PES INSTITUTE OF MEIDCAL SCIENCES AND RESEARCH, KUPPAM

Dr YSR University of Health Sciences, Vijayawada, Andhra Pradesh.

Synopsis of Research Proposal
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1. Title page: Preputial retractability/adhesions in children from age 1-14 years

2. Introduction: It is a curious fact that one of the operation most commonly performed is accorded
the least critical consideration. In order to decide whether a child's foreskin should be ablated, the normal
anatomy and function of the structure at different ages should be understood

3. Development of the Prepuce:

Embryologically, the glans penis derives from the genital tubercle, which has developed by 4-6 weeks
of gestation. The prepuce appears in the fetus at eight weeks as a ring of thickened epidermis which
grows forwards over the base of the glans penis. It grows more rapidly on the upper surface than the lower
. and so leaves the inferior aspect of the preputial ring deficient (Hunter, 1935). At 12 weeks the urethra still
opens on the inferior aspect of the shaft of the penis and the terminal part of the urethra has yet to be
constructed. Arrest at this stage produces the glandular type of hypospadias, with the " hooded " prepuce only
partially covering the glans. From the inferior aspect of the glans a pair of outgrowths are pushed out and meet
(the sulcus on the under aspect of the glans marks their fusion), so enclosing a tube which, becoming
continuous with the existing urethra, advances the meatus to its final site. These outgrowths from the glans
carry with them the prepuce on each side, thus completing the prepuce inferiorly and forming the frenulum. By
16 weeks the prepuce has grown; forwards to the tip of the glans. At this stage the epidermis of the deep
surface of the prepuce is continuous with the epidermis covering the glans, both consisting of squamous
epithelium. By a process of desquamation the preputial space is now formed weeks; at about term. in the
following manner .In places the squamous cells arrange themselves in whorls, forming
epithelial cell nests. The centres of these degenerate, so forming a series of spaces; these, as they increase
in size, link up until finally a continuous preputial space is formed.
About the end of the second month a low ridge appears round the coronary sulcus marking off the
glans. This ridge is the beginning of an upgrowth of the superficial tissues proximal to the sulcus, which
continuing its growth leads to the formation of the prepuce. As it grows the epithelial cells covered by it form
a solid layer deep to it: they break down subsequently, leaving the structure applied to the underlying glans
without any adhesion between their surface other than remnants of the epithelial attachments
It has been shown that, since during the first few years of life the prepuce is still in process of developing, it is
impossible at this period to determine in which infants the prepuce will attain normal retractability. In fact, only
about 10% will fail to attain this by the age of 3 years. Of this 10% of 3-year-old boys, in most it will be found
a simple matter to render the prepuce retractable by completing its separation from the glans by gentle
manipulation. In a very few this may prove impossible and circumcision might then be considered a justifiable
precaution. Higgins (1949), with long experience of paediatric urology, also concludes that circumcision
should not be considered until " after the age of, say, 2 to 3 years." The prepuce of the young infant should
therefore be left in its natural state. As soon as it becomes retractable, which will generally occur sometime
between 9 months and 3 years, its toilet should be included in the routine of bath time, and soap and water
applied to it in the same fashion as to other structures, such as the ears, which are customarily treated with
special assiduousness on account of their propensity to retain dirt. As the boy grows up he should be taught
to keep his prepuce clean himself, just as he is taught to wash his ears. If such a procedure became
customary the circumcision of children would become an uncommon operation. This would result in the
saving of about 16 children's lives lost from circumcision each year in this country, besides saving much
parental anxiety and an appreciable amount of the time of doctors and nurses. The development of the
prepuce is incomplete in the new born male child, and separation from the glans, rendering it retractable,
does not usually occur until some time between 9 months and 3 years. True phimosis is extremely rare in
infancy. During the first year or two of life, when the infant is incontinent, the prepuce fulfils an essential
function in protecting the glans. Its removal predisposes to meatal ulceration. The many and varied reasons
commonly advanced for circumcising infants are critically examined. None are convincing. Though early
circumcision will prevent penile cancer, there is reason to suppose that keeping the prepuce clean would
have a like effect in preventing this disease. In the light of these facts a conservative attitude towards the
prepuce is proposed, and a routine for its hygiene is suggested. If adopted this would eliminate the vast
majority of the tens of thousands of circumcision operations performed annually in this country, along with
their yearly toll of some child deaths

Need for the study: Although many studies were previously done on Preputial adhesions and circumcision
in children, they lack proper results so this present study is being done to further evaluate.

III. Objectives of the study:

1. The aim of the study is to assess preputial retractability in children at various ages.
2. To determine the stage of preputial adhesions and necessary treatment for the same.

IV. Review of the Literature:

 Prasanna Kumar et al study 2009: A prospective study of 100 consecutive children
of presumed phimosis referred for circumcision. They were assessed and classified by the
senior author as having either preputial adhesions or phimosis. The patients in the former
group underwent outpatient preputial adhesiolysis while those in the latter group were offered
circumcision primarily.
 Varun kumar et al study 2022: A retrospective review was performed of the health
records of children who presented with preputial adhesion. The study included 65 symptomatic
patients (ballooning of the prepuce in all cases and additional dysuria in three cases) who
underwent preputial adhesiolysis. All cases were followed up for 2 years. Circumcision was
subsequently carried out for patients who developed fibrous scarring resulting in difficult
retraction due to the development of thick adhesions or skin fissuring with persistence of
symptoms. Of the 65 boys, 58 (89.2%) achieved complete retraction of the prepuce. The
 remaining 7boys (10.8%) presented with recurring symptoms and thick fibrosed prepuce, and
they underwent circumcision due to the dense adhesions

V Materials & Methods (Methodology):

1. Study design: Prospective Study
2. Study setting: PESIMSR Hospital, General Surgery, Paediatrics
3. Study period: 2 months (Jan 2023- March2023)
4. Study population: Children between age 1-14 years of age attending Paediatrics and General
Surgery out patient department in PESIMSR hospital.

 What are the expected outcomes of the study?

To know the prevalence of preputial adhesions and stages of adhesions in school going children and
necessary treatment for the same

.
 What is the impact of the study in the population or in science?
We can improve the management of the preputial adhesions and if the results are fruitful large field
studies can be done on the basis of this study

 Funding: Institute (PESIMSR) funded.

 Conflict of Interest (if any) in the project: Nil.

 How is the confidentiality of participants ensured?

Each person will be given one identification number. The name & identity will not be disclosed.
Thus, the personal data about every subject will be kept confidential.

 Ethical clearance & approval:

Ethical clearance is yet to be obtained from the Institutional Human Ethics Committee, PESIMSR,
Kuppam.