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need some info (re: balanitis and circ)

post #1 of 46
Thread Starter 
i have a 3 yo uncirced little boy (rhys). rhys has gotten balanitis
now twice - the first time was right around the time claire was born
(6-8 mos ago - she is 6 mos old and my brain can't think of the date -
it was summer, and she was either a newborn or i was very preggo).
anyway, he has it again. peds on base has been consistent in their
suggestions, but i just need some info.

current suggestions from peds:
1- retract as far as possible (he's not fully retractable - they are
not suggesting forceful retraction, but just to where he *can*) and
make sure he's clean

2- abx for actual infection

3 - at second infection consider circ (consult with urology to follow
if the current infection gets any worse) and at the third infection
we "should" circ.

all of this has happened in the last 6-8 months, and i don't *want*
to circ him, but if he needs to be circ'd, i'd rather do it now than
later. but i don't want to at all. i'm just not sure what to do
now - i dont' want him to hurt (and this is a *painful* infection for
him). another friend that posts here suggested you guys might have
some info for me.

liv
post #2 of 46
Sooner or later someone will come on with better knowledge than I but I would be wary of the retract and clean. That doesn't seem right to me in fact a quick search dug up this from circumstitions.
Quote:
Birley and colleagues found that balanitis was associated with more frequent daily washing of the genitals with soap and could be managed by restriction of washing.
So perhaps it is the frequency and/or type of soap you are using. He could have recently become sensitive to it. Anyway like I said someone with better knowledge in this area will likely follow up. If not perhaps you could contact someone at NOCIRC to locate a intact friendly doctor/urologist
post #3 of 46
Are you retracting him at all? That in itself could be causing it.
post #4 of 46
Thread Starter 
*we* are not retracting at all. *he* retracts himself (as far as he is comfy) and rinses with his bathwater.

Liv
post #5 of 46
My recommendations:

First, forgo the retraction bit and do warm water baths. no soap. Have him swish his penis around and manipulate it as he wants in the bath...kinda making him aware of penis washing in his own way.

Use an over the counter topical-- I always forget the name-- bactroban? I will look it up for you, if you suspect an infection. Go with abx only if something like that doesn't work.

If the these don't help the situation, I would want to look deeper and not go for cutting. I would want a good ped urologist and a second opinion. It could be a bigger problem like lichen sclerosus.

If his problem is due to a tight foreskin, a dorsal slit or the like is what would be offered to you outside of the USA...here doctors like to cut it all off. This is why it is important to seek a foreskin friendly urologist and a second opinion.

Circumcision is not always a cure for this. see here:

Quote:
Among the 238 boys under 3 years, those circumcised were significantly more likely to have non-cosmetic problems, including coronal adhesions, trapped epithelial debris... and balanitis than were boys with a foreskin
He found that 15.5% of the circumcised boys presented with balanitis. So I would def be looking for the underlying cause before even considering any surgery.

http://www.cirp.org/library/complications/vanhowe/
post #6 of 46
Quote:
Originally Posted by Momof2xy View Post
*we* are not retracting at all. *he* retracts himself (as far as he is comfy) and rinses with his bathwater.

Liv
Liv, from NOCIRC pamphlet 7

Quote:
Balanitis xerotica obliterans (BXO) is recognizable by a whitish ring of tissue at the tip of the foreskin, which constricts and prevents retraction. This is an uncommon condition affecting no more than 1% of boys by their fifteenth birthday. It is confirmed by biopsy. Conservative treatment by a physician for BXO with 1% Clotrimazole and 1% hydrocortisone cream mixed together and applied three times a day is usually effective.
I am wondering if we are talking about the same thing according to this balanitis might prevent retraction. If so, has the ped recommended the cream? (Even before ABX)

Just wondering. As I said before I am just taking a stab; but there are others who know way more so if this isn't useful just sit tight.



ETA: Again from circumstitions:


Quote:
Balanitis Xerotica Obliterans

An infection of the glans or foreskin, characterised by a white, somewhat hardened surface. (BXO, also known as lichen sclerosus et atrophicus, LSA, even more fearsome-sounding), can be treated without surgery. Assman et al. treat it with tacrolimus ointment 0.1%.

Marilyn Milos writes:

A Florida pharmacist says BXO is not uncommon and easily treatable with this:

1% Clotrimazole cream and 1% Hydrocortisone cream, mixed together and applied 3 times daily.

Improvement is noticeable within seven days and full retraction returns in 30 days.

This therapy has worked on more than a dozen men since I learned about the treatment. The only person it didn't work on was the man who wasn't diligent in the application of the creams.

(Gk balanos = acorn, xero- = dry, L. obliterans = blotting out)
post #7 of 46
Quote:
Originally Posted by Momof2xy View Post
*we* are not retracting at all. *he* retracts himself (as far as he is comfy) and rinses with his bathwater.

Liv
that is good, i would def continue to let him take the lead. are you using bath bubbles at all? those are a big contributor to irritation issues in intanct boys.
post #8 of 46
I also agree with jwhispers...blanitis is kinda of a general term and has specific types under it. If you are dealing with a form that is causing a tight foreskin, there are therapies for that that do not involve circumcision. I forgot about the cream route in my first post, but, yeah that would def be among the first moves before thinking about a dorsal slit (after, of course, it is confirmed that this is the issue)


also, note that "infection" in these cases can be bacterial or yeast. And giving abx for yeast will only make the problem worse. Make sure they are culturing to find out what the infection is if you plan on going the medication route. If he has balanitis caused by yeast (which is common), abx will only make the problem worse.
post #9 of 46
First of all, what is commonly referred to as an "infection" may not really be something caused by a bacteria or fungus, rather it may be more of an inflammation caused by chemical or mechanical irritation.Things like soap and bubble bath can be a big problem for many kids' genitals, both boys and girls. Try to eliminate any possible irritants like these, or concentrated chlorine (like jacuzzis) or detergent residue in under wear. Make sure he's drinking plenty of water to keep the urine dilute; overconcentrated urine can be irritating to the tissues.

If he's been on antibiotics before, give him acidophlius internally (capsule or powder)and externally (liquid) on the penis to balance out the bacteria flora. You might want to investigate allergies especially in regard to diet. Sugar intake in particular might also be a factor.

When treating balanitis, it's important to have any discharge cultured, so that you know what organism you're dealing with, and get the right prescription for the right bug. Yeast is not an uncommon problem in young kids, so a trial of over the counter yeast medicine might be worth a try for a day or so, to see if it helps. Or just go straight to topical acidophillus. Before the applications, have him do warm tub soaks to keep it clean, and bring circulation into the area. If it stings to pee, have him pee in the tub or in a cup of warm water.

For future prevention, teach him good hand washing habits, especially if he likes to handle his penis a lot (little boys can have grubby hands), and keep his fingernails trimmed.

BTW, besides a true microbe-caused infection or a chemical or mechanical irritation/inflammation, occasional redness or swelling of the foreskin may be a transitory non-infectious reaction, as sections of the the foreskin separate from the glans during natural penile development, leaving a slightly raw or sensitive surface underneath for a day or so.

Here are a couple of sources that might be helpful reading for you:


Remember, circumcision is so far down the list of ways to treat a local infection, I wouldn't even worry about it. And don't let any doc browbeat you into it. Military docs, especially, have their protocols all spelled out for medical decision-making, but that doesn't mean that they are well informed of conservative methods of treatment. Ask them how they would treat a little girl that had had two or three irritations of her vulva. Certainly not with amputation! Let them know it it's not an option.
http://www.nocirc.org/publish/4pam.pdf
http://www.mothering.com/articles/ne...uncircson.html
Let us know how things are going!

Gillian
post #10 of 46
Thread Starter 
specifics for rhys.... since we're not sure we're talking about the same thing....

rhys woke up this AM (and the AM that he had the last infection, too) complaining that "my penis hurts" - i looked @ it, and it was red and swollen. gave tylenol for pain. last time, we figured it was just "one of those things" and said we'd wait and watch. w/in 12 hours, he had pus coming out of his (even redder and more swollen) penis. so far with this round, it's just red and swollen still. doc said it's not "at that point yet" but that we may end up back tomorrow for abx. last time, he had some sort of wound under his foreskin that had pus coming out of it - doc said we needed to clean it to that point daily (several times) until the infection was gone in addition to oral antibiotics. this was *REALLY* traumatizing for him. seriously, when we went in today, he didn't even want to get weighed. it took an apple and a banana (in addition to being in the monkey room) and the promise that they would "look and not touch" before he would calm down. we "pinkie dealed" that mommy wouldn't let them hurt him, and he *finally* calmed down. a little. ::sigh::

hubby is getting ready to do bath time with him now (per the pedi, our every other night baths are moving to nightly baths until this is resolved). so if soemthing has majorly changed (healed or pus, either way...) i'll update then.

Liv
post #11 of 46
Balanitis is an inflammation+ of the glans (balanus), but is not necessarily an infection*. Balanitis may occur together with posthitis (inflammation of the foreskin), when it is known as balanoposthitis.

Balanitis can occur in both circumcised and intact (non-circumcised) males.6 Van Howe reported significantly more balanitis in circumcised boys as compared with intact non-circumcised boys.10 Balanitis has a wide variety of causes, including physical trauma, an irritant, or an infection.6,8,13 Infectious balanitis may be caused by yeast, fungus, bacteria, or virus infection.6,8,9,13 Identification of the cause is essential for successful treatment


Birley et al. documented that balanitis is associated with excessive washing of the penis, with the use of soap or other irritants, and with fungal or other infections.6 Excessive washing removes normal skin oils and causes non-specific dermatitis (NSD) which is confused with balanitis.6 If the inflammation is caused by NSD, the treatment is to stop washing with soap, apply emollients, and allow natural skin oils to return.6,13 Washing may worsen the condition.

physical insult may cause balanitis. Inflammation may be caused by premature forcible retraction of the foreskin which may tear the synechial membranes that retain the non-separated foreskin in the young boy.14 The tearing of the synechia creates raw surfaces which may become infected.14



Non-infectious irritants may cause atopic balanitis.4,6,8,13 For example, swimming a in heavily chlorinated swimming-pool is known to cause balanitis. The irritant should be avoided.11 Emollients should be applied.13

The foreskin is designed by nature to protect the body from infection.11 In the young boy, balanitis is best prevented by leaving the prepuce or foreskin alone and allowing it to perform its protective immunological functions.8,11 No attempt should be made to retract or wash underneath the prepuce or foreskin

A few medical doctors advocate circumcision for repeated cases of inflammation of the glans. However, there is no documented medical evidence that circumcision is more effective than proper penile care - which includes leaving a boy's foreskin alone, and avoidance of irritants, such as excessive washing, especially with soap.
post #12 of 46
Thread Starter 
we are not retracting him (see above). he retracts himself and uses his bathwater to rinse. doc did not do cultures (ER doc @ military hospital - blech). @ initial diagnosis, his whole penis was red and swollen (especially in the glans area), and had pus coming out of it. pus was not cultured. saw a pedi the next day, who confirmed balanitis (military pedi as well) and said to cont. abx and cleaning until infection clears. infection looked obviously better by day 3 or 4, and he had a 10 day course of abx.

this go, he woke with a red/swollen penis (generally swollen). doc said that it was "most likely another case of balanitis" but as there was no pus, we were to "wait and see" and that most likely "you'll be back tomorrow and we'll do abx and a urology consult."

Liv
post #13 of 46
Thread Starter 
oh, and to be honest, i don't remember the name of the antibiotic (i was either WAYYYYY preggo or had just had my daughter, so my brain is a little fuzzy on the specifics, i'm sorry). it was pink and required refridgeration, so my guess is amoxicillin (docs here are very fond of it).

also, fwiw, rhys is prone to skin infections - immediately before this (in june last year) he got cellulitis in his foot from a regular ol' scrape. ::sigh::.

lastly, i pointed out to the doc today that both cases were after bath night (we bathe them every other night b/c we live in the far north and it is cold and dry here. my kids have sensitive skin.). she said "well since you bathe every other day, that could just be chance." not sure. WE don't retract him. he retracts himself and cleans with warm water from his own bath.

Liv
post #14 of 46
amoxicillin which is the pink bottle doesn't treat balantitis -it never will -it may be asymptompatic thing that goes away on its own -like a virus
post #15 of 46
yup the medcine prescribed was amoxicillin which will not fix balantitis my son had a ear infection once
post #16 of 46
It may not be an infection at all.

It could just be seperation trauma, which is completely harmless and normal, but can cause pain and swelling just as cutting a tooth can cause pain. It is possible that the pus was actually smegma. Smegma is just normal secretions and dead skin cells. It can build up before the foreskin seperates, then a whole bunch can come out all at once.

Don't over do bathing it can be irratating. If it is infection it may be yeast and not bacterial, if it is yeast antibiotic treatments will make it worse not better.
post #17 of 46
Thread Starter 
amoxicillin can fix a wide variety of ailments....including (Bacterial) ear infections. whatever happened last time IMPROVED with the antibiotic, so i'm relatively certain that it was not yeast (would've made the issue worse), but rather was some sort of bacterial infection (i don't know of anything that will get better with abx that isn't bacterial - someone correct me if i'm wrong, please). while i'm sure there are other alternatives to circ (WHICH IS WHY I'M HERE and DS wasn't circ'd in the first place....) i don't know what they are and i'm being told that in order to make the infections stop i should circ. i don't WANT TO. i *want* to leave him intact or i would've circ'd him as an infant.

sorry, had to clear that up, as i'm getting a "you want to circ your kiddo" vibe from some of these posts (and you know how notorious the internet is for not being able to hear tone, so please forgive me if i'm wrong).

1 - we do not use soap on his penis.
2 - we do not retract for him - he retracts himself
3 - we bathe them every other day
4 - it could be irritation, but that irritation leads to infection because there was *pus* coming out of his penis. i'm relatively certain that a doc can identify pus, even if he thinks circ is a good idea (:P) - and even if s/he can't, i CAN. this is not my first kiddo, and i've worked medical before (actually up until i started staying home with our third kiddo). it was PUS.
5 - i think rhys is prone to skin infections as is (this is not his first, nor the first location of a skin infection for him).

after his bath tonite, we noticed that he is *much* more swollen and said it hurt when he tried to retract HIMSELF tonite (so obviously he didn't do it), so there is *something* up. we'll end up taking him to the pedi tomorrow for abx i'm sure (i'm 99% sure he's got pus under there - there is a lump just like last time from which the pus came). i do NOT want to circ him, but i DO want him to get better.

Liv
post #18 of 46
Quote:
Originally Posted by Momof2xy View Post
(i don't know of anything that will get better with abx that isn't bacterial - someone correct me if i'm wrong, please).
If it was seperation trauma it would have cleared up on it's own anyway. The antibiotics wouldn't have been helping, but since they also wouldn't hurt it the issue would still clear up.


1 - we do not use soap on his penis.
But is it already in the bath water?
2 - we do not retract for him - he retracts himself
Did he discover this for himself or was he told to do so?


Quote:
i'm relatively certain that a doc can identify pus, even if he thinks circ is a good idea (:P) - and even if s/he can't, i CAN. this is not my first kiddo, and i've worked medical before (actually up until i started staying home with our third kiddo). it was PUS.
Lot's of Drs have mistaken smegma for pus.

Quote:
(i'm 99% sure he's got pus under there - there is a lump just like last time from which the pus came).
The lump is probably a smegma pearl. They are very common.

Quote:
while i'm sure there are other alternatives to circ (WHICH IS WHY I'M HERE and DS wasn't circ'd in the first place....) i don't know what they are and i'm being told that in order to make the infections stop i should circ. i don't WANT TO. i *want* to leave him intact or i would've circ'd him as an infant.

sorry, had to clear that up, as i'm getting a "you want to circ your kiddo" vibe from some of these posts (and you know how notorious the internet is for not being able to hear tone, so please forgive me if i'm wrong).
We know you do not want to circ him, but we also know that most US Drs are extremely circ happy and you likely will be advised to by them to circ him. We want to help you see how foreskin ignorant they are, so you can protect your DS.

Have you read this article http://www.mothering.com/articles/ne...uncircson.html
post #19 of 46
Thread Starter 
generally no, there is not already soap in the water - generally speaking, rinsing bits off is the first part of bath time. then they use soap (actually, they still like the baby wash, so we let them use it :P) to wash their hair and bodies. then they get to play (we bathe both boys together) until they get rowdy, then time to get out.

rhys started retracting on his own (well, it started as fiddling and then he figured out that he has <in his words> a "second penis in there!"....)

i need to go read the article though.

Liv
post #20 of 46
I'd insist on a culture to ascertain exactly what sort of bacteria is present. It will give you a much more certain sense of what is happening and assure you that if you do give him antibiotics, you are using an antibiotic that is effective for that bacteria.

If you are washing their hair in baby wash and then allowing them to continue playing in the rinsed off water, he is still sitting in water that contains soap. Any sort of wash/soap can be irritating to tender genital skin. I'd be weary of this as a contributing factor. Can you let him play in clear water then wash hair and immediately rinse and drain the tub and get him out? (I know, they just love the playtime in the tub with any sort of bubbles!)
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