What are the relative indications for circumcision?
Circumcision is performed for various conditions, but their natural course suggests that this is not always necessary. There are also many relative indications for circumcision, including the prevention of penile and cervical cancer, the prevention of sexually transmitted infection, particularly HIV, and the prevention of urinary tract infection. Many surgeons would also perform a circumcision during surgery for hypospadias.
Paraphimosis occurs when the foreskin is not pulled back over the glans after retraction. A tight constricting band ensues, causing swelling of the distal penis and acute discomfort . Reduction under local or general anaesthesia is nearly always possible with several minimally invasive methods.
A condition that happens when the foreskin cannot be easily pulled back over the head of the penis. Men with this condition frequently experience pain during sexual intercourse or masturbation..
Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main) cause of pathological phimosis. Other causes may include scarring caused by forcible retraction of the foreskin, and balanitis..
In Balanitis the glans and/or the foreskin become inflamed. It can affect men of all ages including boys (most commonly around the age of three or four).
Poor hygiene, a tight foreskin, skin disorders, allergy to products such as soap or washing powder or to the latex or spermicides in condoms can all damage the skin and, if this becomes infected, balanitis can develop. .
Balanitis xerotica obliterans(BXO) is regarded as a common (or even the main) cause of pathological phimosis. Other causes may include scarring caused by forcible retraction of the foreskin, and balanitis.
Prevention of urinary tract infection in boys with urological abnormalities
The association between urinary tract infection and the uncircumcised state was first recognised in 1982 Since then, there have been several observational and case-control studies, and these have found a 3-7 times increased risk of urinary tract infection in uncircumcised infants compared with circumcised ones, with the greatest risk in infants under 1 year old. A meta-analysis of the effect of circumcision in boys suggested that only those at high risk of urinary tract infection—that is, those with recurrent infections or with abnormal urinary tracts such as high grade vesicoureteric reflux—would benefit from circumcision.
The absolute indications for male circumcision in childhood are rare and include phimosis secondary to balanitis xerotica obliterans and recurrent balanoposthitis, both of which affect about 2% of children.
Phimosis: when the distal prepuce cannot be retracted over the glans penis, it is known as phimosis. In preschool children it is not unusual for there to be thin adhesions to the glans. This physiological phimosis is quite normal. At age 3 years about 10% of boys are unable to retract the foreskin but, by adolescence, 99% of boys achieve retraction. Severe phimosis is quite rare in young children and can be demonstrated by bulging of the foreskin during micturition. It should be remembered that circumcision is not the only option and preputioplasty can also be performed (this preserves the prepuce). Acquired phimosis occurs because of:
Repetitive forceful retraction of foreskin.
What is a "circumcision revision"?
A "circumcision revision" is a change to the appearance of the original circumcision. The original may be too loose, have unappealing scars or even skin tags. A circumcision revision can correct many of these problems. We can help patients change how their circumcision looks and attain their desired goals.
Isolated trauma to the foreskin is unusual and in young boys should always raise the possibility of non-accidental injury. Tears, zipper injuries, or crush injuries usually heal leaving a scarred foreskin, but, unless this scarred foreskin subsequently becomes non-retractile, circumcision is not indicated. Uncircumcised men also seem to have a relatively high incidence of microtrauma and frenular tearing during penetrative intercourse.
Relative indications include urinary infection in association with an abnormality of the urinary tract, an abnormally formed foreskin, and the possible benefits of a reduced risk of sexually transmitted infection and penile cancer. Specialist referral for these relative indications is justified, for worried parents, to discuss the risk:benefit ratios.
The most common complications that can take place can be grouped into three categories: 1) Too much skin removed. 2) Too little skin removed. 3) Remaining foreskin that is stuck to the head or glans of the penis (adhesions).4) Old Scar of Circumcision which becomes painful 5) Rough ugly looking scar of old circumcision
First, if the distribution of redundant foreskin is uneven, with one part of the remaining foreskin being significantly longer than other parts, or if the amount of foreskin left is particularly large, then normal penile growth will not result in the child “growing out of it” in the way that can happen when the foreskin is evenly redundant all the way around. Whether surgery will ultimately be necessary is a judgment call for the urologist evaluating the child.
What are the absolute medical indications for circumcision?
Medical indications for circumcision are generally accepted as phimosis secondary to balanitis xerotica obliterans and recurrent balanoposthitis, which occur in 1.5% and 1% of boys respectively.
Balanitis xerotica obliterans is a chronic skin condition of unknown cause that most often affects the glans and prepuce but sometimes extends into the urethra. Recent reports have suggested that it is under-recognised. Its association with early penile cancer is also not fully substantiated, although a recent report suggested that the quoted incidence of 2-6% of penile cancer being preceded by balanitis xerotica obliterans is a gross underestimate. In a consecutive series of men with penile cancer over a 54 month period, 44 patients out of 155 (28%) had balanitis xerotica obliterans.
Second, if preputial adhesions have completely fused to the point where they cannot be easily broken by hand in the clinic, then a formal operation under general anesthesia will be required to cut these adhesions, remove any redundant foreskin, and suture the skin together again.
Third, if the redundant foreskin is so difficult to keep clean and free of smegma that there is recurrent irritation and inflammation, then surgical intervention is needed. A related problem that requires surgery is when the redundant foreskin cannot be kept from forming adhesions in spite of the parents’ best efforts at proper care.
Fourth, sometimes the penis will be a “buried penis,” where it retracts into the fat pad of a child’s pubic area. The cause of a buried penis is a congenital absence of normal definition of the skin angle between the penile skin and scrotum below, and between the penile skin and the pubic skin above. If a child is uncircumcised, he will usually grow out of the buried penis as the “baby fat” of the pubic area is lost over time. But in a circumcised child, a buried penis more often than not leads to adhesions and irritation. Repair of a buried penis is a more complicated circumcision revision, and involves placing sutures at the base of the penis to fix the penile skin to the shaft of the penis itself.
While the vast majority of circumcisions performed at birth go perfectly and without any complications, there are a small number of cases that will require an urologist’s attention in the first couple of years of life or at adult age to revise the original circumcision. Once the circumcision has been revised, it is extremely rare for any further problems to take place. Consultation with Dr.Kuber experienced in evaluating and treating these conditions is ultimately the only way to determine for certain whether your child’s/ Adult circumcision needs to be revised.