Evaluation of a possible inflammatory response after appendectomy for non-perforated appendicitis in children.

BACKGROUND: The inflammatory process in the post-appendectomy period is not well characterized. In a pilot study, we prospectively followed the kinetics of different inflammatory mediators before and after appendectomy in children, and compared the results of the groups open appendectomy (OA) and laparoscopic appendectomy (LA). MATERIAL AND METHODS: Levels of sP-selectin, tPA, MCP-1, IL-6, IL-8, sVCAM-1, and sCD40L were measured before appendectomy and on the next three consecutive days in the serum of 25 children (16 males and 9 females) aged 7 - 16 years (mean 12.6+/-2.47 years) with non-perforated acute appendicitis. RESULTS: LA and OA were performed in 16 and 9 patients respectively. None of the markers of inflammation differed significantly by surgical approach at any point of observation. However, sP-selectin, MCP-1 and sVCAM-1 levels were found to have significantly different postoperative kinetics with a trend towards higher values in the laparoscopic group compared to the open appendectomy group (p=0.034, p=0.016 and p=0.025, respectively). CONCLUSIONS: The cytokines sP-selectin, MCP-1 and sVCAM-1 may play a role in the possible post-appendectomy cytokine activation after non-perforated appendicitis. Since this phenomenon is more evident after LA than after OA, the contribution of the different LA procedures has to be further investigated.

Is laparoscopic appendectomy in children associated with an uncommon postoperative complication?

BACKGROUND: Laparoscopic appendectomy (LA) is controversial due to the high rate of intraabdominal abscess (IAA). We report a postlaparoscopic appendectomy complication (PLAC) observed in pediatric patients discharged after an uneventful postoperative period. METHODS: In this case series, a review of the medical records of children who underwent LA or open appendectomy (OA) during a 5-year period was performed. The diagnosis of PLAC was based on three well-defined criteria: time of appearance, clinical and laboratory findings, and ultrasonographic characteristic features. RESULTS: A total of 374 patients underwent appendectomy (LA, 129 patients; OA, 245 patients). One patient with conversion of LA to OA and 35 patients with gangrenous or perforated appendicitis (seven from the LA group and 28 from the OA group) were excluded from the study. After LA, nine children developed intraabdominal complications during their hospitalization (six infiltrate in the right lower quadrant and three IAA); these were also excluded. Discharge from the department was done when three conditions were fulfilled: normal body temperature, normal leukocyte count, and passage of a stool. Among the 112 LA patients, PLAC was observed in 15 (13.4%), aged 12.5 +/- 2.9 years, who were discharged after LA in 2.7 +/- 0.9 days. Number of PLAC and time of its appearance were not significantly different in patients with normal or pathological appendix. Sonographic findings of PLAC at admission were fluid alone (n = 11), edematous mesenteric fat (n = 7), thickening of bowel wall (n = 9), and more than one sign (n = 9). At repeated sonography, these signs were present in all patients, and IAA developed in one of them. All children were successfully treated with antibiotics for 10.1 +/- 3.9 days, one of whom underwent a CT-guided percutaneous drainage for IAA. CONCLUSIONS: PLAC may be the result of a slow development of local interstitial infection in the ileocecal area due to mesothelial damage caused by CO2 pneumoperitoneum and local thermal effect produced by energized systems. This may explain its delayed appearance and the efficacy of the antibiotic treatment.

Treatment of the toe tourniquet syndrome in infants.

INTRODUCTION: The "toe tourniquet syndrome" is the circumferential strangulation by human hair or fibers of one or more toes in infants, which may induce prolonged ischemic injury and tissue necrosis. Release of the strangulation is mandatory to avoid autoamputation of the digit. We recently encountered several incompletely treated cases and would like to emphasize the effective method of treatment. METHODS: A retrospective analysis of pediatric emergency department records of patients treated for "toe tourniquet syndrome" during 1990 to 2001 was performed. Patients undergo a short, longitudinal, deep incision over the area of strangulation on the dorsal aspect of the toe, until the phalanx bone, which allows the complete section of the constricting fibers to be removed without injury to the anatomical structures of the toe. RESULTS: Twenty-one infants (12 boys and nine girls), aged 0-11 months (average 4.6 months), were treated for tourniquet syndrome of one (15 infants) or two (six patients) toes. In 12 patients (57.1%) the right foot was involved. Eight patients (38.1%) had undergone an attempt in the previous few days to release constriction. No complications were encountered. CONCLUSION: The above-described technique is simple and safe and secures the complete release of the strangulation by removal of all hairs or fibers without injury to the anatomical structures of the toe.

Successful treatment of recalcitrant warts in pediatric patients with carbon dioxide laser.

AIM: Warts are difficult to treat and none of the several modes of treatment suggested for their cure has been proven to be the most effective. We evaluated the efficacy of a modification of the CO (2) laser technique for recalcitrant warts in pediatric patients. PATIENTS AND METHODS: During a period of 5 years, 40 consecutive pediatric patients (average age: 12.7 +/- 2.8 years) were treated by CO (2) laser for 54 recalcitrant warts. Previous treatments were caustic and/or surgical procedures (average 2.7 procedures). Local anesthesia or digital block was performed in all patients, with intravenous sedation in two patients. The laser was used at 5 W in super-pulse mode throughout the procedure. The skin was cut with the focused laser beam in a circular fashion, about 5 mm around the wart, until all the layers of the skin down to the subcutaneous tissue were penetrated. The lesion was drawn aside and excised, using the laser beam as a scalpel. No curettage was used. The base of the wart was then vaporized with the laser in a defocused fashion, until a clean surgical field was obtained. Follow-up was weekly up to 1 month, and at 3, 6, and 12 months. RESULTS: Warts were located on fingers (24 cases), in the plantar area (10 cases), on hands (9 cases), knees, and legs (4 cases each), arms (2 cases) and elbow (1 case). Twenty-seven patients (67.5 %) had a solitary wart and the other 13 children had multiple warts (up to 6) at one or more locations. Fingers were the most common location of multiple warts (10 cases). All patients underwent the procedure in one session. No case of intractable operative bleeding, local infection, or prolonged exudative drainage was encountered. One patient complained of severe transient postoperative pain. The healing time was 4 to 5 weeks. At 12 months, there was no recurrence of the warts. No significant or disabling scarring was noticed, but hypopigmentation was noted in 11 cases (27.5 %). CONCLUSION: This technique provides a high success rate with minimal side effects and is well tolerated by young patients.

Pleuro-pulmonary involvement in children with blunt splenic trauma.

OBJECTIVE: Evaluation of the importance of pleuro-pulmonary involvement in paediatric patients with blunt splenic trauma. METHOD: A retrospective chart review of 27 patients, aged 2-16 years, treated for blunt splenic injury between 1992 and 1999 was performed. RESULTS: All patients except one were treated conservatively. In 12 patients (44.4%) left-sided pleuro-pulmonary involvement was diagnosed as primary traumatic injury or as a late complication. While Grade I and II splenic injuries were prevalent, pleuro-pulmonary involvement patients had a more severe degree of splenic injury. Chest pain, dyspnoea and diminished respiratory sounds were present on primary examination in patients with chest trauma. Body temperature during the first 5 post-trauma days was significantly higher among pleuro-pulmonary involvement patients. Specific pleuro-pulmonary involvement diagnoses on admission in six children with primary chest trauma were: lung contusion, pleural thickness, or haemo-pneumothorax. Three of them developed delayed pleural effusion. In the other six children with pleuro-pulmonary involvement, late complications appeared during 2-5 days post-trauma. CONCLUSIONS: Pleuro-pulmonary involvement was observed in almost half of patients with blunt splenic trauma. Pleuro-pulmonary involvement occurred either early as a result of direct chest trauma or was delayed. High suspicion, careful monitoring of body temperature and repeated chest X-ray studies are recommended for early diagnosis and treatment of delayed pleuro-pulmonary involvement.

Excision with primary closure and suction drainage for pilonidal sinus in adolescent patients.

Controversy persists regarding the treatment of pilonidal sinus (PS). To evaluate the efficacy of excision with primary closure and closed-suction drainage in adolescent patients, between 1990 and 1999, 34 consecutive patients aged 13-18 years (mean 16.4) underwent PS excision with primary closure and suction drainage. Anesthesia was general in 16 (47%) and spinal in 18 (53%) with a statistical age difference ( P< 0.001) (15.5 vs 17.2 years, respectively). No complications due to the anesthetic were observed. Twenty-one patients (61.8%) had day-case surgery while the others were hospitalized for 2 to 4 days (average 2.3 days). The drain was removed on postoperative day 2 to 6 (average 2.2). Primary healing with no postoperative complications occurred in 30 patients (88.2%); 1 underwent partial opening of the wound because of rupture of the drainage tube during its removal. Postoperative infections requiring incision, drainage, and lay-open occurred in 3 cases (9.1%). No recurrence was found at 12-month follow-up. One recurrence (2.9%) was noted 3 years after surgery. Excision with primary closure and closed-suction drainage as an ambulatory procedure is thus a simple and effective method of treatment of uncomplicated PS in adolescents.

EMLA cream prior to digital nerve block for ingrown nail surgery does not reduce pain at injection of anesthetic solution.

BACKGROUND: Needle penetration and local anesthetic infiltration are painful steps of digital ring block. The objective of this study was to evaluate the efficacy of EMLA cream application prior to digital ring block for surgery for ingrown big toenail. METHODS: We conducted a prospective, double-blinded, placebo-controlled, randomized clinical trial with 81 patients (range: 12-75 years, mean +/- SD: 30.3 +/- 17.5 years), who underwent big toenail surgery. Prior to the digital block, EMLA cream (Group E) or a placebo cream (Group P) was applied. A visual analog scale (VAS) and a verbal rating score (VRS) from 1 to 10, 10 being most severe pain, were used for assessment of pain during the skin needle penetration and during the infiltration of the anesthetic product. RESULTS: Data of the VAS and of the VRS during the two steps, respectively, show no significant difference in pain rating between the two groups. In Group E, the gender of the patients had a significant effect on pain perception. Male patients reported less pain than female patients, both during the needle skin penetration and during the infiltration step (P < 0.005). In Group P, reported pain did not differ by gender in either step of the procedure. CONCLUSIONS: We found no clinical benefit in using EMLA during digital nerve block. Although the digital nerves are not deeply located in the small subcutaneous space of the digit, topical anesthesia may not reach them. Moreover, swelling due to injection of the anesthetic product in this small space may also amplify the sensation of pain.

Intravenous fluids warming by mattress is simple and efficient during pediatric surgery.

BACKGROUND/AIM: Temperature control is essential during pediatric surgery. The effectiveness of two methods of warming intravenous (i.v.) fluids to preserve normothermia was compared during abdominal surgery. METHODS: Intraoperative core temperature (CT) was measured in 59 children, 8 years of age and younger. Patients were randomly allocated to two study groups according to the method of fluids warming. In Group M (n = 30), fluids were warmed by placing the i.v. tubing under a warming mattress, and in Group T (n = 29), by using an active i.v. fluid tube warming system. Observations of CT, infusion fluid temperature (IFT) at the entry to the patient and other relevant parameters were made at 30-min intervals throughout the surgical procedure. RESULTS: The two groups did not differ significantly by age, gender, body weight or length of surgical procedure. Although baseline IFT was significantly lower in Group M than in Group T (33.8 degrees C vs. 35.1 degrees C), it increased during the procedure by 1.2 degrees C in Group M compared to a 0.2 degrees C increase in Group T. Baseline CT was also lower by 0.5 degrees C in Group M compared to Group T (NS), but CT increased in Group M by 1.0 degrees C compared to 0.2 degrees C in Group T, resulting in similar final CTs. CONCLUSIONS: The increase in CT was more pronounced in patients where fluids were warmed under the warming mattress (Group M) than in those with fluids warmed by a coil warming device (Group T). The elevation in CT seen in Group M is associated with an increase in infusion fluid temperature at the line just before the i.v. cannula. Both methods of fluid warming (by placing the i.v. tubing under warming mattress and by using a fluid warming system) effectively preserved normothermia during abdominal surgery in children.

Epididymitis in childhood: a clinical retrospective study over 5 years.

BACKGROUND: Acute scrotal pain in children presents a major diagnostic and therapeutic challenge. Epididymitis has been considered uncommon in childhood. The clinical spectrum and therapeutic policy of the acute scrotum in children is continually being reassessed. OBJECTIVES: To determine whether there has been an increase in the incidence of epididymitis in children and to advocate a more selective surgical approach to the acute scrotum. METHODS: We conducted a retrospective review of 65 children admitted to our department of pediatric surgery with the diagnosis of acute scrotum during a 5 year period. RESULTS: Of the 65 children admitted with the diagnosis of acute scrotum, epididymitis was diagnosed in 42 (64.6%). The remaining cases included torsion of the testis in 12 patients (18.5%), torsion of the appendix testis in 5 (7.7%), scrotal pain and minimal physical findings in 4 (6.1%), and scrotal hematoma and idiopathic scrotal edema in one patient each. Doppler ultrasound of the groin, color Doppler ultrasound of the testis and testicular nuclide scintigraphy (Tc-99m scan) examinations were performed on 49, 30 and 57 occasions, respectively; the Tc-99m scan was the most effective tool. All the patients with epididymitis were diagnosed before surgical intervention and were treated conservatively. CONCLUSIONS: We observed an increasing frequency of epididymitis in children admitted with the diagnosis of acute scrotum.

Hiatal hernia in pediatric gastroesophageal reflux.

BACKGROUND: This study compares esophageal pH-monitoring parameters of children with gastroesophageal reflux (GER) with or without hiatal hernia (HH) and determines the outcome of those with GER and HH. METHODS: Among 718 children with GER, 45 children (6%) with associated HH were retrospectively studied. They were divided into those with neurologically normal development (NN, n = 35) and those with neurologic disorders (ND, n = 10). The pH-monitoring parameters of 27 of these (60%) were compared with pH-monitoring parameters of 27 control children who had GER without HH. RESULTS: Esophageal clearance was longer in patients with HH compared with those without HH (P < 0.05). All 35 NN patients underwent a trial of conservative treatment, which failed in 9 patients (25.7%). Surgery was the initial treatment in 8 ND patients. Follow-up was available in 20 NN and 10 ND patients. Nine of 11 conservatively treated NN patients improved. All NN (n = 9) and ND (n = 8) patients who underwent surgery improved. Conservative treatment failed in 2 NN and in 2 ND patients. CONCLUSIONS: Presence of HH in children with GER is associated with prolonged exposure of the esophagus to acid and a high failure rate of nonoperative treatment. However, medical treatment should be tried in NN children despite the significant failure rate.

An outbreak of echovirus 11 in a children's home.

An outbreak of echovirus 11 infection was observed in a children's home that housed 16 children. Nine children younger than 1 year shared a large room on the first floor, which contained a large basin. Three of them presented with aseptic meningitis with CSF and stool samples positive for echovirus 11. The other six infants who shared the room were asymptomatic but their stools were positive for echovirus 11. Seven infants aged 1-2 years stayed on the second floor and were asymptomatic. One of them had positive stool culture for echovirus 11. No virus was isolated from stool samples taken from the 26 staff members. However, serology was suggestive for recent echovirus 11 infection in seven asymptomatic staff members. All seven worked either exclusively on the first floor or alternately on both floors. Our survey demonstrated that echovirus 11 may spread very efficiently in children's homes. The rate of meningitis in the infected infants was 30% while all the recently infected adults were asymptomatic.

Phenotypic pattern of B cells in the appendix: reduced intensity of CD19 expression.

UNLABELLED: The lymphoid tissue of the appendix is considered as part of the gut-associated lymphoid tissue (GALT). In order to understand better the immunological significance of the appendix we analyzed the cellular composition of normal and inflamed human appendix tissue by flow cytometer with special attention to expression of the CD19 and CD5 markers on B cells. Cellular analysis was also performed on peripheral and appendical vein blood samples as well as on omentum and peritoneal fluid samples. The study population included seventeen patients aged 2-15 yr. (mean age - 11.5 yr.) undergoing appendectomy. Ten children were diagnosed with acute appendicitis while 7 had a normal appendix. RESULTS: Compared to the peripheral blood, the appendix contained a significantly higher percentage of CD19 cells (47.6% of total lymphocytes versus 15%, p<0.0001), and B1 cells (4.98% of total lymphocytes versus 2.42%, p=0.001). In addition, the intensity of CD19-staining was markedly decreased in the appendix (mean - 395.7), and also in the omentum (mean - 398.2) as compared to peripheral lymphocytes (mean - 497.7, p<0.0001 for both comparison). Comparison between the inflamed and the non-inflamed appendices revealed that the inflamed appendix contained a significantly higher proportion of B1 cells (5.64% of total lymphocytes versus 3.53%, p=0.032), and also a higher B1/b cell ratio (0.13 vs. 0.07, p=0.01). CONCLUSIONS: These results indicate that the appendix tissue contains higher number of B1 (and B) cells compared to the peripheral blood and that these cells play a role in the primary immune response to acute infection/inflammation in the appendix. Appendiceal B cell population is unique in term of CD19 intensity expression on their surface.

Does the size of nasogastric tubes affect gastroesophageal reflux in children?

BACKGROUND: To evaluate the effects of nasogastric tube insertion and different nasogastric tube sizes on gastroesophageal reflux in children. METHODS: During a prospective randomized study, 29 patients aged 1 month to 4 years (median, 9 months) underwent 24 hours of continuous esophageal pH monitoring to rule out gastroesophageal reflux as the cause of severe pulmonary problems. Each patient was monitored without nasogastric tube for 16 hours (baseline), and thereafter the first nasogastric tube, small (8-Fr) or large (10-Fr or 12-Fr), was placed. Four hours later, the original nasogastric tube was replaced by a new one of large (instead of small) size or of small (instead of large) size. We selected the times of wakefulness in these study periods and compared the number of reflux episodes (NREs), the number of reflux episodes that lasted more than 5 minutes (NRE>5), and the percentage of time with esophageal pH less than 4 (PTP<4). RESULTS: The 12-Fr group in comparison with the 8-Fr group and baseline showed significant difference (P<0.05) in the NRE>5 and PTP<4 parameters. No significant differences were found when comparing 8-Fr versus 10-Fr groups and baseline. In children with (n = 20) and without (n = 9) gastroesophageal reflux, comparison of the various reflux parameters between baseline and the different sizes of nasogastric tubes showed the same results. CONCLUSIONS: Size of the nasogastric tubes is a significant factor in predisposing the child to gastroesophageal reflux. Large nasogastric tubes interfere with the clearance of the refluxed acid from the esophagus.

Unusual presentation of esophageal communicating duplication in a child.

Communicating esophageal duplication and true congenital esophageal diverticulum are entities rarely encountered during childhood. The authors report an unusual case of midesophageal communicating duplication with secondary upper esophageal obstruction.

Alkalinizing local anesthetic does not decrease pain during injection for dorsal penile nerve block.

STUDY OBJECTIVE: To evaluate whether alkalizing local anesthetic with sodium bicarbonate reduces pain related to infiltration of local anesthetic during dorsal penile nerve block for circumcision. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: E. Wolfson Medical Center, Holon, Israel. PATIENTS: 144 patients aged 15 to 54 years (mean +/- SD = 22.7 +/- 8.8 years), randomized before the block into four groups of 36 patients each. INTERVENTIONS: Group A (control) received a standard solution of 1 mg/kg lidocaine 2% mixed with 0.5 mg/kg bupivacaine 0.5% without epinephrine (pH = 6.3). Patients in Group B, Group C, and Group D received this mixture added with 8.4% sodium bicarbonate for a mean final pH of 6.90, 7.16, and 7.43, respectively. Penile block was performed using a 23-gauge needle by an anesthetist who was blinded to the pH of the solution. MEASUREMENTS AND MAIN RESULTS: Patients were questioned regarding pain suffered during injection of the anesthetic solutions by another physicians who also was blinded to the drug used. Pain was rated by a previously reported subjective pain scale. Mean pain scales were 2.0 +/- 0.17, 2.3 +/- 0.15, 2.2 +/- 0.16, and 1.94 +/- 0.15 for Groups A to D, respectively. The differences between these results were not statistically significant. CONCLUSION: Alkalinizing the acidic local anesthetic solution by sodium bicarbonate does not decrease pain related to infiltration during penile nerve block for circumcision.

Slow injection of local anaesthetic will decrease pain during dorsal penile nerve block.

PURPOSE: To evaluate whether a very slow injection of local anaesthetics during dorsal penile nerve block for circumcision causes less pain than a more rapid injection. METHODS: In a prospective, double-blind, randomized study, 75 patients aged 15 to 53 yr (mean +/- SD = 22 +/- 8.4 yr) were randomized into two groups. A solution of 2% lidocaine, 1 mg.kg-1, and 0.5% bupivacaine, 0.5 mg.kg-1 without epinephrine to a maximum dose of 10 ml was injected using either a very slow rate (injection time 100 to 150 s, Group A) or a faster rate (injection time 40 to 80 s, Group B). Patients were questioned regarding pain by a physician who was blinded to the mode of therapy. Pain was rated as 1) mild (negligible), 2) moderate (non-negligible, but easily endurable), 3) intense (but endurable) and 4) total refusal to continue. RESULTS: A significant pain score difference was found between Groups A and B (median = 1 vs. 2, P = 0.0006) as well as a significant correlation between pain score and the rate of infiltration (rs = -0.394, P < 0.0001). CONCLUSIONS: Slow injection is an important factor in reducing pain during penile block.

Intussusception in children: reduction with repeated, delayed air enema.

PURPOSE: To evaluate the efficacy of pneumatic reduction of intussusception with an emphasis on repeated, delayed trials. MATERIALS AND METHODS: Seventy-one patients with intussusception were treated with air enemas. Before 1993, one trial of air reduction was performed; since 1993, up to three trials of air reduction were performed. The patients were categorized according to the duration of signs and symptoms: less than 12 hours (group A), 12-24 hours (group B), and longer than 24 hours (group C). RESULTS: The success rate for air reduction was 83% overall (59 of 71 patients), 89% in group A (25 of 28 patients), 83% in group B (20 of 24 patients), and 74% in group C (14 of 19 patients). The success rate was 70% (19 of 27 patients) before 1993 and 91% (40 of 44 patients) since 1993 (P < .05). When patients in whom air reduction was successful were compared with patients in whom it was unsuccessful, there was a statistically significant difference in radiographic signs of intestinal obstruction and duration of signs and symptoms but no important difference in age or rectal bleeding. There were no episodes of complications. CONCLUSION: Repeated, delayed pneumatic reduction of intussusception improves the outcome.

Efficacy of EMLA cream prior to dorsal penile nerve block for circumcision in children.

BACKGROUND: While circumcision may be performed solely with dorsal penile nerve block (DPNB), some painful steps in its use are skin needle penetration and infiltration of the anesthetic product. The objective of this study was to evaluate the efficacy of EMLA cream, prior to DPNB for circumcision in children. METHODS: We conducted a prospective, randomized, double-blinded, placebo-controlled study with 42 children undergoing circumcision with DPNB alone, as an ambulatory procedure. Overall efficacy of EMLA cream (Group A) during needle penetration and infiltration was assessed using a visual analog scale, compared with a placebo cream (Group B). Patients were asked to orally report any pain during skin needle penetration and infiltration of anesthetic, and were graded from 1 to 4 according to intensity of pain, as 1) none, 2) slight, 3) moderate, or 4) severe. The child graded the global discomfort of the entire procedure using the visual analog scale. RESULTS: When assessing needle penetration, none from Group A suffered any pain, whereas all from Group B suffered at least mild pain. Considering infiltration of the anesthetic, all children suffered at least slight-to-moderate pain. Based on the children's visual analog scale scores, EMLA cream has no beneficial effect for penile block. CONCLUSION: Since the dorsal penile nerves are located under the Buck's fascia, topical anesthesia may not reach them and other techniques may be necessary to anesthetize them. We found that although EMLA cream is efficient as a topical anesthesia during needle penetration for DPNB, it has no beneficial effect during infiltration.

Comparative periurethral bacteriology of uncircumcised and circumcised males.

BACKGROUND: It has been established that lack of circumcision increases the risk of urinary tract infection in infants. During the first six months, the presence of foreskin is associated with a greater quantity and a higher concentration of uropathogens in the periurethral area. Very little is known about this association in older males. OBJECTIVE: To compare the periurethral bacteriology of uncircumcised healthy males of more than one year of age. METHODS: The periurethral area of 125 uncircumcised and 46 circumcised healthy males (mean age, 26.5 and 28.3 years, respectively) was swabbed and cultured for facultative and anaerobic bacteria, genital mycoplasmas and Chlamydia trachomatis. RESULTS: Facultative Gram positive cocci predominated in both groups (62% and 80%, respectively). Pure culture of facultative Gram negative rods was more common in uncircumcised males (17% v 4% in circumcised males, p = 0.01). Streptococci, strict anaerobes and genital mycoplasmas were found almost exclusively in uncircumcised males of more than 15 years of age. No case of C trachomatis was identified. CONCLUSIONS: The higher prevalence of potential uropathogens in the subpreputial space is in accordance with a previous finding of increased risk of urinary tract infection in uncircumcised young men. Our results also support the role of the prepuce as a reservoir for sexually transmitted organisms.