The Inconspicuous or "Disappearing" Penis

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Letters

to the

Editor

240 PEDIATRICS Vol. 94 No. 2 August 1994

Statements appearing here are those of the writers and do not represent the official position of the American Academy

of Pediatrics, Inc. or its Committees. Comments on any topic, including the contents ofPEDIATRICS, are invited from all members of the profession: those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from

authors and others.

Letters should be submitted in duplicate in double-spaced typing on plain white paper with name and

address of sender(s) on the letter. Send them tojerold F. Lucey, MD, Editor, Pediatrics Editorial Office, Medical

Center Hospital, Burlington, VT 05401.

Capillary

Refill?

To the

Editor.-Gorelick et a1 in their article “Effect of Ambient Temperature

on Capillary Refill in Healthy Children” report that cool ambient

temperature can prolong capillary refill time (CRT) in children

with normal circulatory status. This suggests to them a limitation

of the use of CRT in the assessment of ill or injured children. In the

accompanying editorial2 entitled “Capillary Refill: Is It a Useful

Clinical Sign?,” Dr Baraff takes the aforementioned limitation one

quantum step further to completely dismiss the use of CRT,

stat-ing it “adds nothing” in the evaluation of circulation. Physicians

are admonished to “remain skilled observers and open minded”

so that clinical signs such as CRT are not utilized until proper

analysis of such a sign is achieved.

In fact, proper analysis of CRT has been achieved.3 We have

demonstrated that this sign, when performed and interpreted

correctly, can help differentiate children in shock from those not in

shock. For example, in 10 of 11 infants with a volume of deficit in

excess of 100 mL/kg body weight, CR1 was significantly

pro-longed when compared with control values.3 Like any other

bed-side clinical observation, CRT can be affected by multiple

envi-ronmental and physiologic variables that should always be taken

into consideration, within a clinical context, by the “skilled

ob-server.” For example, the many signs of dehydration or circulatory

failure of the infant with enteritis in the tropics or in the United

States are very different from those of a trauma victim in a cool

environment at night. Dry mucous membranes, skin elasticity

(tenting) and sunken eyes are also useful signs in assessing the

state of hydration of a patient, but do not permit quantitation as

well as does CRT. They, too, would not fuifill Dr Baraff’s demands

for specificity and sensitivity. Applying his logic, they would also

be dismissed.

A good clinician will not rely on a single sign if there is conflict

with other evidence. Medical evaluation with its inherent

variabil-ity in circumstance and examiner will always have limitations, as

we have pointed out about CRT.3 However, given that the

quan-titation will be reasonably accurate most of the time (90% in our

hands) it becomes the best measure for the initial estimate of

hypovolemia in infants with the fluid losses of gastrointestinal

disease. When benefits outweigh risks and valuable information

can be ascertained easily, effectively, reliably and without cost to

the patient, the use of a physical sign such as CRT should not be

abandoned.

GLENN

D. Hs,

MD

Pediatric

Critical

Care

East

Carolina

University

Medical

Center

Greenville, NC

JOSE

M.

SAAVEDRA,

MD

Nutrition Support Services

Johns

Hopkins

University

School

of Medicine

Baltimore,

MD

LAURENCE FINBERG, MD

Children’s

Medical

Center

of Brooklyn

SUNY Health Science Center/Kings County Hospital

Brooklyn, NY

REFERENCES

I. Gorelick MH, Shaw KN, Baker MD. Effect of ambient temperature on

capillary refill in normal children. Pediatrics. 1993;92:699-702

2. Baraff U. Capillary refill: is it auseful clinical sign? Pediatrics. 1993;92: 723-724

3. Saavedra JM, Harris GD, Li 5, Finberg L. Capillary refilling (skin turgor) in the assessment of dehydration. AJDC. 1991;145:296-298

In

Reply.-We do not disagree with many of the points made by Dr Harris

and his colleagues. Specifically, we do not advocate eliminating

this test. In our discussion, we state, “Our results suggest several

important limitations to the use of capillary refill in the assessment

of circulatory status in children.” All tests have limitations, and

appropriate utilization by clinicians requires knowledge of those

limitations. Our study was intended simply to evaluate one such

potential limitation, ie, cool ambient temperature.

As Dr Baraff indicates in his editorial, there are conflicting data regarding the performance of capillary refill time in the evaluation

of dehydration. In the study cited by Dr Harris,’ capillary refill

was found to have reasonable sensitivity (10/11 91%) in

pre-dicting the presence of a fluid deficit of 100 mL/kg or greater in

children, although the 95% confidence interval for this point

esti-mate is rather wide (59%, 100%). Conversely, in their study on

adults,2 Baraff and Schriger found a sensitivity of 6% to 46%,

depending on the nature and severity of volume loss. A third

study examining a number of signs of dehydration in children,3

found that “decreased peripheral perfusion,” without

quantifica-tion, had a sensitivity of 35% (95% CI: 21%, 51%) in predicting a

dehydration of 4% or more of body weight. Clearly, more work

remains to be done on this and other clinical signs to define more

clearly their utility and limitations, which will allow more rational

diagnosis of dehydration in children.

MARC H. GORELICK, MD

KATHY

N. Sw,

MD

M.

DOUGLAS BAKER,

MD

Pediatric

Emergency

Care

Associates

Children’s

Hospital

of Philadelphia

Philadelphia, PA 19104

REFERENCES

I. Saavedra JM, Harris GD, Li 5, Finberg L. Capillary refilling (skin turgor)

in the assessment of dehydration. AJDC. 1991;145:296-298

2. Schriger DL, Baraff U. Capillary refill-is it a useful predictor of hy-povolemic states? Ann Emerg Med. 1991;20:601-605

3. Mackenzie A, Barnes G, Shann F. Clinical signs of dehydration in

children. Lancet. 1989;ii:605-607

The Inconspicuous or “Disappearing” Penis

To the

Editor.-I see that male genitalia are once again conspicuous in the

pages of the Green Journal.’3 I was horrified to read and see what

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LETFERS TO THE EDITOR 241

is happening to young males in the Phoenix area, as described in

the article by Bergeson et al. Their primary care pediatricians are

threatened with litigation. All for a common, normal developmental

phenomenon, whose only treatment should be simple reassurance.

I first became aware of this “problem” 15 or 20 years ago when

an occasional father would show up for the 9- or 12-month

well-child visit. He would sit silently, and watch carefully, as I

exam-ined his son. He had changed a diaper, somehow, and become

worried about his son’s equipment. An explanation that most

boys, especially when well-nourished, have a presymphysis fat

pad, which the penis “disappears” into, and a demonstration that

the shaft and glans were normal, when the fat pad was retracted,

was reassuring. The penis always re-emerges when their boys

become ambulatory, acquire abdominal tone, redistribute their

body fat, and lose their “baby belly.” This happens in almost all

boys by the time they are 4 to 6 years old. The buried or

“disap-pearing” penis is less obvious in uncircumcisized males because

the foreskin is still adherent to the glans in this age group and this

tends to hold the shaft and glans out of the presymphysis fat pad.

It is true that some boys, who are morbidly obese, continue to have

a buried or “disappearing” penis well into later childhood. The

problem is not with their penis, but with their obesity. To subject

these boys to the risks of surgery, including Z-plasties and

lipec-tomies, is to avoid their real problem.

I am so upset by the pictures in Fig 3 in the Bergeson article’

that I am unable to sleep. I see infant males who look exactly like

the preoperative figure on a weekly basis. They all develop

nor-mally, and their penises always emerge with age. The thought that

more of these procedures are planned on infant boys in the

Phoe-nix area leaves me with a sad and sickened feeling.

The enclosed Figure is photos of two patients, with follow-up 7

years later, with this common “problem.” As can be easily seen,

the “problem” cures itself. I had planned to write a note on the

“disappearing” penis years ago, so that it would be better

recog-nized in the pediatric literature. I am sorry now that I did not. I did

not realize the mischief that the urologists were up to. This is

worse than the orthopedists used to be with their DB splints for

flexible metatarsus adductus and tibial torsion.

Please reassure your readers that it is not the size of the organ,

but its function that is important. The described surgery is strictly

Figure. A and B, Patient I at 9 months of age. C, Same patient at 7#{189}years of age. D and E, Patient 2 at 9 months of age. F, Same patient

at 7#{189}years of age.

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242 LETI’ERS TO THE EDITOR

cosmetic, not functional, and is being done for the parents, not for

the patient. To operate on these boys, for no other indication, is

truly surgical mischief.

JAMES

R.

LITULE,

MD,

FAAP

Jackson

Pediatrics,

PC

Jackson, WY 83001

REFERENCES

1. Bergeson PS, et al. The inconspicuous penis. Pediatrics. 1993;92:794-799 2. Wiswell TE, et al. Postneonatal circumcision. Pediatrics. 1993;92:791-793 3. Schoen EJ. Circumcision update-indicated? Pediatrics. 1993;92:860-861

In

Reply.-The inconspicuous penis encompasses a number of different

entities. Over the years, this problem has engendered much

con-troversy and endless discussion by urologists but has remained

surprisingly unknown among other medical practitioners. Dr

Lit-tle raises some of the issues that have led to the controversy

concerning the buried penis. (The buried penis is but one of the

entities comprising the inconspicuous penis).

Our paper describes the different types of inconspicuous penis

so that pediatricians can recognize the physical manifestation and

make the appropriate referral to specialty care. It is also important

for the practitioner to avoid circumcision in these cases. The

congenital malformation known as the buried penis has been

recognized and surgically treated in respected children’s centers across the United States)3

As we explained in our paper, the buried penis will

spontane-ously resolve in many children without surgical treatment, which

is what Dr Little witnessed in his practice. However, there is a

select group of patients whose buried penis will improve only

with surgical intervention. Many of these are bound down by

fibrous bands. The difference in the patient experience in an

individual pediatrician’s practice and that of a tertiary care

refer-ral center should not be underestimated. Given the incidence of

the buried penis, individual pediatricians would not necessarily

be expected to treat the full range of presentations in their careers.

The large number of patients who are self-referred for this

problem demonstrates that this congenital malformation

fre-quently goes unrecognized by medical practitioners and is

under-treated rather than overtreated, much to the detriment of the

affected children. We certainly have seen children who have

de-veloped serious psychological effects as a result of this problem.

ROBERT BAILEY, MD

LEIGH MCGILL, MD

PAUL S. BERGESON, MD

JANICE

P.

PlAiT,

MD

ROBERT HOPKIN, MD

Ambulatory Pediatrics

Phoenix

Children’s

Hospital

Phoenix, AZ 85006

REFERENCES

1. Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical

correction of the buried penis: description of a classification system and a technique to correct the disorder. I Urol. 1986;136:268-271

2. Shapiro S. Surgical treatment of the ‘buried’ penis. Urology. 1987;30: 554-559

3. Devine CD. Commentary part II, Section I: concealed penis. In: Hinman F, Jr. Atlas of Urology. Philadelphia PA: WB Saunders; 1989:65-68

Universal Hepatitis B Immunization: The Dose of HBIg That Should Be Administered at Birth

To the

Editor.-In the article entitled “Universal Hepatitis B Immunization”

(Pediatrics 1992;89:795-800) it is confirmed that perinatal

transmis-sion of hepatitis B virus (HBV) infection from hepatitis B surface

antigen (HBsAg)-positive carrier mothers to their infants may be

efficaciously prevented by combined passive-active

immuniza-tion, the efficacy of which has been previously

well-document-ed.’ In that report the Committee on Infectious Diseases

recom-mends, in particular, that infants born to HBsAg-positive mothers

should receive the dose of 0.5 mL of hepatitis B immunoglobulin

(HBIg) at or shortly after birth.

Because different types of HBIg with different concentrations

are commercially available (eg, in Italy they are licensed: Uman

Big Biagini HBIg that contain 180 IU/mL, and two formulations of

Hepuman B Berna HBIg that contain 100 IU/mL and 200 IU/mL,

respectively), we do not consider as “universal” the dose

recom-mended by the Committee on Infectious Diseases. Indeed, the

suggested dose of 0.5 mL in Italy might mean either 90 IU per

newborn-if Uman Big Biagini HBIg are used-or only 50 IU per

newborn-if one of the two formulations of Hepuman B Berna

HBIg is utilized. Because it has been previously reported that the

risk of hepatitis B in infants born to HBsAg-positive carrier

moth-ers depends on both the virus load and the neutralization capacity

of the HBIg injection,3 we think that an adequate dosage of HBIg

is very important. If we consider the rates of HBV infection in

infants born to HBV-carrier mothers reported in different

stud-ies,’3 we observe a correlation of these rates with the doses of

HBIg administered. Indeed, Lee3 using doses of 50 IU of HBIg per

newborn found HBV infection in 20% of the infants treated with

passive-active immunization; Beasley’ using doses of 150 IU of

HBIg per newborn found HBV infection in 6%; Wong2 using either

only one dose of 200 IU of HBIg at birth or a dose of 200 IU of

HBIg at birth followed by 6 monthly injections of 100 IU did not

prevent HBV infection in 6.8% and 2.9%, respectively.

On the basis of these results, Schalm4 has previously suggested

that neutralization of HBV in infants of HBsAg-positive mothers

requires HBIg doses of 150 LU or more for the newborn. Therefore

considering that in the different countries there are commercially

available different HBIg preparations and that the neutralization

capacity of the HBIg is closely related to their amounts, we think

that in the “universal” recommendations for hepatitis B

immu-nization the dose of HBIg has to be indicated in lU and not in

mL. The indication of only volume can be responsible for an

incorrect dosage that could compromise the efficacy of the

immunoprophylaxis.

REFERENCES

ANGELA VEGNENTE,

MD

RAFFAELE IoRlo, MD

ELENA DE ROSA,

MD

Dept

of Pediatrics

University

of Naples

via

S Pansini

n 5

80131 Napoli

Italy

1. Beasley RP, Hwang LY, Lee GCY, et al. Prevention of perinatally

transmitted hepatitis B virus infections with hepatitis B immunoglobu-lin and hepatitis B vaccine. Lancet. 1983;ii:1099-1102

2. Wong VCW, Ip HMH, Reesink HW, et al. Prevention of the

HBsAg-carrier state in newborn infants of mothers who are chronic carriers

of HBsAg and HBeAg by administration of hepatitis B vaccine and

hepatitis-B immunoglobulin. Lancet. 1984;i:921-926

3. Lee SD, La KJ, Tsai YT, et al. Role of caesarean section in prevention of mother-infant transmission of hepatitis B virus. Lancet. 1988;ii:833-834

4. Schalm SW, Grosheide PP. Prevention of hepatitis B transmission at

birth. La?:cet. 1989;i:44

In

Reply.-Dr Vegnente et al raise an important point regarding the

dif-ferent concentrations of antibodies to hepatitis B surface antigen

(anti-HBsAg) in preparations of hepatitis B immune globulin

(HBIg) prepared by manufacturers outside the United States. The

American Academy of Pediatrics (AAP) recommendations were

based on products manufactured in the United States (US). These

products have been standardized to contain anti-HBsAg

concen-trations equivalent to or exceeding the potency of anti-HBsAg in a

reference standard hepatitis B immune globulin (human)

pre-pared by the Food and Drug Administration (FDA). The products

marketed in the US have not been standardized international units

because the US reference standard was developed before the

international unit standard was established by the World Health

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1994;94;240

Pediatrics

James R. Little

The Inconspicuous or "Disappearing" Penis

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1994;94;240

Pediatrics

James R. Little

The Inconspicuous or "Disappearing" Penis

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The Inconspicuous or "Disappearing" Penis

Letters

Capillary

GLENN

Pediatric

LAURENCE FINBERG, MD

Children’s

MARC H. GORELICK, MD

Pediatric

REFERENCES

To the

LETFERS TO THE EDITOR 241

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JAMES

Jackson

ROBERT BAILEY, MD

Phoenix

Universal Hepatitis B Immunization: The Dose of HBIg That Should Be Administered at Birth

REFERENCES

of Pediatrics

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entirety can be found online at:

Pediatrics

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1994 by the