Phimosis ,paraphimosis ,circumcision.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also . Good for self study also. Display blank slide> Think what you already know about this > Read next slide . See notes for bibliography.

2. Learning Objectives

3. Learning Objectives Introduction & History Relevant Anatomy, Physiology Aetiology Pathophysiology Pathology Classification Clinical Features Investigations Management Controversies Prevention Guidelines Take home messages

4. Introduction & History.

5. Introduction & History. Inability to retract the distal foreskin over the glans penis.  Physiologic phimosis  occurs naturally in newborn males Pathologic phimosis  defines an inability to retract the foreskin after it was previously retractible or after puberty. Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus  

6. Aetiology

7. Aetiology Idiopathic Traumatic Infections /Infestation Neoplastic (Benign/Malignant) Congenital/ Genetic Nutritional Deficiency/excess Autoimmune Degenerative / lifestyle Iatrogenic Psychosomatic Poisoning/ Toxins/ Drug induced

8. Etiology Idiopathic Congenital Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative

9. Etiology Poor hygiene and recurrent episodes of  balanitis  or  balanoposthitis lead to scarring of preputial orifices, leading to pathologic phimosis .  Forceful retraction of the foreskin leads to microtears at the preputial orifice that also leads to scarring and phimosis . Elderly persons are at risk of phimosis secondary to loss of skin elasticity and infrequent erections Penile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin

10. Aetiology of Aetiology Idiopathic Traumatic Infections /Infestation Neoplastic (Benign/Malignant) Congenital/ Genetic Nutritional Deficiency/excess Autoimmune Degenerative / lifestyle Iatrogenic Psychosomatic Poisoning/ Toxins/ Drug induced

11. Pathophysiology

12. Pathophysiology The foreskin cannot be retracted proximally over the glans penis. In physiologic phimosis , the preputial orifice is unscarred and healthy appearing. In pathologic phimosis , a contracted white fibrous ring may be visible around the preputial orifice

13. Pathophysiology The foreskin is retracted behind the glans penis and cannot be replaced to its normal position. The foreskin forms a tight, constricting ring around the glans . Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis).

14. Pathophysiology With time, the glans becomes increasingly erythematous and edematous . The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation. With time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and worsening swelling. As the swelling progresses, arterial supply is compromised, leading to penile infarction/necrosis, gangrene, and eventually, autoamputation

15. Clinical Features

16. Clinical Features Demography Symptoms Signs Prognosis Complications

17. Demography

18. Demography Up to 10% of males will have physiologic phimosis at 3 years of age, and a larger percentage of children will have only partially retractible foreskins. One to five percent of males will have nonretractible foreskins by age 16 years

19. Symptoms

20. Symptoms Painful erections, dyspareunia Hematuria Recurrent urinary tract infections, Preputial pain, Weakened urinary stream.  

21. Paraphimosis

22. Paraphimosis The foreskin is retracted behind the glans penis and cannot be replaced to its normal position. The foreskin forms a tight, constricting ring around the glans . Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis). With time, the glans becomes increasingly erythematous and edematous . The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation.

23. Paraphimosis

24. Prognosis

25. Prognosis Morbidity Mortality rate 5 year survival in Malignancy

26. Complications

27. Complications Bleeding. Retention of urine Infection.

28. Investigations

29. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology Germ line Testing and Molecular Analysis Diagnostic Laparotomy.

30. Investigations Laboratory Studies

31. Investigations Laboratory Studies

32. Investigations in Malignancy

33. Investigations in Malignancy For diagnosis For staging For Screening For Monitoring

34. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

35. Differential Diagnosis

36. Differential Diagnosis Acute Angioedema Allergic Contact Dermatitis Anasarca Balanitis Balanitis xerotica obliterans Cellulitis Foreign body tourniquet, including hair, thread, metallic object, or rubber bands Insect Bites Penile carcinoma Penile fracture Penile hematoma

37. Management

38. Paraphimosis Emergency management Manual reduction Puncture method Hyaluronidase method Aspirate 3-12 mL of blood from the glans Vertical incision

39. Paraphimosis Emergency management Manual reduction facilitated by-  ice and/or hand compression on the foreskin, glans , and penis Soaking the penis in a glove full of ice for 5 minutes before attempting manual reduction An elastic bandage can also be wrapped from the glans to the base of the penis for 5-7 minutes to minimize edema Noncrushing clamps Osmotic method Granulated sugar  50% dextrose

40. Operative Therapy

41. Operative Therapy Circumcision.

42. Circumcision:Introduction & History .

43. Circumcision:Introduction & History . Circumcision of males involves removing the prepuce. Female Circumcision is a form Female genital mutilation In practice since time immemorial.

44. Indications

45. Indications R eligious, cultural,  hygienic  . phimosis , paraphimosis , balanitis Posthitis children who require clean, intermittent catheterization to facilitate this procedure.

46. Contraindications

47. Contraindications Prematurity , Anomalies of the penis chordee , hypospadias , epispadias , concealed or buried penis, micropenis , webbed penis, ambiguous genitalia. recurrent urinary tract infections Bleeding diatheses are not absolute contraindications for circumcision

48. Indications: Benefits and drawbacks

49. Indications: Benefits and drawbacks Protective against penile cancer . The prepuce provides protection to the glans from dryness and keratinization.

50. Position

51. Position Supine

52. Anesthesia

53. Anesthesia GA in children. Penile block in adults.

54. Incision Dorsal slit Circumferential incision in both layers of prepuce about half cm distal to corona.

55. Operative findings

56. Operative findings Confirm healthy glans.

57. Operative steps Hemostasis . Figure of eight suture at frenulum. Seal with tincture benzoin.

58. Post op. Management

59. Post op. Management Nothing specific.

60. Prevention

61. Prevention If the prepuce does not readily retract, parents should not attempt to clean under it Inability to retract the foreskin during routine cleaning or bathing. Parents may also be alarmed by "ballooning" of the prepuce during urination — a normal finding

62. Get this ppt in mobile Download Microsoft PowerPoint from play store. Open Google assistant Open Google lens. Scan qr code from next slide.

63. Get my ppt collection https:// www.slideshare.net/drpradeeppande/edit_my_uploads https:// www.dropbox.com/sh/x600md3cvj85woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl=0 https://www.facebook.com/doctorpradeeppande/?ref=pages_you_manage