 Phimosis

 Paraphimosis
 Balanitis or posthitis
 Other indications
Management of recurrent urinary tract infections
Reduce risk of penile cancer
Religious/cultural reasons
 Condition in which the distal prepuce cannot be retracted over the
glans penis
 In infants, toddlers and preschool children, the foreskin may appear
tight and nonretractable with thin adhesions to the glans. This
situation persists until progressive keratinization of the epithelial
layers occurs between the glans and the inner prepuce dislodges the
foreskin from the glans. This is known as physiologic phimosis
 Severe phimosis in the young age groups is rare and can be
demonstrated by bulging of the foreskin during micturition.
 A person with true phimosis may have pain during sexual activity.
 Acquired phimosis occurs as a result of poor hygiene, chronic
balanitis, or repetitive forceful retraction of the foreskin, which
eventually leads to the formation of a fibrotic ring of tissue close to
the opening of the prepuce which prevents retraction to expose the
glans
 without proper hygiene, the individual is at risk for chronic skin
irritations, yeast infections, balanitis, posthitis, and the forceful
retraction of the foreskin may result in paraphimosis.
 Betamethasone cream 0.05% two to three times a day applied to the
tip of the foreskin and the area touching the glans for 3 months is
often effective.
 If conservative measures are ineffective, circumcision is the
preferred surgical option.
 Paraphimosis is entrapment of the foreskin in the retracted
position; it is a medical emergency.
 If not treated promptly, it can result in venous engorgement and
edema of the glans and foreskin which, over time, progresses to
arterial occlusion with its ensuing risk of ischemic loss of portions or
of the entire glans
 Paraphimosis can result when parents or caregivers forcibly retract
the foreskin to clean the penis or attempt catheterization and do not
return the foreskin to its original position.
 Edema, tenderness, and erythema of the glans are seen, along with
edema of the distal foreskin and flaccidity of the penile shaft
proximal to the areas of paraphimosis.
 Firm circumferential compression of the glans with the
hand may relieve edema sufficiently to allow the foreskin to
be restored to its normal position.
 If this technique is ineffective, a dorsal slit done using a
local anesthetic relieves the condition temporarily.
 Circumcision is then done when edema has resolved.
 Posthitis is an infection of the prepuce, whereas balanitis is
an infection of the glans penis.
 In posthitis, signs and symptoms include erythema,
swelling, warmth, and tenderness of the foreskin.
 In balanitis, erythema, swelling, warmth, and tenderness
are noted in the glans penis.
 A foul-smelling, thin, seropurulent exudate may be evident.
 Balanitis, posthitis, or both may be the result of poor
hygiene
 prematurity,
 anomalies of the penis (eg, chordee, or curvature of the
penis),
 hypospadias,
 epispadias,
 concealed or buried penis,
 Micropenis
 Ambiguous genitalia
 Beleeding: may occur along the skin edges between sutures or from
a discrete blood vessel, most commonly at the frenulum
 Infection: Due to the superb dual blood supply of the penis, wound
infection occurs infrequently
 Loss of skin/ wound dehiscence
 Redundant foreskin
 Preputial adhesions (children): Preputial adhesions often result from
either inadequate lysis of natural adhesions prior to circumcision or
from distal migration of the skin from a prominent suprapubic fat pad
 Urethrocutaneous fistula
Preputial adhesions following
circumcision
 Advantages:  Disadvantages:
 Can be learned by surgeons/surgical  Leaves 0.5–1.0 cm of mucosal skin
assistants who are relatively new to proximal to corona
surgery  Cosmetic effect may be less
 Ideal for use in a clinic with limited satisfactory
resources
 Can be done without a surgical
assistant
Step 1: Skin preparation, draping and anaesthesia (as previously
described)
Step 2: Retraction of foreskin and separation of any adhesions
This step is common to all the methods of circumcision.
With the foreskin in a natural “resting” position, indicate
the intended line of the incision with a marker pen. The
line should correspond with the corona, just under the
head of the penis.
 Some uncircumcised men have a
very lax foreskin, which is
partially retracted in the resting
position.
 In such cases, it is better to apply
artery forceps at the 3 and 9
o’clock positions, to apply a little
tension to the foreskin before
marking the circumcision line.
 It is important not to pull the
foreskin too hard before marking
the line, as this will result in too
much skin being removed.
Grasp the foreskin at the 3 and 9
o’clock positions with two artery
forceps, on the natural apex of the
foreskin in such a way as to put equal
tension on the inside and outside
surfaces of the foreskin.
Put sufficient tension on the foreskin to pull the previously made mark
to just below the glans. Taking care not to catch the glans, apply a long
straight forceps across the foreskin just proximal to the mark. Once the
forceps is in position, feel the glans to check that it has not been
accidentally caught in the forceps.
Using a scalpel, cut away the foreskin flush with the outer
aspect of the forceps. The forceps protects the glans from
injury, but nevertheless particular care is needed at this
stage.
Grasp and trim any skin tags on the inner edge of the foreskin to
leave approximately 5 mm of skin proximal to the corona. Care
must be taken to trim only the skin and not to cut deeper tissue.
FORCEPS GUIDED METHOD: STEP 8
Stopping the bleeding:
 Pull back the skin to expose the raw area.
 Identify bleeding vessels and clip with
artery forceps as accurately as possible.
 Tie each vessel or under-run with catgut and
tie off. Take care not to place haemostatic
stitches too deeply.
 When dealing with bleeding in the frenular
area, care must be taken not to injure the
urethra.
Vessels may be occluded by ligation (A), or
by transfixion sutures (B)

B
 Stopping the bleeding: Cut blood vessels should be located
accurately and tied or transfixed.

1. Using forceps (tweezers), 2. The blood vessel is then held with 3. The artery forceps is then
the blood vessel is the forceps and gently pulled up so applied, taking the minimum
located. that an artery forceps can be applied. amount of extra tissue.
Blood vessels should be accurately clipped with artery forceps, taking care to avoid taking
too big a chunk of tissue. If it is difficult to see the source of bleeding, apply pressure with a
swab and wait for 2–3 minutes and usually the bleeding vessel can then be occluded
accurately.
 a b c

Horizontal mattress suture at the frenulum (6 o’clock). Vertical mattress

sutures at 9, 12 and 3 o’clock and simple sutures between these.
Place a horizontal mattress suture at the frenulum. When
placing the horizontal mattress suture at 6 o’clock
position, take care to align the midline skin raphe with the
line of the frenulum (see below). A common error is to
misalign the midline and raphe, which results in
misalignment of the whole circumcision closure.
Place a vertical mattress suture at the 12 o’clock position.
The suture should be placed so that there is an equal amount
of skin on each side of the penis between the 12 and 6
o’clock positions. Place two further vertical mattress
stitches in the 3 o’clock and 9 o’clock positions.
After placement of the sutures at 6,12,
3 and
9 o’clock, place two or more simple
sutures in the gaps between.
FORCEPS GUIDED METHOD
 Final outcome:

Note residual mucosal portion of the foreskin

Once the procedure is finished, check for
bleeding and apply a dressing
(described later).
 Provides best cosmetic results
 More room for surgical error
 The technique requires an assistant
 The sleeve resection method requires good surgical
skill
 Better suited to a hospital rather than a clinic setting
Step 1: Skin preparation, draping and
anaesthesia
Step 2: Retraction of foreskin and
separation of any adhesions
 SLEEVE RESECTION METHOD:
STEP 3—MARKING THE OUTER LINE
Mark the line of the outside
cut, just below the corona
Mark the intended outer line of the
incision with a V- shape, pointed
towards the frenulum, on the
underside of the penis

The apex of the V should

correspond with the midline raphe

Note “V” shape pointing towards frenulum

SLEEVE RESECTION METHOD: STEP 4—
MARKING THE INNER MUCOSAL LINE
Retract the foreskin and mark the inner (mucosal)
incision line 1–2 mm proximal to the corona. At the
frenulum, the incision line crosses horizontally as shown by
the arrow.
SLEEVE RESECTION METHOD: STEP 5
Using a scalpel, make incisions along the marked lines,
taking care to cut through the skin to the subcutaneous tissue
but not deeper. During the incision, the assistant retracts the
skin with a moist gauze swab.
Make the inner
incision

Outer and inner

incision
completed
SLEEVE RESECTION METHOD: STEP 6
Cut the skin between the proximal and distal
incisions with scissors.
SLEEVE RESECTION METHOD: STEP 7
Hold the sleeve of foreskin under tension with two artery
forceps and dissect the skin from the shaft of the penis, using
dissection scissors. Tie off any bleeding vessels with under-
running sutures.
Step 8: Haemostasis and suturing are the same
as described for the forceps guided method.
Step 9: Suturing the circumcision is the same as
described for the forceps guided method.
Step 10: Check for bleeding, and provided
there is none, apply a dressing as described
later.
APPLYING THE PENILE DRESSING
 Irrespective of the method of circumcision, a standard
penile dressing technique is used:
 Check that there is no bleeding.
 Once all bleeding has stopped, place a piece of
petroleum-jelly-impregnated gauze (tulle gras) around
the wound.
 Apply a sterile, dry gauze over this, and secure it in
position with adhesive tape.
 Take care not to apply the dressing too tightly.
REMOVING THE PENILE DRESSING
 The dressing should be left in position no longer
than 48 hours.
 If the dressing has dried out, it should be gently
dabbed with antiseptic solution (aqueous cetrimide,
Savlon) until it softens.
 It can then be removed gently. It is important not to
disrupt the wound by pulling at a dressing that
has dried to the wound.