In 90% of uncircumcised males, the foreskin should be retractable by adolescence. Before this age, the prepuce may normally be tight and not need treatment. After this age, the inability to retract the prepuce is termed phimosis. The condition may be congenital or the result of inflammation. Paraphimosis occurs when the prepuce has been retracted behind the coronal sulcus, cannot resume its normal position, and causes swelling of the glans or pain.
The meatal opening in hypospadias may be located anteriorly (on the glans, coronal, or distal third of the shaft); on the middle third of the shaft; or posteriorly (near the scrotum). Testes are undescended in 10% of boys with hypospadias. Inguinal hernias are common. Males with hypospadias should not be circumcised, particularly if the meatus is proximal to the glans, because the foreskin may be necessary for later repair. Most pediatric urologists repair hypospadias before the patient is 18 months old.
Phimosis is rarely symptomatic. Parents should be reassured that loosening of the prepuce usually occurs during puberty. Treatment, if needed, is topical steroids. If the narrowing is severe, gentle stretching may be useful. Circumcision is reserved for the most severe cases. Paraphimosis with venous stasis and edema leads to severe pain. When paraphimosis is discovered early, reduction of the foreskin may be possible with lubrication. In some cases, emergent circumcision is needed.
Undescended testes (cryptorchidism) are found in about 1% of boys after 1 year of age. It is more common in full-term newborns (3.4%) than in older children. In neonates, cryptorchidism is more common with shorter gestation (20% in 2000to 2500-g infants and 100% in <900-g infants). Cryptorchidism is bilateral in 30% of cases. Spontaneous testicular descent does not tend to occur after 1 year of age, but failure to find one or both testes in the scrotum does not indicate undescended testicles. Retractile testes, absent testes, and ectopic testes may resemble cryptorchidism in presentation.
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A history of maternal drug use (steroids) and family history are important in the evaluation of a child for apparent cryptorchidism. Whether the testis was ever noted in the scrotum should be asked. The true undescended testis is found along the normal embryologic path of descent, usually in the presence of a patent processus vaginalis. An undescended testis is often associated with an inguinal hernia; it is also subject to torsion. There is a high incidence of infertility in adulthood. When bilateral and untreated, infertility is uniform. There is an increased malignancy risk (five times the normal rate) with undescended testis, usually presenting between the ages of 20 and 30. The risk is greater in untreated males or those with surgical correction during or after puberty.
Retractile testes are normal testes that retract into the inguinal canal from an exaggerated cremasteric reflex. The diagnosis of retractile testes is likely if testes are palpable inthe newborn period but not at later examination. Frequentlyparents describe seeing their son’s testes in his scrotum whenhe is in the bath and seeing one or both “disappear” when hegets cold.
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