CIRCUMCISION : HOW WE DO IT?

Circumcision means removal of the foreskin of the penis.

 

 

Indications:

 

It is medically indicated in recurrent balanoprosthitis, phimosis,recurrent UTIs.It is also done in cases of paraphimosis.

Circumcision is also done in cases of early carcinoma penis confined to the prepuce.

 

Religious indications:

 

It has been a religious custom in Islam, Judaism, Coptic Christians. Its also practiced as a religious rite  by the people of Ethiopian Orthodox church.

This procedure has been accepted and practiced in large parts of America, South East Asia and African countries.

 

 

Advantages of performing circumcision:

 

Circumcision has been found to reduce incidence of HIV( Cochrane meta-analysis 2009--- 38-66%), HPV( ONCOGENIC), HSV( reduction of the risk by 28%).It also gives protection from penile cancers and UTIs.

 

Side effects and complications of the circumcision:

 

Although bleeding, hematoma and infection are post-operative complications as such they resolve over a period of time.

The most common side effect is either too much removal of the skin or too less removal of the skin. Sometimes needing revision circumcision. The skin if not removed uniformly ; it can give a ragged appearance leading to psychological embarrassment. We  get many patients coming for revision as they feel the skin has been removed not uniformly.  

 

There are many advantages of the circumcision but as such the advantages are modest so there is no consensus amongst various medical organizations regarding  routine circumcision in all neonates. The pain , bleeding  etc. is  also  a concern. There are ethical and legal implications also.

 

 

Can we avoid circumcision:

 

Many a times tight foreskin may not need circumcision. The couple can enjoy the sexual activity with using lubricants.

Balanoprosthitis can be treated with antibiotics and local antibiotic and steroid creams and the patient can be taught about penile hygiene by washing the area regularly. The foreskin should be retracted fully and the glans should be cleaned and all collected secretions( smegma) should be removed.

Children below 3 years have prepucial adhesions so they can be treated with 3% hydrocortisone cream and regular retraction of the prepuce. Most of the cases resolve and the foreskin becomes supple.

In refractory cases; circumcision should be advised.

 

Alternatives for circumcision:

Many people are averse top loosing their foreskin. In these cases if alternative procedure like dorsal slit or frenuloplasty ( as per the indications and suitability) can be done.

DORSAL SLIT : A GOOD PROCEDURE IN EMERGENCY  AND IN CASES OF PARAPHIMOSIS

FRENULOPLASTY A PROCEDURE TO RELEASE THE FRENULUM BREVE ( PHIMOSIS BECAUSE OF TIGHT FRENULUM)

How we do the circumcision:

We lay a special emphasis on patient comfort and appearance post operatively. We do the surgery on day care basis.We call the patient in the morning on empty stomach and administer prophylactic broad spectrum antibiotic before the procedure.
The procedure is done under sedation and penile block. The procedure takes around 20 minutes to complete.

We mark two circumferential incisions ...one at corona when the prepuce is covering the glans and the other around 10 mm from the corona   after retracting the foreskin fully.
Then the foreskin is kept retracted and the marked sleeve ( the part of the skin in between the incisions) is removed.
The incision site can vary as per the surgeons experience (depending upon how much loose or tight he wants to make the penile skin) .

We keep a loose bandage on the circumcision wound and call the patient after 48 hours. We then remove the dressing and ask the patient to apply antibiotic cream over the wound.
We allow the patient to resume his normal activities after the surgery but coitus / sexual acts only after a   month till the wound completely heals.