Daycare Surgeries – Circumcision! (March, 2007)
In a male child the tip of sexual organ, the penis, called as “glans penis” is covered and protected by a two layered skin sheath called “prepuce”. In most babies this prepuce cannot be retracted to expose the glans till about the age ten years or so. By this time the parent should be able to retract (pull back) the prepuce to wash and clean the glans while bathing. Unless washed daily once or more often, a whitish chalky material called “smegma” collects inside the prepucial sac. This smegma has the potential to irritate the glans and result in repeated episodes of infection or even cancer in the long run. If the prepucial opening is too small making it difficult or impossible to retract it in order to expose the glans, it is a condition called “phimosis”. In such a situation, it is also possible to have some problems at the time of sexual intercourse. The prepuce may automatically retract, but after the sexual act, it may not be possible to restore it to its former position of covering the glans. This is a painful condition called “paraphimosis” and has to be corrected, as an emergency by a Surgeon/Doctor by some manipulation or surgery. On the inner aspect of the prepuce on the lower side there is a band of tissues connecting it to the glans ; this is called as “frenulum”. In some it may be a tight band and may rupture and bleed after sexual intercourse. These are the three aberrations which call for some corrective surgery. Ideally this should be surgically corrected in childhood itself, if detected. But often the abnormality is not noticed by the parent or the family doctor or by the patient himself. He may seek medical advice only when a problem arises, like repeated infection and discharge or a paraphimosis or pain and/or bleeding after sexual episode. Rarely a subject with untreated phimosis seeks medical aid when he develops”cancer” in that part!
Surgery for Phimosis and other problems in that part.
Circumcision is done routinely in all males belonging to some religions either immediately after birth or about the age of 4-5 years. From the medical point of view this is a good routine and it keeps the genitals clean. Also chances of such children developing cancer in that area is almost nil. If phimosis is detected at anytime, either in childhood or later, it is advisable to correct it by doing circumcision. Surgery may be needed as a semi emergency for “paraphimosis”; at this time a simple cut would give temporary relief and a formal circumcision can be done later. Sometimes, when conditions are ideal, circumcision may be performed straightaway. Tight frenulum resulting in pain and /or bleeding is treated by a small Plastic Surgery procedure called Z-plasty with or without circumcision. Diabetic persons may develop acquired phimosis in adulthood or even old age due to repeated occurrence of painful fissures or cracks in the prepuce. They need to undergo circumcision.
Anaesthesia for Circumcision:
In babies and small children complete general Anaesthesia may be preferred. In adults local anaesthesia by giving a couple of small injections of Xylocaine or similar drug, at the root of penis is good enough for a safe and painless surgery. Rarely in very apprehensive adults, we may have to give general anaesthesia. Generally the baby, child or adult patient undergoing this surgery can go home in 2-4 hours time.
Technique of Circumcision:
The purpose of circumcision is to remove excess prepucial skin to either always expose the glans penis (as required by certain religions) or to allow easy movement of prepucial skin over the glans even in the erect state of the penis. The prepuce may or may not fully cover the glans.
There are quite a few technical variations in the exact method of performing this operation. Suffice it to say that excess skin of both inner and outer layers of prepuce are cut out, meticulous control of bleeding is ensured and the cut edges of the two layers are resutured using sutures which get absorbed in a few days’ time. Excess removal of the prepuce may result in tightness and pain during erection and sexual intercourse; hence the Surgeon has to avoid this possible complication.
Generally a non adherent dressing is applied at the site of surgery and the patient is sent home in a few hours.
Post operation care and instructions:
The patient is sent home with some pain killer (analgesic) tabs to be taken if needed. Erection of the penis in the post operative period can cause pain and sometimes produce severe and alarming bleeding. Erection in adults can be avoided by mentally banishing thoughts on sex and by some tablets, particularly in children. Erection also tends to occur in sleep if the urinary bladder gets full. Hence frequent emptying of bladder at night is advised. The first change of dressing is generally after 48 hours; at this time the patient is taught how to wash and apply some medications and a simple protective dressing. Most adults would be able to attend office/college/school after 48 hours. Complete healing generally takes 15 to 20 days, though rarely a small spot of wound on the lower side may take much longer in a few persons. As a rule we do not administer any antibiotics unless the patient is a Diabetic or there is already some infection as in some cases of paraphimosis.
When not to do Circumcision.
If there is any abnormality in the genitals – like “hypospadias” or “epispadias” circumcision should not be done until a specialist – a Plastic Surgeon or a Paediatric Surgeon is consulted.
Readers are most welcome to seek any further clarification regarding any aspect of Phimosis and Circumcision. Use “Ask your doctor..” feature in our site.
*** Additional information as on Sept, 2010:
The penile foreskin is an integral, normal part of the penis. It protects the glans or the
head of the penis and it has unique zones with several kinds of specialized nerves that are
important for optimum sexual sensitivity. Hence it is believed that circumcision may reduce
erotic sensations during sexual act.
Ref: Money, J., and Davison, J. "Adult Penile Circumcision: Its Erotosexual and Cosmetic
Sequelae." Journal of Sex Research 19 (1983): 289-92.
Dr. M.Mohan Rao, MBBS,MS,FICS,MCH,
Director & Senior Surgeon (Retired but not tired),
Dr. U Mohan Rau Memorial Hospital.
Updated on 01.03.2007.