Department of Children's Infectious Diseases Rost State Medical University, 2006 - 2 articles; in the collection of materials of the annual joint scientific and practical conference of the departments of surgical diseases * No. 2 and 4 GOU VPO Rost GMU Roszdrav, Rostov-on-Don, 2007 - 1 article. A textbook for doctors “Pathology of the foreskin. Methods of treatment in childhood” (RMAPO, Moscow, 2006).

This work was carried out at the Department of Pediatric Surgery (head of the department - Doctor of Medical Sciences, Professor Sokolov Yu.Yu.) RMAPE (Rector, Academician

14 of the Russian Academy of Medical Sciences, Professor Moshetova L.K.), on the basis of the St. Vladimir City Children's Clinical Hospital (chief physician Kasyanov P.P.) in Moscow and the MUSIC Children's City Hospital in Taganrog (chief physician Kuvikov V.F.).

SCOPE AND STRUCTURE OF THE THESIS

The dissertation is presented on 179 pages of typewritten text and consists of an introduction, a review of the literature, 5 chapters of own research, a conclusion, conclusions, practical recommendations, an index of literature and an appendix.

The work is illustrated with 6 tables and 59 figures. The bibliography contains 90 sources, of which 23 are domestic and 67 foreign authors.

Anatomical and physiological aspects of the development of the preputial sac

PM, covering the head of the penis, is an important natural anatomical part of the external genitalia in humans. The outer epithelium performs a protective function covering the glans penis, meatus and inner preputial epithelium, which reduces the risk of irritation and contamination. PM is a special connective mucocutaneous tissue that forms the border between the mucosa and the skin; it is similar to the skin of the eyelids, labia minora, anus, and lips. In addition, PM in men provides sufficient mucocutaneous coverage of the entire penis during erection. The unique innervation of the PM also performs an erogenous function.

According to A.Orsola, CP is a specialized, nerve-supplied, mucocutaneous connective tissue that forms the anatomical membrane of the head of the penis. At the birth of a child, it is usually non-retractable, because the inner epithelial surface is connected to the head of the penis; this normal anatomical condition in infants is very often mistaken for phimosis. Within 2-3 years, the PM is separated from the head of the penis due to the formation of keratinized epithelial nodules. As a result of this, as well as intermittent erection, the PM is separated, which ultimately leads to its complete physiological retraction. In 80-90% of children who have not undergone circumcision, the PM is amenable to retraction by 3 years. True "phimosis" is extremely rare before 3 years of age. To date, the etiology of "phimosis" is still poorly understood.

The PM has somatosensory innervation via the dorsal nerve of the penis and branches of the perineal nerves (including the posterior scrotal nerves). Autonomous innervation of the PM begins in the pelvic plexus. The parasympathetic visceral adductor nerve and afferent fibers originate from the sacral center, and the sympathetic preganglionic nerve and visceral adductor fibers originate at the lumbothoracic center. Parasympathetic nerves are located along the membranous wall of the urethra and penetrate it. Although most operations are performed in neonates and children without anesthesia, the complex innervation of the PM explains why nerve dorsal blockade of the penis provides partial pain relief during circumcision in infants. Similarly, blocking the IF ring cannot block the visceral adductor fibers from the cavernous nerve, nor the posterior scrotal somatosensory branches of the perineal nerve. Sensory receptors can be classified as mechanoreceptors, such as sensory Meissner bodies (Fig. 8), lamellar bodies of Vater-Pacini (Fig. 9), and Merkel discs/cells (Fig. 10), as well as nocireceptors (free nerve endings). A wide variety of terms are used to refer to these encapsulated, encysted receptors, for example iron/Krause receptor, Dogiel receptor, sex receptors, Endkalpsen receptor, and mucocutaneous cell receptors. placental membrane. The head of the penis is supplied with nerves, mainly through free nerve endings, and has tactile sensitivity with narrowly localized sensations (including pain, temperature, and certain sensations with mechanical contact). In the glans penis (Fig. 11), cellular receptors are scattered, and are mainly found along the crown of the glans and frenulum. The ridge-like band of PM in men at the site of the mucocutaneous junction has a high degree of concentration of these receptors. The difference in the degree of innervation of the head of the RV from the spinal band of the PM rich in corpuscular receptors is a natural additional part of the erogenous tissue of the RV. The mucous epithelium of the PM and the heads have the same structure. It is not divided until the appearance of hormonal factors. The epithelium of the PM of the fetus, soldered and tightly fitting, has intraepithelial nerves, and according to some studies, Langerhans cells. Own PM is well vascularized, which explains the presence of common hemorrhagic complications during circumcision. The PM contains more free collagen than the proper fascia of the head of the PV.

The smooth fleshy membrane of the scrotum is characteristic exclusively of the male external genital organs and most of this membrane. is within the PM. It consists of smooth muscle cells surrounded by elastic fibers (Fig. 12); thin, tender from PM surrounds the shaft of the penis to the scrotal membrane. The fleshy membrane of the penis is sensitive to changes in temperature and is responsible for changes in the volume required for an erection, and its loss during circumcision explains the decrease in temperature sensitivity of the penis. In infants, the muscle fibers are intertwined and arranged in a mosaic pattern, causing the distal PM to fold into folds, ending as a one-way valve. This explains why, during the examination, the distal part of the PM in the infant is folded, a. in an adult, it is more free. An increase in the mass of elastic fibers may be necessary for an uncomplicated eversion of the penis head in an adult. Although the etiology of this transformation is still unknown, steroid hormones are able to have an effect, because. their topical application may accelerate PM retractability in boys; not reached puberty.

The skin of the PM consists of connective tissue, blood vessels, nerve trunks, sensitive bodies in the area of the tubercles, scattered sebaceous glands, and elastic fibers. The difference between the elastic fibers in the preputial fascia and the skin contributes to the formation of a structure resembling a "muzzle" around the head of the penis. The elastic skin tissue of the PM, along with the scrotum and frenulum, restrains the PM and helps it return to its anatomical position after deployment during an erection or after manual retraction. The outer layer of the PM has rare sebaceous and sweat glands.

Congenital physiological phimosis. Comparative results of two different management tactics. Complications and preventive measures

Congenital physiological phimosis (FF) is the narrowing of the preputial sac, in which there are no cicatricial changes in the skin of the area of the preputial ring. The skin of the preputial ring is soft, stretches well; when trying to remove the head, it is possible to see part of the meatus (Fig. 19). The preputial sac in FF is pink in color, has a normal length, and there are no signs of inflammation.

This condition can be considered as one of the manifestations of functional immaturity, disproportion in the growth of the PM and the preputial ring. According to our observations, under the influence of hormonal changes in boys of the pubertal period, there is a particularly rapid and easy expansion of the skin of the preputial ring and, as a result, a freer removal of the head. A similar effect was observed in boys after treatment of the head of the IF and PM with testosterone ointment during a test for sensitivity to testosterone. It is generally accepted that FF or (unstretched preputial ring) can be observed in boys up to 2-5 years. However, our research has proven that the concept of physiological phimosis has no age limits and can occur at any age (from a newborn to a 17-year-old boy). We observed signs of FF in 15 adolescents aged 16 who never tried to open their heads and were not observed by a pediatric surgeon (Fig. 20). The graph shows a clear trend towards a decrease in the number of children with FF as their age increases.

The degree of PC narrowing was different. In cases of moderate narrowing of the PC, it was possible to examine the meatus and partly the head of the IF. Such a prepuce ring lends itself to stretching quite easily. In cases of pronounced narrowing, when it was often impossible to visualize even the meatus, we noted diagnostically significant ischemia of the PC tissues (“ring of ischemia”), the appearance of which was seen with rigid, difficult to stretch and easily injured skin of the PM.

Distribution of children with physiological phimosis by age groups Out of 1512 (88.3%) cases of congenital FF detected in a single-stage study, up to 5 years, narrowing of the PC was in 855 (49.9%) cases, and a significant decline in these changes can be traced by 15 years - 327 (25%) people, which can be seen in the graph presented in Fig. twenty.

In 1406 (92.9%) cases, the skin of the PM was elastic, easily stretchable, in 106 cases (7.1%) it was rigid, “tight”, easily vulnerable and more often occurred between the ages of 5 days and 6 years (Fig. 21, a). The head of the IF was partially removed in 1141 (75.4%) cases, not removed in 320 (21.1%) cases (Fig. 21, b). Moderate narrowing of the PC was in 1263 (83.5%) people, pronounced narrowing in 249 (16.5%), while the meatus could not be visualized in 123 (49.4%) cases (Fig. 21, c).

General characteristics of observations in congenital physiological phimosis

The skin of the preputial sac in FF does not have cicatricial changes, is soft, stretches well. However, when trying to quickly or roughly remove the head, radial cracks appear in the transition area of the inner and outer sheets of the PM. The deepest ruptures can be observed during simultaneous removal of the head in boys with FF.

It is difficult to explain why, but in many guidelines of past years, the procedure for complete simultaneous removal of the head is considered as the main method of treating FF, which ceases to be considered as such after 6 years (Lopatkin A.N., Lyulko A.V. 1987). Therefore, doctors of all specialties - neonatologists, pediatricians, surgeons, urologists and even orthopedists, consider it their duty to perform the procedure of simultaneous removal of the head of the IF, with a narrow PM. Most importantly, not knowing the characteristics of the physiological development of the boy's PM, doctors carry out the above manipulation, without taking into account the age of the child and the state of the PM! The sad thing is that even among neonatologists in the maternity hospital there are doctors who perform such manipulations on boys and give recommendations to parents to continue them at home, explaining this by the need to perform hygienic care for the foreskin.

It is important to remember that the simultaneous removal of the head is not a harmless procedure for all children. These manipulations are accompanied by episodes of bleeding, severe edema of the PM, pain and difficulty urinating up to acute urinary retention. Significant ruptures of the PM often heal with the formation of rough scars and lead to the formation of cicatricial phimosis (Fig. 22, a, b, c). That is why we consider it erroneous to attempt to conduct; simultaneous removal of the head. In order to assess the degree of narrowing: and the condition of the skin of the PM, it is absolutely not necessary to completely withdraw the head (take the PM out of the coronary sulcus). Moreover, this manipulation is meaningless (has no medical indications), sharply painful and very harmful. Even more dangerous are the recommendations to parents; carry out one-stage: removal of the head independently, at home. The propensity of PM to edema, the trauma and pain of manipulation predispose to the development of paraphimosis.

The last 10 years we; abandoned any attempts at simultaneous withdrawal; head PN, and used the technique of gradual gentle stretching PMі developed in the clinic (hospital - Єvyatogo Vladimir): The method is based on two principles.

The first principle is a slow impact on the narrowed area of the MI; treatment continues for months, hurry up; no reason. їїolovka PN; should be open by prepubertal age (12-15 years). Data: the terms are determined - by hormonal changes in -: the body: a boy .. Important; remember that the free removal of the head; necessary only-for; painless sexual intercourse. Second; the principle of stretching EQV1 should occur in the most gentle way, even minimal trauma is not allowed; narrowed area (rupture, cracks). After each procedure; and they were carried out; 2 times a week, it is necessary to achieve stretching, (displacement) of the prepuce bag nag 1-2 mm from its original position, no more. For; improvements, stretching: PM before manipulation it is recommended to perform a hygienic bath, with decoctions of medicinal herbs (chamomile, string, celandine) lasting 10-15 minutes Skin steamed in warm water, stretches easier and less; is injured. After the procedure. THEM? it is advisable to treat with a baby: cream or solcoseryl, for: better epithelialization, occasionally occurring, micro tears of the skin.

Acquired cicatricial phimosis (complicated, uncomplicated). Etiology. Clinical manifestations. Operative treatment. Complications and measures for their prevention

This group of patients consisted of boys with cicatricial phimosis 73 (4.3%). According to the anamnestic data, we tried to find out the causes of cicatricial changes in the PM. In the majority of children 31 (42.4%), cicatricial narrowing of the PC occurred against the background of complete health. Signs of balanoposthitis shortly before the appearance of the prepuce scar were observed in 25 (34.2%) patients. Traumatic simultaneous removal of the head preceded cicatricial phimosis in 17 (23.3%) children. Depending on the clinical manifestations of all patients with cicatricial phimosis, we conditionally divided into 2 subgroups. The percentage of the causes of cicatricial changes in PC is shown in the diagram (Fig. 43). it is not possible to withdraw due to cicatricial narrowing of the preputial ring. The diameter of the PC can be narrowed to a point, or remain fairly wide up to 1.0 cm in diameter. With a significant narrowing of the PC, it is not possible to examine the meatus, urination is disturbed. Often there are dense, difficult to separate adhesions of the PM and the head, often accompanied by moderate or severe inflammation of the prepuce.

For the period of time 1996-2006. 179 children were operated on in the department for cicatricial changes in the skin of the PM. To analyze the results of surgical treatment of the Russian Federation, we used a retrospective analysis of a group of children (106 people) operated on during the period 1996-2003. and prospective analysis of a group of children operated on during the period 2003-2006 (73 people).

The study included patients with signs of changes in the PM characteristic of the Russian Federation: skin color of the PM, cicatricial changes and the degree of narrowing of the PC, the possibility of removing the meatus and the head of the PV, the presence and nature of synechia, signs of inflammation of the PM, urination disorders.

Conducting a prospective analysis of a group of children operated on during the period 2003-2006, depending on the clinical manifestations, we conditionally divided all patients from the Russian Federation into 2 subgroups: those with signs of inflammation of the PM and impaired urination against the background of cicatricial changes in the PM and not having the above symptoms .

The first subgroup consisted of 62 (84.9%) boys with uncomplicated cicatricial phimosis. Visually, the PM was slightly changed, there were no obvious signs of inflammation (edema, hyperemia, tissue infiltration). All children urinated freely, painlessly, in a wide stream. When trying to remove the head, a dense cicatricial ring was determined, which did not allow examining the head. The diameter of the cicatricial ring of the PM significantly exceeded the external opening of the urethra, so there were no signs of urination disorders. On Fig. 44 (a, b, c) shows photos of boys with signs of uncomplicated cicatricial phimosis, a wide diameter of the cicatricial ring. opening of the PC), the separation of these synechiae was accompanied by the formation of a large erosive surface on the glans penis with diapidetic bleeding. It was in these children (17 people - 9.3%) in the postoperative period that the phenomena of pronounced balanitis, fibrin deposits, and painful urination were observed. Healing of erosions on the head was slow, lasting from 2 to 3 weeks. On Fig. 50 shows the PI of an 8-year-old child with signs of severe postoperative balanitis, after separation of adhesions into operations.

Signs of postoperative balanitis in cicatricial phimosis The following surgical techniques were used: traditional circular excision of the preputial sac (circumcisio), plasty of GTM according to Roser. Circumcision in RF was carried out according to the generally accepted method, preliminary, brilliant green markings were applied to the skin of the outer leaf to determine the level of excision of scar tissue. Further, after cutting off the cicatricial prepuce, hemostasis was performed. Bleeding vessels were coagulated during the operation with bipolar forceps. The outer and inner sheets of the PM were matched with interrupted sutures with chrome-plated catgut (4-0, 6-0). At the end of the operation, a circular, pressure bandage was applied to the PV, which was abundantly soaked with glycerin. This dressing prevented the development of edema, and served as a method for preventing residual secondary bleeding from the postoperative wound. The bandage was removed on the 3rd day, after which baths with a 0.5% solution of potassium permanganate were prescribed. With the development of postoperative balanitis, the head was treated with 5% synthomycin emulsion, levomecol or solcoseryl ointment until complete epithelialization. Roser's operation was performed with a narrow PC, which prevents the free removal of the RV head during erection, a narrow PC of an elongated CM, and at the insistence of the parents. With a short frenulum of the IF and cicatricial change of the PM, the technique of 2 incisions was used so as not to damage the vessels of the frenulum of the IF. For surgical interventions on the PM, modern methods of anesthesia (penial, caudal block) have been introduced and used, which facilitates the postoperative period.

Analysis of the results of surgical treatment of RF and HF, as well as conditions associated with them (paraphimosis) showed that out of 179 operated children, in 4 (2.2%) cases, the following complications were noted. We observed an unsatisfactory cosmetic result in the form of a long-term lymphostasis of preserved PM in 1 boy with HF during prepuce plasty according to Roser, as a result of a rather extended dorsal incision and violation of the integrity of the lymphatic collectors located in this zone. For a long time, the CP remained edematous, but gradually the lymph flow began to recover, and the edema decreased. On Fig. 51 (a, b) shows the PC of a 9-year-old child, with signs of pronounced lymphostasis of the preserved PM in HF (a consequence of an extended dorsal incision and violation of the integrity of the lymphatic ducts), 4 months later. after Roser's operation.

Long-term results of treatment of inflammatory changes in the preputial sac in children

The results of treatment of boys with all forms of phimosis were evaluated from 6 months. up to 4 years. In the group of patients with physiological phimosis (185 people), after conservative treatment (using the technique of gradual gentle stretching of the PM), 162 (93%) boys recovered. No recurrence of physiological phimosis was observed. In 13 people (7%), phimosis persisted, although there was a positive trend from the initial data. Among them, children of younger age groups predominated. Follow-up and conservative treatment were recommended to continue. In 3 (1.6%) cases, after 6 months. the effect of conservative therapy was not obtained, possibly due to the structural features of the prepuce ring or incomplete implementation of recommendations for conservative treatment. These children (3 people) were operated on, circumcision was performed.

In the comparison group (103 people), where children with FF underwent simultaneous removal of the head, a positive effect of manipulation (recovery) was achieved in 43 (41.7%) children. Phimosis recurrence was not observed. In 15 (14.6%) boys, the effect of treatment by simultaneous removal of the head was not achieved, signs of narrowing of the PC remained. Moderate narrowing of the PC is currently preserved in 7 (6.8%) young children, it was decided to continue conservative1 therapy. Significant prepuce ruptures after simultaneous removal of the head were noted in 60 (58.3%) boys. In 15 (14.6%) cases, radially located, non-extended PM scars were noted, occupying 1/4 of the PC diameter. We treated these children with Contractubex. Twice a day for 2 weeks, PM was lubricated with anti-scar ointment, rubbing it into the scar area. The next step was the gradual stretching of the PM according to the standard method. The duration of treatment was up to 6-8 months. 9 (8.7%) boys succeeded in stretching the preputial ring and eliminating the phenomena of phimosis. 6 (5.8%) people continue treatment and are under observation. There are currently no indications for surgery (circumcision). The final decision on tactics will be made in the prepubertal period. If phimosis persists, surgery will be recommended. An unsatisfactory result of the simultaneous removal of the head of the PV in FF was observed in 45 (43.7%) boys, all of them had signs of a rough cicatricial narrowing of the PC, they underwent excision of the scar with a positive result.

Thus, the technique of gradual gentle stretching of the PM is effective in 93% of patients with FF, and there is no recurrence of FF in the long term. The use of simultaneous removal of the head in phimosis makes it possible to achieve correction of phimosis only in 41.7% of cases, no effect was noted in 14.6% of patients, and an unsatisfactory result with scarring of the PM that required surgery (circumcision) was detected in 45 (43.7%) patients.

In the group of patients with hypertrophic phimosis (69 people), after a gradual stretching of the PM, recovery of the narrowing of the PC was not observed. Cicatricial phimosis after a previously obtained satisfactory result was detected in 2 children (2.9%), circumcision was performed.

In children with hypertrophic) phimosis (21 people), who underwent simultaneous removal of the head, in 9 (42.9%) boys, a PC scar formed, which required surgical treatment.

In the group of patients with cicatricial phimosis (179 people), only 1 (0.6%) case needed a second one! surgery for excision of the scar after PM plastic surgery without radical excision of scar tissue. In the case of lymphostasis after Roser's operation, a long-term swelling of the tissues of the prepuce was noted, the result was recognized as cosmetically unsatisfactory, however, a positive trend was noted and it was decided to continue the observation.