Phimosis – Circumcision - Preputial Adhesions

DEFINITION

It is a condition where, in men, the foreskin cannot be fully retracted over the glans penis (the head of the penis).

 

IN GENERAL

The glans penis is covered by a tube of skin called the foreskin. The foreskin is a double face tube, its surface on the outside consists of normal skin while the inside, actually in contact with the glans penis is a mucocutaneous tissue. This part of the tissue secretes a white fluid called the smegma which lubricates the foreskin.

Naturally, the foreskin covers the entire glans penis and protrudes for 1 to 2 cm.

The foreskin tube’s diameter must always be more significant than the glans penis’s one. This must be the case when the penis is flaccid as well as when it is erected, in order for the glans penis to be easily unveiled. If the glans penis fails to effortlessly unveil then a man feels pain during sexual intercourse and there is risk of traumatism.

It is common, after a boy is born, for his foreskin to be stuck to his glans penis through natural preputial adhesions. Parents often refer to this situation as phimosis, which is wrong. Preputial adhesions, in order not to lead to phimosis, must be separated with the doctor’s help and using anesthetic cream topically before the child reaches its first year of age. The use of a cortisone based cream before this separation can be necessary in order to loosen up the foreskin’s ring.

It is estimated, that about 10-12% of the male population, will be operated due to phimosis. It is the most frequent operation of our specialty. It is important for a man to reach the age of the first sexual intercourse with his penis ready. It is very unpleasant for young men to fail their first intercourse, due to phimosis.

IT IS THEREFORE ESSENTIAL FOR A MAN TO HAVE A CLOSE INSPECTION OF HIS GENITALS BY A QUALIFIED DOCTOR AT HIS 14TH YEAR OF AGE.

 

IDEAL AGE FOR OPERATION

If, after his first birthday, the foreskin’s ring is still too narrow (this is the case of serious congenital phimosis), we can proceed with the surgery. This is an ideal moment, for the child does not understand much and the operation is painless to the rest of the family.

However, a second group of children, who suffer from phimosis, are operated during their adolescence when they realize they cannot unveil their glans penis when erected, or when they try to have sexual intercourse fro the first time and fail. Ideally the operation should be executed at an early age and certainly before the first sexual intercourse.

 

OPERATION

When the foreskin’s ring is too narrow, circumcision is an one-way. The operation consists of removing the foreskin, thus revealing the glans penis. Partial circumcision (removal in the first place of a small ring of skin) can sometimes prove insufficient. In that case we sometimes have to proceed with a second operation.

When partial stenosis of the foreskin is diagnosed (this meaning the foreskin’s ring is not that narrow) we can proceed with a plastic surgery to enlarge the foreskin. Mathematical and geometrical restrictions apply to this operation: the foreskin’s diameter can only be enlarged by 20%. We must know that this type of intervention by itself does not guarantee 100% the effortless inveiling of the child’s glans penis.

During erection the glans penis gets wider; the foreskin on the other hand does not participate in the erection and thus maintains the same diameter. The surgeon must therefore take account of these geometrical parameters.

This proves, that as partial and small the phimosis’ operation might be, it must be conducted by a specialized doctor, especially when in an early age. The surgeon must also take care of the penis’ aesthetics, placing the sutures symmetrically and in the right place, because nowadays the penis’ appearance is important…

Any type of phimosis, is operated under a light general anesthesia which lasts for about 20 to 35 minutes. It does not imply neither intubation of the child during surgery, nor its stay at the hospital post-surgically. The child can leave the hospital after 2 to 3 hours from the time the surgery has ended. We use absorbable sutures (that do not need to removal by a doctor) and the penis is not banded after the operation; thus, we avoid the procedure of changing bandages. Parents are called to implement topical antiseptics; the doctor’s presence, so unpleasant to a child, is thus, spared.

 

HISTORY BENEFITS OF THE CIRCUMCISION

The need for sexual activity has led men to proceed to circumcision as early as the antiquity. In his ancient manuscripts, Hippocrates describes minutely the technique of circumcision. Circumcision offers the penis cleanness and hygiene. Muslims, systemically proceed to circumcision of their sons’ penises during their baptism at the age of 7 to 8 years olds. Jews, the day the child returns from the maternity hospital. In many countries, such as the U.S.A. and Canada, where insurance companies have a larger influence, doctors proceed systematically to circumcision, at the time of the boy’s birth. This is done to eliminate future problems the foreskin can cause to a man, and consequently the cost to deal with them. The benefits of circumcision have been described in thousands of medical articles. Indicatively, boys suffer far less from urinary tract infection and the risk of topical infections of the glans penis and the appearance of balanoposthitis, especially in smaller boys, are eliminated. Moreover, cancer of the penis is less frequent to a circumcised man, uterine carvix cancer less frequent to a circumcised man’s wife, the transmission of the HIV virus harder, not to forget the better performance during sexual intercourse. In Europe, the foreskin is usually kept untouched and circumcision executed only when there is a medical necessity to proceed to it, that is to say phimosis.

 

Aspect of a classic congenital phimosis in a 1.5 years old baby.

 

Aspect of another kind of congenital phimosis in a 9 years old boy. The opening of the foreskin is not on the axis of the penis but looks towards the face of the boy periscope-like submarine.

 

Postoperative outcome after circumcision. The glans of the penis can be postoperatively more exposed than in the upper panel, according to the anatomical features of each phimosis.

 

 

 

PARAFIMOSIS

Parafimosis in an16 years old boy. Here is narrow preputial ring wherever possible outsourcing of the glans penis, but with difficulty.

In this case, the boy pulled out the glans and left exposed for some minutes, so developed edema (swelling), which prohibits the rediscovery. This situation causes acute pain. Here the rediscovery can be made by special handling by a physician or require immediate surgery.

Pediatric Urology
and Endocrine Clinics

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