Circumcision: Benign Physical Findings

Penile Findings
Scrotal Findings

Penile Pearl "Pearls" may be found in a variety of locations in the newborn.

"Pearls" may be found in a variety of locations in the newborn. In the mouth, they are are referred to as "Epstein Pearls". The tip of the foreskin is another relatively common location. The pearl is a small, firm, white nodule that contains keratin. It will spontaneously exfoliate and resolve with time. It is a normal finding and is not a contraindication to circumcision, if desired.

photo by Janelle Aby, MD

Foreskin Variant Although the opening of the foreskin is usually tight enough in the newborn to preclude a view of the urethra, variability exists.

Although the opening of the foreskin is usually tight enough in the newborn to preclude a view of the urethra, variablity exists. In this infant, a normal urethral meatus can be clearly seen. No referral or intervention is necessary.

photo by Janelle Aby, MD

Hydrocele Hydroceles are a frequent finding in newborns.

Hydroceles are a frequent finding in newborns. It is important on palpation to identify the normally small testicles (approximately 1 cm) as separate entities from the large, smooth-walled fluid collections of hydroceles. In contrast to inguinal hernias, common (non-communicating) hydroceles cannot be reduced as the fluid is in an enclosed space. Spontaneous resolution is expected. Most hydroceles do not create a barrier to circumcision. If, however, the hydroceles are so large that they are encroaching on the penile shaft, circumcision may need to be postponed.

photo by Janelle Aby, MD

Here one can see how easily the fluid-filled hydroceles transilluminate. Transillumination may be used to assist in making a diagnosis but for an experienced examiner, the diagnosis is usually made by palpation alone.

photo by Janelle Aby, MD

Inguinal Hernia This is a typical appearance of bilateral inguinal hernias.

This is a typical appearance of bilateral inguinal hernias. In contrast to hydrocele, inguinal hernias are associated with a fullness in both the inguinal area and the scrotum and can usually be reduced with digital pressure. At times bowel sounds may even be appreciated over the area of the mass. This infant is preterm, a risk factor for the presence of hernias. While the scrotum may transilluminate with either hydrocele or hernia, other clinical features will usually differentiate the two conditions. The presence of unilateral or bilateral hernias does not automatically preclude circumcision, but careful evaluation should be done. If the hernias are sufficiently large to encroach on the penile shaft (as appears to be the case in the infant above) then circumcision should be delayed.

photo by Janelle Aby, MD

Descending Testicle In a term infant, the testicles have normally completed their migration from the abdomen into the scrotum.

In a term infant, the testicles have normally completed their migration from the abdomen into the scrotum. However, even term infants will at times have one testicle that is undescended or incompletely descended. In this infant, the right side of the scrotum was empty and the testicle was palpated in the inguinal canal (seen as a bulge in the photo above). Because this testicle is located along the normal pathway of descent and is not ectopic, no further evaluation is needed. Spontaneous descent into the scrotum is expected with time. Circumcision is permissible in this situation.

photo by Janelle Aby, MD

Undescended Testicle At times, a testicle is not palpable at all in the scrotum.

At times, a testicle is not palpable at all in the scrotum. In the photo above, the scrotum appears asymmetric with the right side flatter than the left. Palpation confirmed that a testicle was present on the left, but not on the right. Unilateral undescended testicle is fairly frequent finding in term newborns and does not require further evaluation at birth or preclude circumcision. With time (weeks to several months) the testicle is expected to descend spontaneously. Bilateral undescended testicles, on the other hand, are quite unusual at term and should be considered as ambiguous genitalia (with circumcision contraindicated) until proven otherwise.

photo by Janelle Aby, MD

Ectopic Testicle During descent, it is possible for the testicle to pass through the inguinal ring and then veer off course into an aberrent location.

During descent, it is possible for the testicle to pass through the inguinal ring and then veer off course into an aberrent location. On examination of this infant, the right testicle was absent from the scrotum, but a mass was appreciated over the perineum. Ultrasound confirmed the diagnosis of ectopic testicle. Ectopic testicles may be found in the superficial inguinal pouch, the suprapubic area, the perineum, the femoral canal, or even the other side of the scrotum. This may eventually require surgical intervention, but it does not present a contraindication to neonatal circumcision if the parents desire it. (Note the fresh circumcision site in the photo!)

photo by Janelle Aby, MD

During the assessment of a newborn whose parents have requested circumcision, the examiner often encounters findings that, although not dangerous, cause concern or questions.

Many of these findings are benign and do not present a contraindication to circumcision, but any finding in the perineal area should be thoroughly assessed before the procedure is considered.

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Circumcision: Benign Physical Findings