Tuesday 11 December 2018

Dear Dr Nina: 'I am at the end of my tether with my daughter. She constantly complains of an itch in her privates'

Psychological distress often manifests as physical, so it is worth getting checked out
Dr Nina Byrnes
Circumcision only takes a few minutes in a newborn

Nina Byrnes

Question: I am at the end of my tether with my 16-year-old daughter. She constantly complains of an itch in her privates and says she is in agony with it. I have brought her to her GP, who treated her for thrush, even though she said it didn't look like she had anything, but did it as a precaution. When that didn't make a difference, the GP referred her to a gynaecologist who had a look and also found nothing amiss. She has not been sexually active, so there is no risk of an STD. I am starting to think she is either imagining it or that it is a result of anxiety, as her GP suggested. Do you think this could be the case? Can anxiety manifest like this?

Dr Nina replies:  Vulvovaginitis is a condition that causes irritation and itch of the vagina or the skin near the entrance (the vulva). This condition is very common in young girls, most commonly occurring before puberty, but can persist in some. Moisture and dampness of the skin can irritate or make it easier for infection to take hold. Wearing tight non-cotton underwear or clothes can make irritation here more likely. Lastly the use of soaps and bubble baths can irritate the sensitive skin in this area. This condition is more common in girls who are overweight. Dry skin conditions such as eczema or psoriasis can also affect vulval skin.

Threadworm can cause similar irritation. If causes such as thrush or gynaecological issues are ruled out it is worth considering. Threadworm infection occurs when the eggs are ingested through contact with infected hands, surfaces or food. The eggs hatch in the small intestine and then mature and travel as adult worms to the large intestine, where they mate. About one to two months later the female adults travel to the anal area where they lay their eggs, mainly at night, and then die. Symptoms commonly occur due to the eggs irritating the anal area causing itching, especially at night. This leads to scratching. Eggs then transfer to hands and nails and can be ingested again, leading to further worm infection. Eggs can live on any surface for up to 20 days.

Those with vulvovaginitis usually complain of itch or redness and irritation. There may be some discharge visible in underwear and they may also complain of stinging or burning when passing urine.

Medical intervention is rarely required. Your GP may take a swab. If a bacterial infection is found, a 10-day course of antibiotics may be prescribed.

It is important to remind your daughter about genital hygiene. Always wipe from the front to the back. Avoid wearing restrictive clothing or tights. Loose cotton underwear is best as it allows skin to breathe. It may be necessary to change underwear during the day to ensure it stays clean and fresh. Wearing a nightdress and no underwear at night can also help in some cases. Soaking in a bath twice a day may help, but avoid using perfumed soaps and washes.

A gentle emollient or wash designed for those with eczema or sensitive skin is best. Applying a simple aqueous-based cream or one used for nappy rash may also help soothe the area. If itch is unremitting, I would suggest a dermatologist opinion next.

If all physical causes have been out ruled then addressing any underlying anxiety is important. Psychological distress often manifests as physical complaints in children and teenagers. Abdominal pain and headaches would be the most common symptoms, but skin issues can occur.

 

What are the risks? My husband wants to have our son circumcised straight after he is born

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Circumcision only takes a few minutes in a newborn
 

Q My husband wants to have our son circumcised immediately after he is born. There is no medical or religious reason for this, but my husband remembers having it done when he was around 10 and doesn’t want his son to go through the same thing. What are the risks with circumcising a baby? Would it be better to wait and see if it is necessary?

Dr Nina replies: Circumcision is the surgical removal of the foreskin, which is the skin covering the tip of the penis. It is a practice that has been around for a long time and is done for cultural and religious reasons in many countries and societies. Religious circumcision is often done a few days after birth. In certain faiths it is performed by a cleric as part of a religious ceremony. Those of Jewish and Muslim faiths tend to request circumcision on cultural grounds.

The procedure only takes a few minutes in a newborn, but can take much longer in older children and adults. Complications of the procedure are more common in older age groups. Circumcision is not essential. In the majority of boys the foreskin becomes easier to retract as the child starts to grow and in most it is fully retractile by the age of four or five. It is important to be able to fully retract the foreskin as if this doesn’t happen bacteria and adhesions can build up leading to recurrent infection and pain. The penis may be noted to balloon when passing urine and there may be a build-up of pus or discharge under the foreskin leading to odour and irritating the skin below.

Medical circumcision is required in older boys and men who develop an adherent foreskin or in those with recurrent infections. It is true that recovery takes longer in those who are older and post-operative pain and discomfort can be more pronounced.

The issue of purely elective circumcision is controversial. Advocates would argue that is can reduce the risk of penile infection, makes it more difficult to contract HIV and other STDs and may reduce the risk of developing penile cancer. Those who are against would argue that it is a surgical procedure that carries a risk of infection, bleeding and penile injury. If a general anaesthetic is required, this also carries some risk. If the procedure is performed, it should be done by a properly-trained and licensed surgeon in a clinical setting.

Your husband obviously had a difficult experience, but if your son is otherwise well and doesn’t appear to have any issues with his foreskin, there really is no indication to put him through a surgical procedure. Most public hospitals and many insurance companies will not arrange or cover cultural or unnecessary circumcision, so there is a cost implication if you decide to proceed.

Perhaps start by addressing your husband’s concerns and discussing them with a trusted family doctor.

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