Pediatric Urology

 

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Phimosis/Circumcision

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Phimosis/ Circumcision

The term ‘Phimosis’ derived from Greek word for ‘muzzling’ has been widely applied to narrow foreskin. It is essential to understand normal appearance in a newborn child to know when Phimosis is abnormal or when it will require surgery

What is a normal foreskin?

The skin over the tip of penis normally folds on itself as a sleeve and attaches to the head of penis. This extra skin is called foreskin. In newborn babies the under surface of the foreskin is fused to the head of penis. Because of this in 95% of newborn babies the foreskin can not be pulled back. This is referred to as ‘physiological phimosis’ or ‘non retractile foreskin’. In a 2 year old boy it partly opens out like a flower when pulled back. However as they gets older it separates slowly; by 5 years of age, 50% of boys have a foreskin that can be pulled back; and by 15 years almost 90% have normal adult pattern.

Is it normal to have a non-retractile foreskin?

Up to 5 years of age there is a variable proportion of foreskin adherence to the penis. Sometimes there can be accumulation of white discharge called ‘smegma’ giving the appearance of ‘white pearls’ under the skin. Some times the foreskin balloons as the boy passes urine but there is no other problem. These are entirely with in the normal limit and should not be a cause of concern.

Is it advisable to practice retraction to make it better?

If parents resort to the practice of retraction exercises, they might overdo and can cause soreness and bleeding. Also excessive retraction with damage heals with scarring leading to real phimosis. Boys older than 7 years of age can attempt self retraction at bath. However it is essential to put it back after retraction, as skin left retracted can result in swelling called ‘paraphimosis’.

When is Phimosis a true problem?

In a boy with phimosis, surgery is required if the following problems are encountered

bulletScarring of the skin at the tip
bulletRecurrent infections
bulletStraining and only dribbling to urinate
bulletPara phimosis (swelling and inability to put back the pulled foreskin)

What is Circumcision?

Circumcision is one of the oldest operations known to mankind. It basically involves removing the excess skin at the tip of the penis. There are several reasons for doing circumcision

bulletAs a treatment: in true Phimosis
bulletAs a preventive step: In children with recurrent urine infections (circumcision reduces the risk of cancer penis, sexually transmitted disease)
bulletFor religious reasons: in Muslims and Jews
bulletSocial reasons: ‘to look like Daddy!’; 'to look like brother'
bulletAs a routine: in some countries circumcision is performed routinely

What does a circumcision involve?

Circumcision in children is usually done under general anesthesia, as a day case procedure. The operation lasts for around 30 minutes. The stitches are dissolvable and need not require removal. There can be a variable degree of swelling and the penis may look ugly for 2 weeks. As the head of penis has not been exposed, it undergoes drying and scabbing over it.

As the excess foreskin is removed there is no remaining foreskin to cover the tip of the penis. Often parents ask whether skin will grow over it. It does not. Rather the pink moist skin over the end of the penis becomes like the brown pink dry outer lip skin.

Are there any  complications?

Bleeding is a rare complication and usually settles spontaneously. The urinary opening on the penis can become narrow, especially if there is a skin problem called BXO. If this develops, it might require dilatation under general anesthesia.

Are there any alternatives to circumcision?

In an operation called ‘prepucioplasty’ the narrow ring of skin is divided across and sutured along. This widens the narrowing without removing the foreskin. For this operation to be successful, the boys need to self retract after the operation for 2-3 months

Key Points

bulletNon-retractile foreskin can be a normal developmental process in boys under 4 years of age.
bulletCircumcision is indicated if there are recurrent infections, or if there is narrowing with scarring.
bulletCircumcision is a safe operation that can be performed with out the need for over-night stay.
bulletFor a good cosmetic result, and minimal complications, it has to be performed by a well trained surgeon.

Dr. Ramesh Babu, MS, MCh, FRCS, Paediatric Surgeon, Paediatric Laparoscopic Surgeon and Paediatric Urologist Chennai. For further information contact: drrameshbabu1@gmail.com; Mobile 9840359062