Voordracht Pediatrie - Dr. Breugelmans Urologie

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PEDIATRIC
UROLOGY
Dr. Alex Breugelmans, M.D.
Head of Department
Dept. of Urology, Reg. Hosp. Heilig Hart, Leuven, Belgium
INDEX
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UTI
antenatal hydronephrosis
ureteropelvic junction obstruction
vesicoureteral reflux
nocturnal enuresis
cryptorchid testicle
varicocoele
hypospadias
phimosis
UWI

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

= bacteriuria met symptomen van infectie
5 percent van alle meisjes
1 tot 2 percent van alle jongens
0.1 tot 1.0 percent van alle pasgeborenen (10 percent in low-birth-weights)
(hematogenous)

< 1 J : jongens > meisjes

> 1 J : meisjes > jongens


preschool: prevalentie van asymptomatische infecties (diagnose:
suprapubiche aspiratie) bij meisjes is 0.8 percent, vergeleken met 0.2
percent bij jongens
school-groep: incidentie van bacteriuria bij meisjes is 30 maal deze bij
joingens (1.2 versus 0.04 percent)
UWI : Etiologie en Pathogenese
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
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Escherichia coli : 80 percent
Staphylococcus
Streptococcus
enterobacteria (e.g., Klebsiella, Proteus)
occasioneel Candida albicans.
AS ALWAYS: virulentie van de bacterie en de
vatbaarheid van de gastheer zijn van primordiaal
belang in de ontwikkeling van UWI
UWI : oorzaken
Elke conditie die leidt tot urinairer stase

renale calculi
obstructieve uropathie
Plasproblemen/stoornissen

vesicoureterale reflux (ook indien steriel ?)


UWI : complicaties

nierparenchym infectie en littekenvorming
(10-15 %, zeker zo < 1 J, zelden > 5 J)

hypertensie (23 %)
nierinsufficientie (10 %)

Steriele reflux ?

Relatie tussen UWI en
verlies van nierfunctie.
UWI : Klinische Presentatie
VARIABEL …………..
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
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"asymptomatische" bacteriuria: enuresis, “squatting”,
…
Algemeen zieke neonatus (lethargisch, hypotensief)
Hoewel kinderen vaak worden behandeld op basis van
klinische symptomen alleen, zijn deze onbetrouwbare
predictoren voor het al dan niet risico op
pyelonephritis en littekenvorming in de nier
UWI : Anamnese

Zuigeling
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
koorts
slecht drinken
ongelukkig zijn
slecht groeien
NIETS
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Peuter - Kleuter :
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
koorts
buikpijn
pollakisurie
dysurie
UWI : Klinisch onderzoek
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hypertensie
abdominale of flank massa
palpabele blaas
neurologisch deficit
abnormale genitalia
abnormale urinaire flow
Aanwezigheid van irritatieve urinaire symptomen in
afwezigheid van bacteriën suggereert een non-UWI
oorzaak zoals vaginitis, urethritis, enterobius-worm,
bubbel-baden.
UWI : Symptomen


Urineweg symptomen
Dysuria
Frequentie
Druppelen/hesitatie
Enuresis optredend na succesvolle toilet-training
Slechtriekende urine
Hematuria
“Squatting”
Abdominale/suprapubische pijn
Systemische tekenen en symptomen
Koorts
Braken / Diarree
Flank/rug pijn
UWI : Klinisch Onderzoek
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Zuigeling
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“acuut” abdomen
sepsisbeeld
meningeaal beeld
Failure to thrive
NIETS
UWI : Klinisch Onderzoek

Groter kind
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koorts
abdominale pijn
(sub)acuut
abdomen
afwezigheid van
andere
koortsoorzaak
UWI : Diagnose

Hoge graad van suspectie bij kinderen met koorts > 48 uren

guidelines van de “American Academy of Pediatrics (AAP)”:
evaluation of fever (39.0°C [102.2°F] or higher) of unknown
origin =>
urinalysis in all cases (pyuria usually present)
urine culture in all boys younger than six months
urine culture in all girls younger than two years
In recurrent episodes, episodes that fail therapy or in girls
with pyuria without bacteriuria, a culture is recommended.
UWI : Diagnose
Goed afgenomen urine-cultuur is essentiëel

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Kleine kinderen : suprapubische aspiratie /
blaascatheterizatie
Grotere kinderen: “clean-voided midstream” specimen
adhesieve perineale zakjes / luiervocht: suboptimaal (fecale
contamination of urethrale colonizatie)
> 5 witte bloedcellen per high-power veld in
gecentrifugeerde verse urine = positieve screening test
UWI : Urine opvangen
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Zuigeling
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huid ontvetten
huid ontsmetten
steriel urinezakje
regelmatig nakijken
staal snel naar het
labo

Peuter
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
huid ontsmetten
steriel potje
staal snel naar het
labo
Kleuter
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huid ontsmetten
midstream urine
staal snel naar het
labo
UWI :Urine-Onderzoek

URINE STICK
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ph
glucose
eiwit
bloed
nitriet
leucocyten
DIP-SLIDE
URINE
MICROSKOPIE
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Morfologie
Gramkleuring
Telling
Sediment
URINECULTUUR
UWI : Aanvullend
Onderzoek
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Meisje
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
jonge zuigeling
sepsisbeeld
pyelonefritis
peuter, kleuter
cystitis
recidief
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Jongen

altijd
UWI : Medische beeldvorming

Echografie
- heeft IVU grotendeels vervangen
- echo alleen is vaak niet voldoende
(niet betrouwbaar in opsporen van vesicoureterale
reflux, nierlittekens of inflammatoire
veranderingen)
- indien reflux of morphologische abnormaliteiten
gevonden worden, zijn nierscintigrafie en mictiecystourethrografie aangewezen

Intraveneuze Urografie
- anatomisch beeld: cysten, hydronefrose
- minder gevoelig dan nierscintigrafie in de
detectie van pyelonephritis en “renal scarring”
- hogere dosis radiatie en risico van reactie op
contrast- medium
=> Nierscintigrafie heeft IVU vervangen als
standaardtechniek in de diagnose van
nierinflammatie en “renal scarring”

Nierscintigrafie
Technetium-99mlabeled glucoheptonaat of
dimercaptosuccinic acid (DMSA)
hoge graad van sensitiviteit en specificiteit
DMSA scanning heeft het voordeel van zowel vroegtijdige
detectie van acute inflammatoire veranderingen en
permanente littekenvorming in vergelijking tot echo en IVU
ook bruikbaar bij neonati en patiënten met slechte
nierfunctie

Computed tomography (CT)
- sensitief en specifiek voor detectie van
acute pyelonephritis (geen vergelijkende
studie tussen CT en DMSA)
- CT is duurder dan scintigrafie en zorgt
toch voor hogere stralendosis

Mictie-Cystourethrografie
- vesicoureterale reflux is een risicofactor voor refluxnephropathie en littekens: vroege D/ noodzakelijk !
- uitvoeren NA R/ van UWI
(vesicoureterale reflux kan het tijdelijke gevolg zijn
van UWI)
- door lage sensitiviteit en specificiteit, en wegens
irradiatie-effect op de gonaden en NW van
catheterizatie: strikte indicatie noodzakelijk

Isotopen Cystogram (met DTPA !)
Ionizatie-radiatie dosis is slechts 1 percent
van deze bij mictiecystourethrografie
Continue monitoring is ook meer sensitief
voor het opsporen van reflux dan de
intermittente flouroscopische monitoring
bij mictiecystourethrografie
Vergelijking van de
Beeldvormende technieken

Belang van de huisarts in vroege
herkenning van UWI (en dus voorkomen
van nierinfectie en sequellen) is hierdoor
nogmaals onderstreept.
UWI: Behandeling

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Toxische pt: IV antibiotica=> opvolgen symptomen (verdwijnen na
3-5d) (dan ontslag en nog 10-14 d AB per os)
Initiële antibiotica therapie zou moeten afgestemd zijn op leeftijd,
klinische ernst, locatie van de infectie, aanwezigheid van structurele
afwijkingen en allergische voorgeschiedenis tov. evt. AB
Starten met breed-spectrum antibioticum => cultuur afwachten en
zo nodig aanpassen
Hospitalizatie: symptomatische babies (< 3 maanden) en alle
kinderen met klinische evidentie van acute ernstige pyelonephritis
(hoge koorts, toxisch uitzicht, flankpijn).
Duur van outpatient treatment : controversiëel (3-7d, 7-10d)
Algoritme voor R/ UWI bij kinderen
UWI : Praktische Aanpak
van de Banale Infectie

Cefaclor (Ceclor)
30 mg/kg/dag in 2x gedurende 10 dagen


Cefadroxyl (Duracef)
30mg/kg/dag in 2x gedurende 10 dagen
Trimetoprim-Sulfa
(Bactrim, Eusaprim, Co-Trimoxazole)
8 mg T/kg/dag in 2x gedurende 10 dagen
UWI : Praxis acute ernstige
infectie



opname Kinderafdeling
correctie shock e.d.
Antibiotica I.V.


Amoxy-Clavulaanzuur (Augmentin)
100 mg/kg/dag in 2x (1g per ampul)
Cefotaxim (Claforan) 50 à 100 mg/kg/d in 2
tot 4 doses (1g per ampul)
UWI : Praxis recidieven



zoals voorgaande
Amoxy-Clavulaanzuur
(Augmentin, Clavucid)
30-50 mg/kg/dag in 3x gedurende 14
dagen
Nitrofurantoïne (Furadantine)
6 mg (1ml) /kg/dag in 2x ged.14 dagen
UWI : Praxis preventie

preventie na infectie voor bv cystografie
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verlengen normale kuur
eenmalige dosis verder
preventie bij afwijking voor lange tijd
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Cefaclor in 1 of 2 doses 10 mg/kg/dag
Co-Trimoxazole in 1x 2 mg/kg/dag
Nitrofurantoïne in 1 x 1 mg/kg/dag
UWI : Special Issues

Asymptomatic Bacteriuria
AB-R/ ???

If recurrent bacteriuria is truly asymptomatic,
no antimicrobial treatment may be the best
option, as some studies have shown that
asymptomatic children are at very low risk of
renal scarring, and prophylactic treatment did
not decrease the risk of UTI recurrence

Recurrent UTI
two or more UTIs over a six-month period
can be caused by inadequate treatment of an
unrecognized anatomic site of bacterial persistence
(small infected calculus or unrecognized anatomic
abnormality)
UTI increases the risk of subsequent renal scarring.

Breakthrough UTI
- change in the resistance pattern of
organisms colonizing the urethra
=> the treating antimicrobial agent for a breakthrough UTI
should, ideally, be different from the prophylactic agent
- noncompliance
- vesicoureteral reflux
- voiding dysfunction
=> “Voiding Dysfunction”

detrusor instability and incomplete bladder emptying (UDT)

often w/ daytime enuresis and constipation

increased risk for the development of vesicoureteral reflux and
UTI


treatment of voiding dysfunction includes timed voiding,
treatment of constipation, prophylactic antibiotics and, in some
cases, use of anticholinergic medication (e.g., oxybutynin
[Ditropan] or propantheline [Pro-Banthine]) or biofeedback
patients with otherwise unexplained recurrent UTI, especially in
the setting of daytime enuresis or constipation, may merit
urodynamic testing (UDT)
UWI : Chemoprophylaxis

A urine culture should be obtained seven days after the completion of treatment to
exclude relapse.

Prophylaxis is recommended for all children younger than five years of age with
vesicoureteral reflux (who are not surgical candidates)

or other structural abnormalities

and in children who have had three documented UTIs in one year


With careful monitoring for side effects, a prophylactic trial of a single nightly dose
of nitrofurantoin 1 to 2 mg per kg per day, or trimethoprim-sulfamethoxazole 2 mg
per kg of trimethoprim per day, may be used for six months or more.
Using low doses of antibiotics for prophylaxis has a theoretic advantage since this
may minimize serum levels and subsequent enteric bacterial resistance while
urinary concentration of the antibiotic remains high enough to maintain sterile
urine.
UWI : Preventie

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good hygiene (including "front-to-back"
wiping after urination in girls)$
avoidance or correction of constipation
avoidance of bubble baths, chemical
irritants and tight clothing
The role of circumcision in preventing UTI
is controversial.
UWI : guidelines pt 1




most common bacterial infections encountered by
primary care physicians
source of significant morbidity in children
minority of UTIs progress to renal scarring,
hypertension and renal insufficiency
Clinical presentation of UTI in children may be
nonspecific, and the appropriateness of certain
diagnostic tests remains controversial
UWI : guidelines pt. 2



diagnostic work-up : uncover functional and structural
abnormalities such as dysfunctional voiding,
vesicoureteral reflux and obstructive uropathy
more aggressive work-up, including renal cortical
scintigraphy, ultrasound and voiding cystourethrography,
is recommended for patients at greater risk for
pyelonephritis and renal scarring, including infants less
than one year of age and all children who have systemic
signs of infection concomitant with a UTI
Antibiotic prophylaxis is used in patients with reflux or
recurrent UTI who are at greater risk for subsequent
infections and complications.
INDEX
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UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
ABDOMINALE MASSA
NIERGEZWEL
CYSTISCH
VAST
DILATATIE
OBSTRUCTIEF (PUJ - VUJ)
REFLUX
NO-NR MEGACALYCOSIS / URETER
POSTNATALE EVALUATIE
echo D1 of 2 : dilatatie = pyelum >15 mm
= > cave :
fysiologische dilatatie
dehydratatie
lage diurese (GFR)
asymptomatisch en geen kleppen
(cystogram ??) : 2 m AB => DMSA
controle echo (D5 en D21):
+  cystogram (laattijdige opname)
isotopen (MAG3) + furosemide +
blaassonde :
PUJ, VUJ, lager ?
Multicystische nieren


"druiventrosnieren" (ureteratresie)
extreem = Potter

K.O. : abdominale massa
echo : cysten D f , geen parenchym

R/ indien pijn (geen Ca-risico)
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Polycystische nieren

autosomaal recessief

zeldzaam


K.O. : abdominalemassa
echo : vergrote echogene nieren

bilateraal  nierfalen
Niertumoren
tumor :
neuroblastoma
mesoblastisch nefroma
Wilms: zeldzaam, 3j,
multiloc. cystenier
vena renalis trombose : + hematurie
Antenatal Hydronephrosis (AHN)

outflow of urine from the kidney is
obstructed

detected by ultrasound (first trimester)

mild, moderate, or severe
AHN : Causes

UPJ stenosis (developing before second trimester)

UVJ stenosis

Posterior urethral valves

Reflux


Duplication anomaly (occurs in 1% of the population
and involves two ureters leading from the kidney; one may
have an obstruction called a uterocele)
Multicystic kidney (nonfunctional kidney)
OBSTRUCTIEVE MEGAURETER




fetale hydrouretronefrose, UWI, buikpijn,
hematurie
isotopen (MAG3) + furosemide + BS
(Whitaker)
R/ heelkunde indien symptomatisch (+
"tailoring")
quid fetale HUN (follow-up +/- AB)
UPJ obstruction:
blockage at the
left
ureteropelvic
junction

Vesicoureteral
reflux on
the left
Posterior urethral
valves: blockage
at the
outlet of
the bladder

Multicystic kidney

Duplication of
ureters on
both sides
with
ureterocele
on left
causing
blockage
AHN : Diagnosis


prenatal ultrasound
during evaluation for a urinary tract
infection in infancy
AHN : Treatment




carefully observing kidney growth and function throughout
the pregnancy by ultrasound
multicystic kidney: removal of the nonfunctioning kidney is
not required unless complications (e.g., tumor,
excessive size)
moderate or severe antenatal hydronephrosis: pyeloplasty
(success rate of 90–95%)
However, in many cases (even moderate to severe cases),
the condition resolves and does not result in kidney
damage. Carefully monitoring kidney growth and function
is the preferred treatment unless surgery proves necessary.
AHN : Follow-up

kidney function must be regularly monitored
(usually by ultrasound performed every 6
months) throughout childhood

low-dose antibiotics may be administered to
prevent infection

cystogram may be performed to determine
reflux
INDEX
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UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
MEGAURETER

obstructief
(cfr. Supra)
. alleen circulaire spier
. jongens, links
. 25 % bilateraal

refluerend

niet-obstructief niet-refluerend
UPJ Obstruction : Overview

severe, minimal

can be intermittent

often diagnosed during prenatal ultrasound

It is the most common cause of
hydronephrosis in utero and in newborns.
UPJ Obstruction : Incidence

1% of prenatal ultrasounds detects AHN

UPJ obstruction in 50% of these

more common in males (5:2)

affects the left kidney more often than the right
(5:2)

about 15–30% of cases occur in both kidneys
UPJ Obstruction : Causes

Congenital abnormalities
- abnormality in the muscles that surround the UPJ
(APERISTALSIS)
- abnormality in the structure or position of the ureter,
kidney, and renal blood vessels

in older children
- compression of the ureter caused by inflammation
- VUR with kinking of the ureter (10 %)
- retroperitoneal fibrosis
- kidney stones
- scar tissue from previous surgery to correct UPJ-O
UPJ Obstruction : Signs
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Back pain
Blood in the urine (hematuria)
Failure to thrive
Flank pain
Flank mass
Kidney infection (pyelonephritis)
Urinary tract infection (UTI) (usually in
adults only !!)
UPJ Obstruction : Diagnosis

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




If hydronephrosis : prenatal ultrasound
Neonatal patients suspected to have this condition are
evaluated for the obstruction using renal ultrasound.
Other diagnostic tests used to evaluate kidney function
and determine the severity of the blockage include the
following:
Creatinine, BUN (blood urea nitrogen), and electrolyte
levels
Complete blood count (CBC)
Diuretic renal scan
Urine culture
Voiding cystourethrogram (VCUG; used to rule out
vesicoureteral reflux)
UPJ Obstruction : Treatment




Newborns with UPJ obstruction and hydronephrosis are placed on
antibiotics to prevent infection and are monitored with renal
ultrasound every 3 to 6 months.
If UPJ obstruction causes a significant reduction in renal function, a
surgical procedure called pyeloplasty is performed to remove the
obstruction.
Patients require follow-up care for several years following
pyeloplasty. Tests to evaluate kidney function are performed
regularly (6 months to 1 year).
The success rate for patients who undergo pyeloplasty is higher
than 95%.
INDEX







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
UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
VUR : Incidence

17–37% of prenatal ultrasounds

M:F = 1:10 (redhair …)

Healthy children : 1 %

Children with UTI : up to 50 % with VUR !

30 % hereditary (how?)
siblings in 75 % asymptomatic : screening because risk
of scarring and reflux nefropathie

VUR : Types & Grades




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

Primary reflux
Secondary reflux
Grade I results in urine reflux into the ureter only.
Grade II results in urine reflux into the ureter and the
renal pelvis, without distention (hydronephrosis).
Grade III results in urine reflux into the ureter and the
renal pelvis, causing mild hydronephrosis.
Grade IV results in moderate hydronephrosis.
Grade V results in severe hydronephrosis and twisting of
the ureter.
VUR : Causes



Primary reflux : abnormality in the intravesical
ureter (short or superolaterally / if duplication :
lower pole).
This condition often resolves as the child grows
and the ureter lengthens (L: ).
Other causes: abnormalities in detrusor muscle
tissue of the bladder, abnormalities in the location
of the urethral opening (e.g., hypospadias), and
abnormalities in the shape of the urethral opening:
high pressure, dysfunctional voiding
VUR : Causes

Secondary reflux is often caused by
urinary tract infection (e.g., cystitis)
that results in inflammation and
swelling of the ureter. UTI may cause
vesicoureteral reflux or vesicoureteral
reflux may promote the growth of
bacteria in the urinary tract, causing
UTI (One-third of UTIs in children are
caused by vesicoureteral reflux).
Secondary
reflux may also be caused by urinary tract abnormalities
(e.g., narrowing, or stricture, of the ureter; duplicated ureters;
ureterocele) and obstructions (e.g., UPJ obstruction, stones, tumor).
VUR : Scarring

scar-risk: 1) UTI
(Big Bang : scar distorsion - intrarenal reflux)
2) sterile reflux + high P
(check lower tractus)

complications : - hypertension (10 %)
- renal failure (DMSA)
VUR : Signs and Symptoms
 UTI







Bedwetting (nocturnal enuresis)
Hydronephrosis / Distention in the abdomen (caused by
HN)
Failure to thrive
Hypertension, caused by kidney damage
Nausea and vomiting
Proteinuria
Pyelonephritis, kidney damage, and progressive renal
failure
VUR : Diagnosis


reflux opsporen bij
. kind met pyelonefritis ("febriele UWI")
. jongen met UWI
. meisje < 5j met UWI
. meisje > 5j met > 2 x UWI
voiding cystogram (Tc ?) – passive / active
VUR : Diagnosis
The most common radiologic studies for the evaluation of reflux are
the voiding cystourethrogram and the isotope cystogram.
The isotope cystogram is more sensitive than the voiding cystourethrogram
Only the voiding cystourethrogram provides enough anatomic detail to
identify the severity of reflux and the presence of anatomic abnormalities.
In boys: initial work-up should include a voiding cystourethrogram to
detect urethral abnormalities such as urethral diverticulum or posterior
Urethral valves.
VUR : Diagnosis



Prenatal ultrasound
Bladder ultrasound (to detect abnormalities that
cause reflux)
Renal ultrasound and renal scan (to evaluate
hydronephrosis, kidney growth, and scarring)


Urodynamic studies (e.g., filling cystometrogram,
voiding cystometrogram)

spontane genezing a 1/ graad

G1
G2
G3
G4
G5
u
10 %
35 %
30 %
20 %
5%
resol.
90 %
75 %
50 %
40 %
5%
scarring
10 %
15 %
30 %
50 %
85 %
VUR : Treatment : Grade I - III

AB profylaxis : daily low-dose antibiotics (e.g.,
trimethoprim-sulphamethoxazole, amoxicillin)
tot reflux verdwenen of risico op scarring klein
(postpuberteit)

FOLLOW UP ULTRASOUND & URINALYSIS

mictietraining (voiding regime)

anticholinergica (oxybutinin, propant.)
VUR : Treatment : Grade I - III





AB met lage serum-/hoge urineconcentratie
gering effect op de darmflora
nitrofurantoine (1-2 mg/kg pm)(G6PDH)
cefalexin (125-250 mg)
TMP(-SMX) (2 mg/kg) (bili-albumine)
VUR : Treatment : Grade IV - V

Secondary reflux that does not resolve with antibiotic treatment, or that results in UTI despite antibiotic therapy
(called breakthrough infections), and primary reflux that is severe (grades IV and V) require surgery to prevent
permanent kidney damage.

heelkunde igv. doorbraak-UWI
scarring bij controle-echo

follow-up na heelkunde blijvend vereist
(subklinische scarring)

STING : 70 % ipv. 98 % (90 - 95 %) :
collageen - autoloog vet - Teflon
URETEROCOELE

duplicatie-ectopie (bovenpool)
(meisjes, 10 % bilateraal)

50 % + VUR

." prenatale hydronefrose"
.UWI
URETEROCOELE

echo en cystogram

isotopen (MAG3) (HUW)

R/ . endoscopische incisie
(+/- 2° reïmplantatie)
. bovenpool-resectie
. pyelopyelostomie
INDEX









UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
De twee meest voorkomende
blaasproblemen bij kinderen zijn :

INCONTINENTIE (Wetting)

PLASPROBLEMEN (Voiding Dysfunction)
ENURESIS : Het blijven voorbestaan
van een ongecontroleerde mictie

NOCTURNA : geen controle ‘s nachts

DIURNA : geen controle overdag
The Cinderella Subject


“Even though
nobody dies from
incontinence, it is
hardly a glamorous
condition”
“Treatment = A
Dream Come True”
E.N. : History





Papyrus Ebers, dated 1550 B.C. : potions from animals, organs, or plants
(e.g. placing a comb from a hen in tepid water and giving it to the child to
drink or putting testicles from a hare into a glass of wine and having the
child drink it, drying the comb of a cock and scattering it over the enuretic's
bed)
Mid-1800s : induce blisters on the child's sacrum
1927 (Friedell) : psychic treatment by restricting fluids and injecting sterile
water along with positive reassurance that this treatment will work
=> 87% success rate and those children who did not respond were found
to have low urine specific gravity at night.
This monitoring of urine concentration holds significant merit in regards to
common treatment modalities used today. Punishment and public
humiliation were also historically very common.
Unfortunately, parents still punish their children for wetting the bed. 61% of
parents perceived bed-wetting as a significant problem and that one-third
dealt with it by punishment.
Chronologie van de mictiecontrole
(stadia)





van 0 tot 6 maand : reflexblaas
van 6 maand tot 1 jaar :
grotere volumes
kleinere frequentie
van 1 tot 2 jaar : gevoel van volle blaas
van 3 tot 4 jaar : onderdrukken van
mictiereflex
vanaf 4 jaar :
volledige blaascontrole
Stadium I : van 0 tot 6 maand



Zuivere reflexblaas
Frequentie : ongeveer 20/dag
Prikkeling afferente banen
 ruggemerg reflex (S2- S4)
 efferente banen
detrusorcontractie
 sfincterrelaxatie


Geen centrale invloeden
Stadium II : van 6 maand tot 1 jaar




Het volume per mictie stijgt
De mictiefrequentie daalt
is het gevolg van een onbewuste
inhibitie van de mictiereflex (centraal)
is eveneens het gevolg van de groei van
de blaascapaciteit
Stadium III : van 1 tot 2 jaar

Het gevoel van een volle blaas
ontwikkelt zich

Eerste aanzet tot controle van de mictie
Stadium IV : van 3 tot 4 jaar

ontwikkelen van de eigenschap, ook bij
niet volle blaas, om te plassen of
plassen te inhiberen

= mogelijkheid om een reflex te
onderdrukken bij elke blaasvulling
Controle darm (stoelgang) versus
blaas (mictie)




eerst : stoelgangscontrole ‘s nachts
daarna : stoelgangscontrole overdag
daarna : mictiecontrole overdag
daarna : mictiecontrole ‘s nachts
ENURESIS (definitie)
= het blijven voortbestaan van deze
(infantiele) ongecontroleerde mictie,
hetzij overdag, hetzij ‘s nachts.
Enuresis: Definitions & Categories
Diurnal enuresis
Wetting that occurs during
waking hours (daytime
incontinence).
Nocturnal enuresis
Wetting that occurs during sleep.
Uncomplicated enuresis
Nocturnal enuresis, normal
physical examination, and
negative urine analysis and urine
culture.
Complicated enuresis
Secondary onset of enuresis,
history of urinary tract
infection(s), abnormal neurologic
examination, and a history of
voiding dysfunction.
Enuresis diurna

Various degrees

15% - 20% of bed-wetters

prevalence rapidly decreases in children over 5 years of
age

+/- symptoms indicative of urgency and/or frequency:
squatting, sitting on one's heel, crossing the legs,
"dancing," or holding the perineum
(bladder instability / detrusor-sphincter dyssynergia)
=> valid voiding history!
E.N. : Terminology
Primary
Bed-wetting since birth without
any significant periods of dryness.
Secondary
Onset of bed-wetting after the child
has been dry for at least 6 months.
Monosymptomatic
Nocturnal enuresis that occurs
with normal daytime urination.
Polysymptomatic
Nocturnal enuresis associated
with urinary frequency, urgency
or other signs of bladder
instability.
Enuresis Nocturna :
Voorkomen

op 5 jaar : 15 à 20 % van de kinderen

daarna wordt elk jaar 10 à 15 % van de
bedwateraars droog

op 15 jaar heeft nog 1 à 2 % der jongeren
E.N.
Enuresis Nocturna : Voorkomen

Primair: 75 - 80 %

Secundair: 20 - 25 %

15 à 20 % der patiëntjes hebben ook E.D.

Jongens hebben meer E.N., meisjes meer
E.D.
E.N. : Incidence
E.N. : causes

-
-
-
Genetic Factors
both parents bed-wetters => their children 77%
chance
only one parent => 43%
molecular genetic heterogeneity (chromosomes
13q and 12q)
E.N. : oorzaken
Enuresis = een symptoom, geen ziekte





Late rijpheid of ontwikkelingsstoornis
Nachtelijke polyurie
Slaapstoornissen
Psychische factoren
Urinaire infectie zonder oorzaak
ONTWIKKELINGSSTOORNIS

Het grootste deel geneest met de tijd toch

Urodynamisch valt op:



kleine blaascapaciteit
onstabiele contracties
Stoornis in het aanleren van zaken
E.N. : oorzaken

Reduced Bladder Capacity

Bed-wetting occurs when functional bladder capacity is reached



The bladder is too small to hold all the urine that is produced at night.
Urodynamic studies indicate that children with NE exhibit frequent
uninhibited bladder contractions and a lower functional bladder
capacity.
Conversely, another study revealed that bladder instability was found
in only 15% of patients with isolated NE, when compared to 97%
having both diurnal and nocturnal enuresis (Breugelmans, et al.)
Children with monosymptomatic PNE rarely exhibit abnormal
urodynamic findings and usually have a normal bladder capacity. This
group may either produce large volumes of urine at night, thereby
reaching functional bladder capacity despite normal bladder function,
or may be unresponsive during sleep, or both.
E.N. : oorzaken

Sleep Disorders

"deep sleepers“ : arousal disorder ??

NO : The fact that the child is a deep sleeper or difficult to arouse
may be merely a characteristic and not a cause

bed-wetting occurs only during the deep sleep stages or when
transitioning from one sleep stage to another ???


NO : enuresis is independent of sleep stages and occurred randomly
throughout the night proportional to the time spent in each sleep
stage
=> Treatment should be directed towards limiting urine output at
night rather than sleep modulation.
SLAAPSTOORNISSEN

Ze slapen «te diep»

Nachtelijk EEG zou een verband
aantonen???

Een bepaald percent (10%?) zou E-tekenen
op EEG vertonen
E.N. : oorzaken



Sleep Apnea (Obstructive sleep apnea syndrome
(OSAS))
Occasionally, nocturnal enuresis is an associated issue.
Cessation of NE with the surgical removal of the
obstructing lesion (adenotonsillectomy) or treatment
with continuous positive airway pressure.
Children who experience NE associated with sleep apnea
historically snore heavily due to enlarged tonsils and
adenoids. Explanations for enuresis in these situations
are related to alteration in hormonal activity and renal
pathology: urine volume and sodium excretion are
increased at night in patients with OSAS => nocturnal
polyuria.
E.N. : oorzaken

Endocrine Factors (pituitary ADH)

Urine output occupies a circadian rhythm in normal individuals, with
a decrease of urine production normally occurring at night.

E.N. children have lower mean nocturnal urine osmolalities and
higher mean urinary excretion rates

However sometimes no alteration in both nocturnal ADH secretion
or nighttime urine output. Furthermore, nocturnal polyuria may be a
factor in the presence or absence of abnormal ADH secretion. This
endocrine-based theory may apply to some enuretics but does not
account for all cases.
NACHTELIJKE POLYURIE

Veranderd dag-nachtritme van de ADHsecretie

bij een normaal kind stijgt de ADHproductie ‘ s nachts
 minder en meer geconcentreerde
urine
NACHTELIJKE POLYURIE

Bij enuretische kinderen stijgt die niet
‘ s nachts
 blaascapaciteit (van overdag) wordt
overschreden  E.N.
MAAR :
Waarom worden ze dan niet
wakker van die volle blaas?
E.N. : causes

Psychological Factors

incidence of psychopathology is relatively infrequent

Enuresis itself can result in psychologic, individual, and
interpersonal distress

The onset of secondary enuresis may be brought about
by an emotional or psychological disturbance, for
example, divorce, death in the family, illness, emotional
or physical trauma, or the birth of a new sibling. Even
though there may be instances wherein a psychologic
event may cause secondary enuresis, it is usually a
matter of a relapse of physiologic enuresis.
PSYCHISCHE FACTOREN ?

Emotionele Stoornissen

Onrijpheid

Minder zelfzeker
E.N. : oorzaken



ADHD (Attention-deficit hyperactivity disorder )
>10 Y : an increase in the percentage of
children with E.N. will have symptoms
associated with ADHD …
it is difficult if not impossible to determine
whether the disruptive behavior of children with
ADHD stems from the embarrassment of
enuresis or whether enuresis is one of the
several "soft" signs of an underlying neurologic
disorder.
E.N. : oorzaken




Diet
10% of children are believed to have a food-related
allergy as a key factor in their nocturnal enuresis.
Patients who were on food-restrictive diets for managing
childhood migraines and/or hyperactive behavior had
cessation in their nocturnal enuresis
Avoid: products high in caffeine and sugar, citrus fruits
and juices, dairy products (especially afternoon),
artificially colored foods and drinks, and chocolate.
E.N. : oorzaken


Secondary nocturnal enuresis may be caused by psychological issues
(e.g., death in the family, sexual abuse, extreme bullying) and is often
associated with stress.
It may also result from an acquired condition such as diabetes,
hyperthyroidism, seizure disorder (e.g., epilepsy), and obstructive sleep
apnea (OSA).

Heart condition that causes an irregular heartbeat (heart block).

Neurological disorders (e.g., cerebral palsy, spinal cord disorders,
neurogenic bladder).




Urinary tract infection (UTI; e.g., cystitis).
Sickle cell disease
Chronic renal failure
R.T.A.
E.N. : oorzaken
Meer a-symptomatische bacteriurie bij
enuretische kinderen
E.N. : Causes - Summary









Bladder Capacity (small / unstable): no evidence
Urine Concentration: in 2/3 ADH production is not increased at night.
This does not explain why they do not wake up.
Sleep and Arousal: not all children are deeper sleepers
Sleep Apnoea (stopping breathing) is associated with night time wetting.
This is usually manifest by snoring, stopping breathing and restarting with a gasp. Large
adenoids may be to blame.
Social and Emotional: Whilst in some children that wet, there may sometimes be
associated emotional or behavioural problems, the association is not clear.
Maturity: Delayed maturity would account for the spontaneous cure rate, however as most
children respond very rapidly to an alarm, this is less likely as a cause.
Toilet Training: Variable opinions exist.
Attempts to train before 18 months may inhibit the normal processes of getting dry.
There is also postulated a sensitive period for bladder training around the 3rd year of life.
Stresses around this time may interfere with the chances of the dryness.
Constipation: Often associated with wetting.
Possibly by giving confusing signals to the brain, or by "irritating the bladder“
Medical Problems: Uncommon - Must Exclude Structural problems / InfectionsDietCaffeine
can irritate the bladder
Fluids: Reducing fluids is of NO Help
Increased fluids during the day is helpful.
ENURESIS (Onderzoek)
1. Anamnese
2. Klinisch onderzoek
3. Urine onderzoek
4. Uroflow
5. Echo Nieren en Blaas, evt. IVP - DTPA
6. Cystogram (Kleppen, reflux)
7. UDO (instabiliteit)
8. Neurologisch onderzoek
9. Psychisch onderzoek
ANAMNESE

Wanneer is het begonnen?
(periodes van grote «droogte»?)

Welke vorm? E.N. of E.D.

Hoe vaak? elke Nacht?
meerdere malen per nacht?

Slaappatroon
ANAMNESE

Hoe veel?
een beetje
kliedernat

Andere symptomen? urgency
moeilijke mictie

Familiale enuresis?

Plaspatroon - Vochtinname (kalender)
KLINISCH ONDERZOEK

Volle blaas?

Genitalia?





Meatus
fimosis
Lage rug (S.B.)
Neurologisch: reflexen, stap, sensorium
Bloeddruk
WELKE ONDERZOEKEN TE DOEN?
1. Bij de onverwikkelde vorm
van 1 tot 5
2. Bij de verwikkelde vorm
alles
E.N. : Definitions & Categories
Diurnal enuresis
Wetting that occurs during
waking hours (daytime
incontinence).
Nocturnal enuresis
Wetting that occurs during sleep.
Uncomplicated enuresis
Nocturnal enuresis, normal
physical examination, and
negative urine analysis and urine
culture.
Complicated enuresis
Secondary onset of enuresis,
history of urinary tract
infection(s), abnormal neurologic
examination, and a history of
voiding dysfunction.
ENURESIS (Onderzoek)
1. Anamnese
2. Klinisch onderzoek
3. Urine onderzoek
4. Uroflow
5. Echo Nieren en Blaas, evt. IVP - DTPA
6. Cystogram (Kleppen, reflux)
7. UDO (instabiliteit)
8. Neurologisch onderzoek
9. Psychisch onderzoek
E.N. : Diagnosis : RX





hydronephrosis
bladder instability
detrusor sphincter dyssynergia
urethral abnormalities
BEHANDELING VAN ENURESIS
2 grote groepen :
1. Gedragstherapie
2. Medicamenteuze therapie

Dubieus :



niet drinken na een bepaald uur
het kind ophalen en laten plassen
Slecht :

het kind straffen
BEHANDELING VAN
ONVERWIKKELDE ENURESIS

Basisvraag :




Houding van het kind?
Houding van de ouders?
Houding van de omgeving? (broers en zussen)
Therapie wordt slechts ingesteld als de
enuresis een probleem wordt
(zelden voor 5 à 6 jaar)
1. Gedragstherapie
motivatietherapie
conditionering
2. Medicamenteuze therapie
GEDRAGSTHERAPIE

Motivatietherapie




kind aanmoedigen
kalender met NAT/DROOG
(pos. Feedback)
 duurt meestal lang
cure rate (monotherapie): 25%
"marked improvement" > 70%
GEDRAGSTHERAPIE

Conditioneringstherapie
= Plaswekker
Werking : reactie op urine.
Het kind wordt wakker gedurende of na de mictie.
Het kind associëert de bel met het gevoel van een volle blaas.
Het leert aldus het gevoel van een volle blaas bewust kennen.

PLASWEKKER (Bedenkingen)

Niet bij te kleine kinderen (vanaf 7 j)


Sommigen worden er niet wakker van
Sommigen worder er bang van
Deep sleeper => motivatie van ouders !

success rate : 65%

not the quick way (time & energy consuming)

stop indien > 4 weken droog

30 % recidiveert later

Bladder Retention Training




based on the presumption that the child has a decreased functional
bladder capacity
normal bladder capacity
= {Age (in years) + 2} x 28 ml
= {24.5 x Age (in years)} + 62 ml
(< 9 Y)
conscious attempts at "bladder stretching" by prolonging the voiding
intervals
cure rate : only 35% (probably due to the demanding nature of the
program and the element of bladder instability and urinary
frequency/urgency seen in some of these children)
FARMACOTHERAPIE
in vraag gesteld:



Sedativa
Stimulantia
Alfa-adrenergica


centraal
sfincter


= management therapy rather than a
cure: high relapse rates after short-term
treatment
long-term therapy either continuously or
on an as-needed basis (sleepovers or
camp)
FARMACOTHERAPIE VAN
ENURESIS

Tricyclische antidepressiva
IMIPRAMINE = TOFRANIL

ADH-analogen
DESMOPRESSINE = MINIRIN

Parasympatholytica
OXYBUTININE = DITROPAN / DRIPTANE
TOFRANIL
Werking :




Verandering slaapmechanisme
Anticholinergisch-antispasmodisch
Anti-depressief (humeur)
Beïnvloeden van ADH-secretie
TOFRANIL

DOSIS :
6 tot 8 jaar:
25 mg/dag
meer dan 8 jaar:
50 à 75 mg/dag
 gedurende minimaal 6 maand
TOFRANIL

NEVENWERKINGEN :
angst
slapeloosheid
droge mond
nausea
karakterstoornissen

Overdoses can cause myocardial effects
(arrhythmias and conduction blocks) and
hypotension. World Health Organization (WHO)
does not recommend using this drug for
nocturnal enuresis.
MINIRIN

WERKING :
Nachtelijke diurese doen dalen tot
een volume, kleiner dan de
functionele blaascapaciteit

The effect usually lasts 6 to 12 hours

68 % respons (monosympt. EN)
MINIRIN

DOSIS (spray) :
2 à 4 pufjes ‘ s avonds
(1 pufje = 10 microgram)

NEVENWERKINGEN :
- congestion, rhinitis, mild headache, and epistaxis
- Hyponatriemie secondary to water intoxication (zeldzaam)
=> CAVE HIGH WATERINTAKE !!!!!!!!!!

Relaps ! (use as safety – sleepovers etc. – until growout)
Minirin : Cave H20-intoxicatie
Rule out :
-
cystic fibrosis
renal disease
endocrine disorders
other disorders that may produce electrolyte imbalances
-
Psychogenic polydipsia and habit polydipsia
-
-
-
DDAVP should not be used in instances where fluid and
electrolyte balance would be affected, such as fever,
viral illnesses, vomiting, or diarrhea, where increased
fluid intake is required.
Combination Therapy

Behaviour modification

Alarm Therapy

Minirin : quick onset counters delayed
effect of other two
DITROPAN

WERKING :
inhibitie van de onstabiele
contracties
mucosa-anesthetisch
vergroten van de blaascapaciteit
DITROPAN

DOSIS :
5 mg 2 à 3x/dag

NEVENWERKINGEN:
Droge mond
Gezichtsstoornissen
Constipatie
Gedragsstoornissen / Humeur
Hyperpyrexie in de zon


Success rates of 90% have been reported
for enuretic children with significant
daytime incontinence and/or bladder
instability.
However, anticholinergics are rarely
beneficial for children with exclusive
nocturnal enuresis.
FARMACOTHERAPIE :
RESULTATEN

Initieel :
50 %

Op termijn : 25 % (na stoppen medicatie)

Eventueel : * kuur herhalen
* combinatietherapie
E.N. : Other treatments


Oral antibiotics (e.g., Bactrim®, amoxicillan,
Macrobid®, Levaquin®) are used to treat UTIs
that cause bed-wetting.
Surgery
Structural abnormalities in the urinary system
(e.g., ectopic ureter) and other conditions, such
as obstructive sleep apnea and heart block, may
require surgery.
Hypnotherapy

Hypnotherapy is not based on conditioning
therapy. It involves the explanation of the
bladder-brain connection and teaching selfhypnosis and visual imaging to the child in
responding to a full bladder during sleep. One
controlled study comparing hypnotherapy with
imipramine reported a 76% dryness rate after
initiating both types of therapy. After 9 months,
68% of the hypnotherapy group remained dry in
comparison to only 24% in the imipramine
group.
OORZAKEN VAN
PLASMOEILIJKHEDEN








Neurogene blaas
Blaastumor (zeer zeldzaam)
Megacystis (+ megaureter)
Prune-Belly
Urethrakleppen
Dyssynergie blaas-sfincter
Stenosen (meatus)
Vreemd voorwerp
AANDOENINGEN VAN DE
URETHRA

Bij Jongens :
Urethrakleppen
 vaak afwijkingen van de HUW

Bij Meisjes :
Terminale urethrastenose
 zelden afwijkingen van de HUW
INDEX









UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
SCROTUM
" ZWELLING "
ACUUT
NIET-ACUUT
TORSIO
EPID.-ORCHITIS
HYDROCOELE
TUMOR
VARICOCOELE
TORSIO

testis : . hooggelegen
. geen cremaster-reflex
. gezwollen funniculus
. opheffen  pijnvermindering

appendix : . blue dot
. harde nodulus (bovenpool)

EXTRAVAGINALE : eerste weken

INTERMITTENTE : "bell-clapper"

DIAGNOSTIEK : indien reële twijfel
(snelheidsfactor !)

urine : pyurie

echo scrotum (kleurendoppler)

isotopenscan

-itis :- echo nieren (ectop.ureter + hydronef.)
- obstructie lagere tractus uitsluiten
Hydrocoele

= open peritoneovaginaal kanaal

sluit in 1ste levensjaar (- 6 %; prematuren)

pijnloze translucente "blauwe" zwelling
(wenen)

variant : funniculuscyste
DD liesbreuk bij het kind (zeldzaam) :
lateraal

R/ heelkunde :
. na 1 jaar
. < 1 jaar (non-communicans, cyste)

geen punctie : recidief / peritonitis
TUMOR

soms acute zwelling na mineur trauma
(slechte angiogenesis)

R/ heelkunde +/- chemo

overleving YolkSac : > 90 %
TUMOR





Kiemcel :
. Yolk sac
. Teratoma
. Seminoma
Stroma :
. Leydig
. Sertoli
. Granulosa cel
Bindweefsel (fibroma, leiomyoma)
Epidermoid cyste
Secundaire tumoren
Varicocoele

v. spermatica
----> v. renalis / VCI

v. pudenda ext. ----> v. saphena longa

v. cremasterica ----> v. iliaca ext.

v. deferentia
----> v. iliaca int.

9 – 17 %
(1:2 verminderde sperma-kwaliteit en
kwantiteit)

bij 30 % van infertiele mannen

unilateraal => infertiel ?

°t + 0.5 °C

bijnier-metabolieten (catecholamines, steroiden,
PG)

Hypoxie


Bij unilat. Varicocoele toch bilateraal verhoogde
flow en °t-stijging (bilat. Effect)
Ook antistofproductie tegen links => rechts

risicofactor = testiculaire hypotrofie ...

wait & see : cave :
. Irreversiebele hypotrofie
. oligo-terato-astheno-spermie (OTA)

relatie OTA en seminoma : 5:1000
R/ varicocoele : Heelkunde






Palomo
Ivanissevitch
Goldstein
laparoscopie
retrograde embolisatie
antegrade sclerosering (MIT)
varicocoele : beware !

cave
acuut
rechts
geen ontzwellen bij neerliggen
retroperitoneale tumor /
renaal cel carcinoma
(trombose VCI of v. renalis)
SCROTUM
"KRIMPING "
CRYPTORCHIDIE
RETRACTIELE TESTIS
RETRACTIELE TESTIS

+ cremaster reflex
koude omgeving
angstig kind

in-uit-fenomeen
normaal scrotum

CRYPTORCHIDIE


3 % (x 10 bij prematuren)
10 % bilateraal (?)

< 3 m (tot 1 j) : 75 % spontane descensus
(95 % bij prematuren)

indaling door
(8ste maand)
- tractie gubernaculum
- stijgen intra-abd. druk
- endocrinol.-neurol.
Signs and symptoms

An undescended
testicle is not located
within the scrotum.
The condition may be
associated with other
abnormalities of the
genitourinary system
(e.g., hypospadias).
Oorzaken






Vader of broer + => hogere kans
Low birth weight (< 2500 g)
Maternal exposure to estrogen during the
first trimester
Multiple birth (e.g., twin, triplet)
Premature birth (before 37 weeks
gestation)
Small size for gestational age
Verwikkelingen van Cryptorchidie

seminoma
(x 10) (20 % contralat.)

torsio
( 50 % + Ca)

open peritoneovaginaal kanaal (90 %)

infertiliteit

trauma bij sport
(bilateraal : 70 %)
Behandeling van cryptorchidie

unilateraal : R/ heelkunde

bilateraal :
hormonale poging
human chlorionic gonadotropin
hormone (hCG: 9.000-30.000 IU)
may be combined with gonadotropinreleasing hormone (GnRH) therapy, but
has not been approved in the United States
(Kryptocur: 3x/d 400 mu)
(succes 10-20 %)
(ook D/)
INDEX









UTI
nocturnal enuresis
varicocoele
hypospadias
phimosis
HYPOSPADIAS
= slecht ontwikkeld corpus spongiosum
(”incomplete development of the urethra in
utero between 8 and 20 weeks of gestation”)


te korte urethra
kromming naar onder bij erectie
(chordae)
HYPOSPADIAS
VOORKOMEN
* 1 op 500 geboortes
* niet erfelijk (? – vide infra)
(meer bij Joden en Italianen)
Hypospadias : Causes




Genetic factors are suggested by an increase in the condition in twins compared to
a single birth. Human chorionic gonadotropin (hCG) is a hormone produced in early
pregnancy that stimulates the production of estrogen and progesterone. In the case
of twins, the production of hCG may not be sufficient to prevent incomplete urethral
development. There is also a 20% chance that an infant born with hypospadias has
a family member with the condition.
Endocrinological factors include low levels of androgens (e.g., testosterone,
androsterone) and the infant’s cells’ inability to use these substances effectively may
also result in hypospadias. Androgens are substances that stimulate the development
of male characteristics.
Maternal exposure to increased levels of progesterone, common during in vitro
fertilization (IVF), increases the risk for hypospadias in the infant.
Environmental exposure to estrogen during urethral development may also be a
risk factor. Exposure can result when the mother ingests pesticides on fruits and
vegetables and milk from pregnant cows.
HYPOSPADIAS
VORMEN
* Glandulair (65 %)
* Peniel (15 %)
* Scrotaal (20 %)
Hypospadias : Symptoms

Voiding problems

Ejaculation problems

Sexual problems: the
farther the opening is
from the tip of the
glans, the more likely
curvature in the penis
(chordee) is present.
Hypospadias : Complications
severe hypospadias
-
-
-
undescended testicles
inguinal hernias
upper urinary tract anomalies
Hypospadias : Treatment Goals




Allow the patient to urinate standing
Correct curvature of the penis (chordee)
Present a cosmetically acceptable
appearance
Preserve fertility
HYPOSPADIAS : THERAPIE
Lichte Vormen (corona)
* niets doen
* besnijden?
HYPOSPADIAS : THERAPIE
Ernstige vormen
* resectie van de chordee
* constructie van een neo-urethra
- gesteelde flap (penis of scrotum)
- vrije flap (penis, wang)
Tussen 6 – 18 maanden leeftijd.
CONGENITALE PENISKROMMING

Congenitale verharding in de tunica
albuginea van de corpora carvernosa

geeft bij erectie kromming naar de kant van
de verharding
CONGENITALE PENISKROMMING :
THERAPIE

Lichte Vormen : NESBITT
(inkeping aan de contralaterale zijde)

Ernstige Vormen :
excisie en inplanten van een nonallergisch materiaal (Lyodura,
Lyoplant)
INDEX









UTI
nocturnal enuresis
Varicocoele
hypospadias
phimosis
FIMOSIS

Echte fimosis :
te nauwe ring

Valse fimosis :
verklevingen tussen
voorhuid en
glans
FIMOSIS : VERWIKKELINGEN





Infectie
Mictiestoornissen
Sexuele problemen
Parafimosis
Peniscarcinoma
FIMOSIS : THERAPIE

Wanneer ? 4 à 5 jaar
(tenzij verwikkelingen)
What is a normal foreskin ?



The skin over the tip of penis normally folds on itself
as a sleeve and attaches to the head of penis. This
extra skin is called foreskin.
In newborn babies the under surface of the foreskin is
fused to the head of penis. In 95% of newborn babies
the foreskin can not be pulled back. This is referred to
as ‘physiological phimosis’ or ‘non retractile foreskin’.
However as they get older it separates slowly;
by 4 - 5 years of age, usually the foreskin can be
pulled back. (90 % at 3 Y => examine !)
Problems of the persisting
non-retractile foreskin?



accumulation of white discharge called ‘smegma’
foreskin balloons during urination
straining and only dribbling when passing urine

Balanitis or UTI
Scarring of the skin at the tip

Paraphimosis

Treatment of Complications

Balano-posthitis : meestal zuiver lokaal

Parafimosis :
* manuele reductie
* incisie ring
Is it advisable to practice
retraction to make it better?




Caveat overdo =>soreness and bleeding
Excessive retraction with damage =>scarring => real
phimosis
Boys older than 5 years of age can attempt self retraction at
bath.
It is essential to put it back after retraction, as skin left
retracted can result in swelling called ‘paraphimosis’.
Use of the Foreskin



glans stays moist => improves sexual sensitivity
increasesd skin mobility => provides increased
stimulation of the stretch receptors in the penile skin
reduced premature ejaculation by protecting the
corona of the glans penis from direct stimulation
FIMOSIS : THERAPIE

Hoe ? * Circumcisio
* Voorhuidplastie
1 maand Hydrocortisone 0.05 – 0. %, 2x/d (?)
Circumcision : “an old religion”



some researchers believe that circumcision was
practiced as early as 6,000 years ago on the
west coast of Africa
bas-relief from a tomb in Sakkara (Egypt; about
2200 BC
portrayed in an Egyptian tomb wall carving from
around 2400 B.C., yet its orgins and ritual
meanings remain obscure.
(The Tomb of Nyhetep-Ptah at Giza and the
Tomb of Ankhmahor at Saqqara)


In ancient days, circumcision or even more
extensive mutilation of the external genitalia was
carried out on defeated enemies, captives, or
slaves as a sign of subjugation.
Circumcision was also a puberty or premarital
rite, or as an absolution against the feared toxic
influences of vaginal (hymenal) blood.

distinct meaning with Abraham: (Genesis 17:12-13)
sign and seal of the covenant between God and God's
chosen people
(According to dictate, the practice was to be universal
among all male members of the community; whether
freemen or slaves. Furthermore, the rite was to be
performed on the eighth day of life.)
Circumcision : Beyond religion


1870: Routine circumcision as a preventative or
cure for masturbation was proposed in Victorian
times in America. Masturbation (and / or
inflammated foreskin) was thought to be the cause
of a number of diseases.
Circumcision in America, England and the other
countries received a strong boost during each of
the World Wars, because it was claimed that the
procedure was necessary for soldiers for "hygienic
reasons". Some soldiers who refused to be
circumcised, were disciplined and/or received
dishonourable discharges.
Comstock Act = Cockstorm Act ?




Circumcision became an omnibus procedure, supposedly effective against dozens of
disorders which were widely feared yet poorly understood, circumcision lent itself
naturally to sexual diagnoses, which in turn helped complete the transition to
routine care for male infants.
Late Victorian America was of course notoriously ill at ease with human sexuality.
The infamous Comstock Act of 1873 captured an attitude toward sex, awkward and
censorious, which was widespread within the middle and upper classes. For a
culture nervous about sex, manifestations of infant and child sexuality seemed
especially disturbing, contradictions of children's pristine purity.
Since the Enlightenment, doctors in Western Europe and America had identified
masturbation as a cause of illnesses. In the course of the nineteenth century it was
linked to madness, idiocy, epilepsy, and from these to a multitude of other
psychological, behavioral, and pathological conditions. "The most serious forms of
disorder attributable to this cause are spinal paralysis, locomotor-ataxia, and
convulsions," declared a physician at Virginia's South-Western Asylum,
"masturbatory insanity”. For ages the Catholic Church had taught that
masturbation, because it existed apart from marriage and procreation, was a mortal
sin. But the medical theory that masturbation caused disease presented a more
immediate threat.
Fittingly in the age of Darwin, biology joined God as the punisher of transgression.

Americans gave a new twist to John Wesley's famous saying that
cleanliness is next to godliness. Increasingly they identified personal
cleanliness with good morals, sound health, and upright character.
So the Victorian moralist William A. Alcott admonished his readers
"that he who neglects his person and dress will be found lower in
the scale of morals, other things being equal, than he who pays a
due regard to cleanliness." The same argument could be applied
broadly. During the later Victorian period, an age obsessed with
racial and social hierarchies, there was an allure to ranking
civilizations, peoples, and social groups from clean to dirty. Used
increasingly by the middle class as a caliper of moral judgment and
evidence of material prosperity, "cleanliness indicated control,
spiritual refinement, breeding; the unclean were vulgar, coarse,
animalistic. Cleanliness, in other words, became an essential
criterion of social respectability. Dirt was seen as a moral, and thus
a social, hazard whose dangers people would strive assiduously to
avoid.

Here is an example of what another sexaphobic American doctor
had to say about masturbation in 1903:
"It (self abuse) lays the foundation for consumption, paralysis and
heart disease. It weakens the memory, makes a boy careless,
negligent and listless. It even makes many lose their minds; others,
when grown, commit suicide.... Don't think it does no harm to your
boy because he does not suffer now, for the effects of this vice
come on so slowly that the victim is often very near death before
you realize that he has done himself harm. It is worthy of note that
many eminent physicians now advocate the custom of
circumcision..."
(Mary R. Melendy, MD, The Ideal Woman - For Maidens, Wives and
Mothers, 1903)
Circumcision : Beyond religion


Circumcision as a safeguard against malignancies was an idea with considerable
appeal, for, like their descendants a century later, Victorians were horrified by
cancer. The awful public ordeal of General Ulysses S. Grant, who died from what his
doctors called "an epithelioma" of the soft palate, transfixed the public and the
medical community alike. Post-mortem analysis convinced Grant's physicians that his
disease had been caused by irritation, in his case irritation in the mouth and throat
from years of smoking cigars. Epithelioma, one of his doctors announced, "as a rule
starts from local irritation, and unlike other forms of cancer, is not dependent upon
hereditary disposition to the disease." Penile cancers were said to develop according
to similar principles. Thus, in a world bereft of effective therapies, the finding that in
many cases of penile cancer it had been demonstrated "conclusively that the
prepuce is the inciting cause as well as the initial point of attack" became an
influential argument to operate before disease struck."
Venereal infections, owing to their virulent contagiousness and social stigma, were
feared nearly as much as cancer. Syphilis in particular raged out of control, seeming
to approach epidemic proportions. During the 1880s and 1890s medical researchers
made great strides in understanding the pathology of syphilis, and later gonorrhea.

Circumcision prevents cancer and syphilis:
epidemiological study of American Jews in 1890,
confirming low rates of morbidity, including
penile epithelioma, syphilis as well as infectious
diseases like diphtheria and tuberculosis, within
Jewish communities, even among the poorest
classes
=> Together with (wonderful timed) antiseptic
and anesthetic surgical improvements, this led
to nation-wide circumcision.

"Circumcision," performed on babies, wrote a
New York doctor, "is no more of an operation
than vaccination." And as the Jews had long
since discovered, babies needed no chloroform
or cocaine. "Infants only a few years old may be
held down by two assistants and the operation
done without any anesthetic, Samuel Newman
advised. For his own part, Newman preferred to
bind his young patients "to a board after the
Indian fashion of strapping the papoose... to
hold the child firmly in place until the operation
is ended."


Medical circumcision thus assumed its own place in the fin-de-siècle search
for rank and social order. It signified precisely that aversion to dirt - and not
just dirt, but vulgarity, nasty habits, and diseases - which symbolically set
one on a higher plane. Undoubtedly this was the enduring source of its
appeal to patients and parents. Outside Judaism, circumcision was
exclusively the province of doctors and patients with enough money to pay
for an elective procedure. Physicians privately suggested it to parents
immediately after the birth of a son. Circumcision, they professed,
represented state-of-the-art medical knowledge and surgical practice. The
operation itself was simple, eminently safe; moreover, it immediately
reduced the infant's chances of becoming infected with the deadly diseases
of childhood.
With each passing year maternity care and childbirth for the middle and
upper classes was shifting from a domestic event managed by midwives,
relatives, and friends into a medical event managed by physicians. Midwives
rarely performed circumcisions, so having one's foreskin removed was
necessarily a byproduct of having been delivered by a physician. It was a
token of the medicalization of childbirth; literally a symbol of the rising
authority of the medical profession over the laity.


Considered in terms of the march of medical science,
circumcision is an anomaly. But as a synecdoche for the
history of clinical practice - above all of surgery - it is
remarkably, not to say disturbingly, comprehensible.
The visible hands that treat patients are not the hands of
scientists, but of practitioners whose conventions,
habits, and modes of practice are molded first by
watching their teachers, then their peers. This is the
process of practical medical education, and also of
cultural transmission.
Motivations for Uncircumcision

No matter what reasons have been given
to substantiate routine male circumcision
throughout the centuries, countless
circumcised males have been unhappy
about what was done to them—so much
so that some have relentlessly sought, by
whatever means were available to them at
the time, to undo the effects of the
circumcision they did not choose for
themselves.
How the West was won …

"I think that I could have accepted
a deformity that was an accident
of nature, but I can't accept
that someone did that to me."
(John A. Erickson. Making America Safe
for Foreskins)


Under Antiochus IV (168 BC) Hellenistic ideals such
as public nakedness at athletic games or in public
baths, emerged in Judea and forced Jews to stretch
their foreskins with a special weight, the Pondus
Judaeus, to cover the glans (I. Maccabees 1)
Similar efforts are reported in the Talmud during
the time of Hadrian (132 AD). Evidence from
mummified remains predating the Ankhmahor relief
indicates that the practice had been established
centuries earlier.


Jewish athletes of the time were able to accomplish this
feat because their circumcisions had removed only the
typically protruding tip of the infant foreskin, leaving the
inner lining of the infant foreskin attached to the glans—
thus leaving the mature male with a "miniforeskin" that
could rather easily be drawn forward over the glans.
Not until about 140 AD, after the Bar Kokba uprising,
was the more radical procedure of "stripping bare the
glans" added to the Jewish circumcision rite so that the
sign of the covenant could not be undone.

levying of special "temple tax“
selective military call-ups of circumcised
youths

persecution of Jews under the Nazi regime

THE GOLDEN SIXTIES …



Why was it, asked the editors of the Journal of the American Medical
Association in 1963, that an operation so well accepted by practitioners
for its power to "'relieve' phimosis, to 'prevent' infection, to be
'prophylaxis' against carcinoma" had attracted no interest from scientists
in the medical research establishment?
Castigating circumcision as "the rape of the phallus," a physician at the
University of Maryland blamed its popularity on women. "Perhaps not
least of the reasons why American mothers seem to endorse the
operation with such enthusiasm," he wrote, "is the fact that it is one way
an intensely matriarchal society can permanently influence the physical
characteristics of its males."
Return of Hippocrates : “Primum non nocere”

Ironically, but predictably in the context of the history of medical arguments
for circumcision, some doctors have conjectured that removing the foreskin
may protect men from the most dreaded epidemic of the post-modern
world: the human immunodeficiency virus (HIV). Using retrospective data
(the epidemiological equivalent of empiricism) from a venereal disease clinic
in Kenya, for example, researchers observed that there were higher rates of
HIV infection in the home communities of uncircumcised than circumcised
men. Ignoring racial, ethnic, and sociocultural variables - the chief factors
dictating whether or not an African boy is circumcised in the first place they hypothesized that circumcision might serve to inhibit the transmission
of the AIDS virus. One wonders whether this theory will endure. But within
a medical community desperate to find some weapon against AIDS, its
appeal is understandable. Even a physician who is a sober skeptic of the
methodologies behind such studies allows that they "do suggest that HIV
may be more infective during heterosexual intercourse if the mate partner
is uncircumcised and has a mucosal or cutaneous ulcer." AIDS, the nemesis
of modern science and medicine, remains a mystery. By some equally
mysterious process, it is surmised, circumcision may help.
Het “Voorhuid-Verlangen”
“Why would any man
who's never had one
want one?"
- Sixties < Seventies :
* increased keratinization
* psychologic (I’m different)
* victim (I did not have the choice)
=> decreased sexual pleasure
NOCIRC (National Organization of Circumcision Information Resource Centers)
NOHARMM (National Organization to Halt the Abuse
and Routine Mutilation of Males)
NORM (National Organization of Restoring Man)
DOC (Doctors Opposing Circumcision)
NRC (Nurses for the Rights of the Child)
Homosexuals => heterosexuals
Many nations that adopted routine infant male circumcision as a "health measure" early
in the 20th century have moved away from the practice.



In 1949, the important work of Gairdner appeared in Britain, which
led to the virtual cessation of medically-motivated circumcision in
that country. Australia and New Zealand now also have very low
rates (5% or less).
The largest problem remains in the United States, where the
procedure has become culturally entrenched. The American public
largely still believes circumcision to be a useful procedure, even
though the rest of the world does perfectly well without it. It is
worth noting that in 1996 the Canadian Paediatric Society issued a
statement depreciating the value of circumcision in rather strong
terms. Most Canadian provinces have dropped insurance coverage
for circumcision, and the rest are expected to follow in the next year
or so.
Circumcision never became an issue in continental Europe and in
most of Asia, where the vast majority of men are intact. Religious
circumcision is popular in some African, Muslim and Middle Eastern
countries.
Porn Flakes
(Kellogg, Graham and the Crusade for Moral Fiber)


"All kinds of stimulating and heating substances; high-seasoned
food; rich dishes; the free use of flesh; and even the excess of
aliment; all, more or less -- and some to a very great degree -increase the concupiscent excitability and sensibility of the genital
organs..." -- Sylvester Graham
"A remedy [for masturbation] which is almost always successful in
small boys is circumcision...The operation should be performed by a
surgeon without administering an anesthetic, as the brief pain
attending the operation will have a salutary effect upon the
mind...In females, the author has found the application of pure
carbolic acid to the clitoris an excellent means of allaying the
abnormal excitement. " -- Dr. John Harvey Kellogg
International Symposium on
Circumcision (ISC), 1989

We recognize the inherent right of all human beings to an intact body.
Without religious or racial prejudice, we affirm this basic human right.

We recognize the foreskin, clitoris and labia are normal, functional body
parts.

Parents and/or guardians do not have the right to consent to the surgical
removal or modification of their children's normal genitalia.

Physicians and other health-care providers have a responsibility to refuse
to remove or mutilate normal body parts.


The only persons who may consent to medically unnecessary procedures
upon themselves are the individuals who have reached the age of consent
(adulthood), and then only after being fully informed about the risks and
benefits of the procedure.
We categorically state that circumcision has unrecognized victims.
Human right ?

Informed consent is not enough …

If it ain't broken, don't fix it
MYTHS AND FACTS
MYTH: A circumcised penis is cleaner.



Cleansing the intact penis is similar to cleansing intact
labia and is simply a matter of common sense.
After the age of reason, one hopes that a boy who has
already learned to tie his shoes can be cajoled into
washing behind his ears and directed to clean his penis.
It is painless, takes only a few seconds, and when it
takes any longer is probably associated with a smile.-Leonard J. Marino, MD
The AAP itself refuted this myth by saying, "...good
personal hygiene would offer all the advantages of
routine circumcision without the attendant surgical risk".
MYTH: Circumcision is minor surgery.


"Minor surgery is one that is performed on
someone else," says Stanford University Medical
School Professor, Dr. Eugene Robin.
Circumcision, like all surgery, has inherent risks,
which include hemorrhage, infection, mutilation,
and death. Circumcision is not a minor
procedure and there are many unrecognized
victims. Dr. Robin recommends, "If it ain't broke,
don't fix it!".
MYTH: Circumcision prevents penile
cancer.




Penile cancer, which has been documented in both circumcised and
intact men, is a rare disease of elderly men and one of the least common
malignancies.
It represents 0.5% of all cancers in men and occurs at "...a rate of less
than one case per 100,000 per year".
The low incidence of penile cancer in the United States is not due to
circumcision because "...the population of American men born before
1940, now in the group at risk for this cancer, is a group of
predominantly UNCIRCUMCISED men".
Research indicates that good hygiene prevents penile cancer and "It is
an incontestable fact...there are more deaths from circumcision each
year than from cancer of the penis".
MYTH: Women with circumcised
partners have a lower incidence of
cervical cancer.




Inaccurate studies of the 1950s
Jewish women have a relatively low rate of cervical
cancer
Moslem women have a much higher rate.
According to the most recent AAP report, "...evidence
linking uncircumcised men to cervical carcinoma is
inconclusive. The strongest predisposing factors in
cervical cancer are a history of intercourse at an early
age and multiple sexual partners".

Cancer of the cervix in women is due to
the Human Papilloma Virus. It thrives
under and on the foreskin from where it
can be transmitted during intercourse. An
article in the British Medical Journal in
April 2002 suggested that at least 20% of
cancer of the cervix would be avoided if all
men were circumcised. Surely that alone
makes it worth doing?
MYTH: Circumcision will decrease
the risk of sexually transmitted
diseases, including AIDS.



There is an epidemic of sexually transmitted diseases,
including AIDS, in the United States, where the majority
of sexually active men are circumcised. It is not the
foreskin that causes these diseases, and circumcision will
not prevent them.
It is relatively more important to alter exposure to
infectious agents than male susceptibility to them.
It is education about safe sex, not amputation of healthy
body parts of newborns, that is sane preventative
medicine for sexually transmitted diseases.

Another British Medical Journal article in
May 2000 suggested that circumcised men
are 8 times less likely to contract the HIV
virus. (It is very important here to say that
the risk is still far too high and that
condoms and safe sex must be used - this
applies also to preventing cancer of the
cervix in women who have several
partners).

Age of male circumcision and risk of prevalent HIV infection
in rural Uganda.

Kelly R, Kiwanuka N, Gray RH.
Department of Population Dynamics, Johns Hopkins University,
School of Hygiene and Public Health, Baltimore


OBJECTIVE: To assess whether circumcision performed on
postpubertal men affords the same level of protection from HIV-1
acquisition as circumcisions earlier in childhood.
CONCLUSIONS: Prepubertal circumcision is associated with reduced
HIV risk, whereas circumcision after age 20 years is not significantly
protective against HIV-1 infection. Age at circumcision and reasons
for circumcision need to be considered in future studies of
circumcision and HIV risk.
MYTH: Circumcision prevents
urinary tract infection.


Many studies reflecting an increase in UTIs
among intact boys are "retrospective," may have
"methodologic flaws," and "may have been
influenced by selection bias".
Since one fourth of my male infant patients are
not circumcised, and if the frequency of UTI in
the uncircumcised is as high as it is said to be, I
should be seeing many UTIs in male infants.
MYTH: Circumcision prevents foreskin
infections.

Yes, it does, in both males and females,
and removing all the teeth would prevent
cavities. Where does this argument end?
Infections are caused by invading
organisms and can be treated effectively
with antibiotics. Fear of infection is no
reason to routinely amputate a tonsil, an
appendix, or a foreskin.
MYTH: Circumcision prevents
phimosis & complications.




Using the surgical treatment of circumcision to prevent phimosis is a
little like preventing headaches by decapitation. It works but it is hardly
a prudent form of treatment.--Eugene Robin, MD.
Smegma is probably the most maligned body substance. It is a normal,
natural body product no more harmful than ear wax. It is definitely not
a carcinogen...Adult smegma serves as a protective, lubricating function
for the glans, just as adult smegma in women protects the clitoris".
When scar tissue has formed at the preputial opening secondary to
premature retraction or ammoniacal burns, there are surgical techniques
(Y-V-plasties and Z-plasty), which can be employed to make the foreskin
retractable without amputating it.
If phimosis has been caused by a rare pathologic condition such as
balanitis serotica obliterans, only the afflicted area need be removed.
However, this is generally a less acceptable intervention from estetical
point of view. HERE IT IS BETTER TO PERFORM A CIRCUMCISION.
MYTH: A boy should look like his dad.

Ironically, this argument was never used when medical
circumcision was initiated just a hundred years ago. Nor
has it been used by Western feminists working to stop
female circumcision in Africa. A simple explanation is all
that is needed for children to understand that there are
individual differences, and to help them feel good about
themselves. A response something like this usually
suffices: "People thought circumcision was important for
health reasons when your dad (or brother) was born,
but now we know better. Your body is perfect just the
way it is. You did not need to be circumcised."
MYTH: It's better to circumcise
babies because they won't
remember the experience.

Quite the contrary. Overwhelming evidence
indicates that experiences during the preverbal
period affect the human being throughout life.
An infant does retain significant memory traces
of traumatic events. When a child is subjected to
intolerable, overwhelming pain, it conceptualizes
mother as both participatory and responsible
regardless of mother's intent.
MYTH: Better to do it now because
it would hurt more later.




This first erroneously assumes that a postnewborn circumcision will
be necessary.
The question of an uncircumcised child requiring later circumcision
is used as a scare tactic--only in the United States. The question is
not foreskin problems, but the attitude of the American medical
profession in pushing what most physicians throughout the world
consider unnecessary surgery. Worldwide, foreskin problems are
treated medically, rarely surgically.
Even if a circumcision were required later in life, the male would be
able to understand the health problem, give an informed consent,
and have the benefits of anesthesia and pain medication.
Researchers Anand and Hickey report that "...neonates were found
to be more sensitive to pain than older infants".
MYTH: Circumcision improves
sexual staying power.


Following circumcision, changes occur to the
sensitive mucous membrane of the glans penis.
Due to this scarification process, circumcision
does render the penis less sensitive.
However, premature ejaculation continues to be
the most common sexual complaint of American
men, most of whom are circumcised, so that this
rationale seems, at best, dubious.
MYTH: Christians should be
circumcised like Jesus.

Circumcision became a controversy in the early
Church because the first Christians were Jews.
These Christians debated whether or not the
Christian gentiles needed to be circumcised in
order to be saved. Peter proclaimed that
Christians were saved only through the grace of
Jesus Christ. Paul later reaffirmed the concept:
"For in Jesus Christ neither circumcision availeth
anything nor uncircumcision; but faith which
worketh by love".
MYTH: Jews don't question
circumcision.



Reexamination of circumcision (brit milah) is occurring within the
Jewish community itself.
For Orthodox Jews, who accept brit milah solely as a religious (not a
health) practice, the medical discussion is irrelevant. But for all
other Jews, who take some comfort in the health attributes, a
profound soul-searching may be anticipated. The answer will not be
found in the epithet "anti-Semite".
Jewish writings of the last decade illustrate this process: "A Mother
Questions Brit Milah", "Letter to Our Son's Grandparents: Why We
Decided Against Circumcision", "A Baby-Naming Ceremony,
Rochester Society for Humanistic Judaism", and "Jesse's
Circumcision". Health care providers who are aware of resources will
be able to provide information to Jewish parents who are grappling
with this difficult issue. The Alternative Brit Support Group is one
such resource.
MYTH: Parents have the right to
decide whether or not to circumcise
their son(s).

Body ownership rights are now being
introduced as an issue in circumcision
lawsuits that claim that every human
being has an inherent, inalienable right to
his own intact body.
MYTH: All circumcised men are
happy that they were circumcised.


Support groups such as RECAP (RECover a Penis) [now called
NORM] and an information network, UNCIRC (Uncircumcising
Information and Resources Center), are rapidly uniting men who
perceive themselves as victims of a sexual assault inflicted upon
them during their earliest days of life and against which they were
unable to defend themselves.
Knowing that men who have realized their loss would prefer to have
their normal bodies intact, and in light of the fact that conclusive
evidence for circumcision as an effective health measure has never
been established, health care professionals are ethically and morally
obligated to put their scalpels down.
Foreskin Restoration



Foreskin restoration, also known as epispasm or
decircumcision
Celsus (25 BC-50 AD) was the first to give a
detailed description of two surgical techniques
for uncircumcision in his De medicina libri octo.
Subsequent works, for example by Galen (131200 AD) and Paulus Aeginata in the seventh
century, only contained a repetition of these
methods without presenting any new aspects
Foreskin Restoration


Ambroise Paré gave a new impetus in the sixteenth
century, suggesting the insertion of a catheter into the
distal urethra to guarantee free passage of urine during
postoperative healing.
In this past century, Johann Friedrich Dieffenbach was
the first to dedicate a whole chapter to the problem of
"posthioplastice" in a modern textbook of plastic surgery.

"Aryan doctors“

Nowadays, reports on surgical foreskin restoration are
still rare.
A CLOSING REMARK:
UNCIRCUMCISION AND THE
FINE ARTS





From 1501 to 1504 Michelangelo
Buonarroti created the statue of David.
This representative of the Jewish
people is shown with his penis not
circumcised.
Was Michelangelo just submitting to
the aesthetic taste of his time, thereby
making use of artistic liberty, as he
had done before?
Or did he fear any discredit of the
Church or his customers by presenting
such an obvious sign of Judaism as a
circumcised penis?
Some authors even postulated that
Michelangelo had in mind to attach the
face and weapons of David to the
statue of Goliath.

Voordracht Pediatrie - Dr. Breugelmans Urologie

Transcription

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