Introduction
This is a minor operation that needs to be done in boys as a type of therapy. In order to understand the reasons for the operation, one needs to know what is normal.
The normal penis has a urethra running through its length, which opens at the top from where boys pass urine. There are 2 parts of the penis - the shaft, and the globular tip called the glans. The skin over the penis is thin supple, stretchable, and goes beyond the glans. However, the part of the skin distal to the glans is double layered. As is seen in the picture the skin of the prepuce folds on itself inwards and ends at the granular groove. Thus, the covering of the glans is an outer and an inner layer. When the skin on the shaft of the penis is retracted backward, normally the terminal skin prepuce opens inside out to expose the glans.
Phimosis
The first is tight phimosis - in this condition, the double-layered skin cannot be retracted at all - hence the tip of the urinary opening cannot be seen and the child strains to pass urine. The parents may notice that when the child passes urine, initially, there is a bulge below the preputial skin and then suddenly the urine rushes out as a thin stream. The child often strains to pass urine, may or may not have a stream, and passes droplets of urine in the underpants. This happens because the skin is not supple, and is narrowed towards the end and hence cannot be retracted. This in turn causes obstruction to the evacuation of urine. This certainly needs a circumcision.
Phimosis
Balanoposthitis
Another problem is that though most of the urine is thrown out, some drops remain outside the meatus but within the preputial skin hood. With stasis, poor local hygiene, and infrequent passage of urine - this may lead to an infection that goes back thru the urethra to give urinary tract infection. This is usually treated with oral antibiotics but may be led to recurrent infections. The inner preputial skin becomes unhealthy and may recover only if given adequate rest and a dry environment for a few days. Both these are not possible since the child has to pass urine every few hours. The result is a long-standing infection, inflammation, swelling, and thickening of the prepuce with pain and or burning urination. At times the parents may also notice pus coming out from beneath the preputial skin. This is called Balanoposthitis and sooner or later the child will require a Circumcision. Some of these boys will manifest with pulling at or frequently touching the preputial skin, itching at the prepuce, rubbing the prepuce against any hard object, or between 2 fingers to reduce the sensation.
Balanoposthitis
Smegma Ball
At times, due to the inability to totally retract the skin and not cleaning below the skin, a collection of whitish material occurs below the skin and looks like a swelling that is growing - this is a smegma ball and this can cause recurrent urinary infections. This gives symptoms similar to Balanoposthitis and there may be an escape of whitish matter with pus from below the preputial skin. This again requires a circumcision.
Smegma Ball
Paraphimosis
Some boys will be noticed to have a long preputial skin and may give a history that though they pass urine properly, their underpants are often wet. This is common because the excessively long prepuce is a holding place for urine which later drips into the boy's underpants. There may also be the possibility that the child has got an infection and has a habit of pulling at the prepuce and hence has lengthened it. This will need an elective circumcision.
A semi-emergency situation is sometimes created by a boy or his parent forcibly retracting a tight phimotic prepuce. The prepuce is very narrow behind the glanular groove and now is not possible to bring the skin back forward to normal position. The retracted prepuce gets tightly fixed on the groove, this forms a ring of constriction on the base of the glans leading to congestion and swelling of the skin of the prepuce. If this is not reduced soon, the constriction will further reduce the blood supply to the glans and even lead to gangrene. This is called Paraphimosis and needs to be shown to the doctor immediately no matter what time of the day or night. Ideally, with compression and gentle manipulation, a doctor will be able to gradually pull the skin forward to normal position. This is followed by administering oral antibiotics, anti-inflammatory drugs, local hot water fomentation, and antibiotic ointment applications for 10 days. The initial swelling will slowly disappear over a few days. This boy will require a Circumcision after 2 weeks of the episode when the swelling has subsided.
Paraphimosis
Prepuce Stuck in Zip
Boys very often wear pants without first wearing underpants. In some of these boys when pulling up the zip on their fly, get their prepuce stuck in the zipper. The child is brought to us in this condition with the prepuce stuck and the zipper cannot be moved. The first thing I do in this case is to apply a bit of Lignocaine jelly to the prepuce and wait for the anesthetic effect to occur. Later, the prepuce is gradually and carefully separated from the zipper without tearing either. There is always an injury on the prepuce, and this is treated with local hot water fomentation, antibiotic ointment for a few days allows the swelling and inflammation to settle down before going in for a regular circumcision. This is required to avoid the injured skin from undergoing fibrosis and narrowing if left alone.
Prepuce Stuck in Zip
Recurrent Urinary Infections
Recurrent urinary infections occurring in a boy, or with modern methods of prenatal detection of vesicoureteral reflux - that is the abnormal reverse flow of urine from the bladder into the ureters and the kidneys, prevention of infection is the single most important principle. To achieve this partially, a circumcision is advised even in the absence of any signs or symptoms described above.
Treatment
There is no ideal age for circumcision, depending upon the presence of the problem, if the indication exists; the age or weight of the child is no bar to having the boy circumcised. This is a small minor operation and is always done on a Daycare basis. The surgery is done under complete general anesthesia, which is extremely safe even in a small infant. The boy comes to the hospital in the morning, undergoes surgery, and walks home the same evening. The procedure is simple - both the outer and inner layer of the folded preputial skin are cut leaving 2 cut edges of the skin which are then brought together with multiple interrupted absorbable sutures. These sutures fall off on their own after 7 - 9 days no sutures need to be removed or cut.
Problem & Precautions
The preputial skin loses unhealthy, and very vascular, hence cutting and suturing always causes a swelling in the postoperative period. This looks ghastly and worries the parents - but this disappears by itself within a few days and nothing specific needs to be given for this. I usually do not give any dressing and the child is allowed to pass urine, some blood may ooze from the suture site the first day, which later dries up and forms a scab. These scabs too are to be left alone and will fall off by themselves. A clot may sit right on the urinary opening and partially block it so the child passes urine from the side of the hole with multiple streams again worrying the parents - but these streams will disappear as the clot falls off to a single stream. After circumcision, I avoid any pants being worn for 8 days. The area of operation is very sensitive and anything that touches or rubs against that part gives exquisite pain to the boy. Thus the child either wears a Lungi or a girl's dress/nighty for the first 7 days. After 4 days the boy is given a regular bath and is made to sit in a tub of hot water to give fomentation to the part. With the hot water fomentation, the edema subsides, the sensitivity goes away, the scabs loosen, and along with the sutures fall off by themselves. This hot hip bath is given with hot water at least 15 minutes each time and 3-4 times a day and is followed by the application of an antibiotic ointment locally each time. This is continued till all the scabs and sutures have fallen off the local part is dry. The entire process of normalization may take up to 10 days through the healing is over in 4 days.
Post Circumcision
