ANOMALIES' OF THE PREPUCE; PHIMOSIS AND ITS COMPLICATIONS (Balanitis, Balomposthitis, Paraphimosis) The development of the prepuce and of the anterior portion of the urethra takes place in the third to the fourth month of embryonal life. During this time a fold which lies at the posterior edge of the developing glans grows over it and covers the glans completely in the fifth inonth.
Congenital defects of the prepuce often appear in families in which preputial deformities are hereditary. They may either appear alone, or associated with other deformities of the genital apparatus.
According to Bakay and Kaufmann, in the normal newborn child the glans is always adherent to the inner menibrane of the prepuce. The space between the glans and the prepuce is filled by an 8-fold layer of pavement epithelium, whose cells reach into the canoe-like pit of the urethral mouth.
The epithelial agglutination becomes loosened by movements during the growth of the first months of life, but it often takes some y-ears before the prepuce can be completely pushed back. Bokay dis tinguishes three degrees in the process of loosening. In the first, when the prepuce is gently retracted the urethral orifice will be just visible in the opening. In the second the prepuce can be drawn over the middle of the glans, but is arrestecl at a point where they are still grown together. In the third degree the only adhesions which remain are in the retro glandular sulcus.
Theoretically' there is a distinct difference between the epithelial agglutination of the prepuce with the glans, as a physiological condi tion, on the one hand, and the narrowing of the prepuce which pre vents the glans from passing through it on the other, aside from the epithelial agglutination which would render this impossible. But in practice this difference cannot be always maintained, since the symp toms are frequently the same. Hofmokel distinguishes four causes of phimosis: (I) a prepuce congenitally too long and too narrow (hyper trophic form); (2) congenital narrowness, restricted to the external opening Of the prepuce; (3) long persistence of extensive epithelial agglutination between glans and prepuce, i4) congenital and abnormal shortness of the frenulum and its location too far towards the front.
In all of these forms the internal membrane of the prepuce appears shorter than the external. Karewski describes, in addition to these forms, the cicatricial phimosis appearing after birth, and the form, rare, it is true in children, which results from (edematous swelling in consequence of acute inflammation, but showing a normal prepuce.
and painful urination are the syniptoms of the affection. Mothers often refer the restlessness of a child to diffi culty in passing the urine, and ask for an operation upon the narrow prepuce. A careful examination often shows that the connection traced by the mother doe.s not exist, and that the restlessness of the ehild will disappear when. for example, the nourishment is properly regulated. Any one who has the opportunity, to witness the passage of urine in babies with phimosis would observe before the action great restlessness, reddening of the face, and eventually violent screaming; and then the urine will be suddenly discharged, or a part flows into the prepuce and distends it like a balloon. In severe cases, the prepuce forms a kind of urine reservoir, out of which the retained fluid constantly drips.
The local results of the conditions are eczema at the urethral orifice, which may spread over the skin of the entire genital region; balanitis, balanoposthitis, the formation of concretions in the stagnant and thickening preputial secretion epreputial The balanitis is a superficial inflammation of the glans with the Production of abundant pus, mixed with the epithelium and creamy secretion of the glands. The affection is usually associated with in flammation of the inner preputial membrane, posthitis, and thus be comes a balanoposthitis. In the presence of this affection the prepuce is swollen and reddened, the membrane is ulcerated in some places and secretes an ill-smelling pus. In cases of greater intensity the swelling becomes more extensive, the exudation profuse,and gangrene may result.