What are the reasons to get a circumcision?
The most common reasons for circumcisions are:
- Phimosis – Tight foreskin with inability to pull back the foreskin over the glans penis
- Paraphimosis (inability to pull the retracted foreskin back over the glans)
- Balanitis and balanoposthitis (inflammation of glans and foreskin)
- Frenulum breve (short frenulum which tears with intercourse)
- Diseases of the foreskin, including cancer
- Genital warts, when large and non-responsive to medication
- Cosmetic appearance
What are the benefits of circumcision?
There is some evidence that circumcision has health benefits, including:
- A decreased risk of urinary tract infections.
- A reduced risk of some sexually transmitted diseases in men.
- Protection against penile cancer
- Prevention of balanitis (inflammation of the glans) and balanoposthitis (inflammation of the glans and foreskin).
Circumcision also makes it easier to keep the end of the penis clean.
Good hygiene can help prevent certain problems with the penis, including infections and swelling, even if the penis is not circumcised.
Circumcisions do not replace the need for condom use during sex to prevent STDs.
How is circumcision done?
During a circumcision, the foreskin is freed from the head of the penis, and the excess foreskin is clipped off. Adult circumcision takes about 30-40 minutes. The circumcision generally heals in seven to ten days.
I perform circumcisions under various anaesthetic methods including: local anaesthesia, local anaesthesia with sedation , or general anaesthesia.
For adult circumcision, I use the sleeve resection technique in which the foreskin is removed as a ring of tissue with a scalpel. In my opinion, this gives a symmetrical, fine incision line. In addition to a refined scar line, this technique allows the outcome to be customized to the patient's specifications if he has a particular cosmetic outcome he would like. This involves making an incision on the outer surface of the foreskin at the level where the edge of the glans (corona) is visible making an impression through the foreskin. I then retract the foreskin and make an incision in the inner (mucosal) surface of the foreskin following the contour of the glans. I mark the incision lines before making any incision and make measurements to be certain that the incisions will result in removing enough foreskin to meet the patient’s cosmetic preferences and allow for comfortable erections.
An adult circumcision should be crafted to accommodate the dimensions of the erect penis. I simulate erect length by stretching the penis. I mark incision lines with an ink marker and then stretch the penis and move the two incision lines into proximity. I want these two points to come together without excessive tension. This will avoid uncomfortable erections. Once I have determined the correct location of the incision lines, I make the outer incision, retract the foreskin and make the inner incision and remove the foreskin as one piece of tissue. Bleeding points are identified and cauterized with electrocautery. The frenulum is then removed if the patient desires this to be done. I then close the wound with fine sutures, placed in a very precise manner so that suture marks and tunnels will not occur, and finally apply a compression bandage to the surgical site.
The cosmetic outcome may be customized to patient preference. Since the incision on the outer surface of the foreskin is made separately from the incision on the inner, or mucosal, surface of the foreskin, these incisions can be made at different distances from the tip of the foreskin. The effect of this is that the incision line may be moved closer to the edge of the glans or further down the shaft. This is a separate issue from the overall tightness of the skin on the penis. The tightness has to do with the overall length of foreskin removed.
How about clamps/Shang Ring?
I do not use these devices because I feel they do not allow the precision necessary to create an individualised outcome crafted to the patient’s unique anatomy. These clamps do not allow careful visualization of both outer and inner skin surfaces of the foreskin. It is difficult to ascertain that the proper amount of skin is being pulled though the clamp before crushing the skin. An adult circumcision should be carefully crafted to result in a good cosmetic as well as functional result.
How about lasers for circumcision?
Lasers are great for use in some types of surgical procedures. For circumcision, a laser offers only the benefit of lesser bleeding, but has potential problems. The surgeon cannot control the depth of the cut with a laser. As circumcision is concerned, it is important that the surgeon be able to control the depth of a cut to a very fine degree. Too much depth of cut can lead to injury to the glans penis or urethra.
On request, and if the patient’s anatomy allows it, I can use the laser for circumcision. Otherwise, I routinely use a stainless steel scalpel for circumcision.
How is adult circumcision different from circumcision for children?
Paediatric circumcision is often performed utilizing one of a number of clamp devices which remove the redundant foreskin, stop bleeding arteries and veins by crushing them, and bond the skin edges without the need for sutures. The most common devices used locally are the PlastiBell clamps and Shang Ring. Each one of these creates a pressure bond to hold together the skin edges so that there is no need for sutures. These devices provide an adequate wound closure for infants/young children because they do not have powerful enough erections to pull apart the skin edges. The bond created by these clamps at the skin edges consists of the clamp crushing the two opposing skin edges together. The force of a powerful erection would pull apart the wound edges resulting in wound 'dehiscence' or opening up of the wound thus making it an inadequate wound closure for a circumcision in an older child or adult.
Adults require suture closure (stitches) to provide a secure enough closure to allow the wound to remain intact despite the force of erections. Careful suture closure leads to a much finer scar once the healing is complete. Sutures guide the healing edges of the wound close together so that the end result is a fine line.
I perform circumcisions for adults only.
How long is the procedure?
The procedures takes approximately 30-45 minutes and is considered a day surgery. In most cases, you should be able to leave the day surgery centre within an hour or two after the surgery.
What are the risks of circumcision?
Like any surgical procedure, there are risks associated with circumcision. However, this risk is low. Problems associated with circumcision include:
- Postoperative pain (this is usually well controlled with pain killers)
- Risk of bleeding and infection at the site of the circumcision
- Reduced sensation of the glans
- Tenderness of the sccare (this is rarely long term)
What is normal after circumcision?
You may experience soreness and swelling for 2-3 days after the surgery. We recommend applying a small ice pack to your penis to help minimize the bruising and swelling. The swelling may linger for 2-3 weeks after your circumcision.
Take these precautions for 2-3 weeks after the procedure:
- Avoid immersion in water such as baths or swimming
- Avoid strenuous physical activity and especially cycling
- Abstain from sexual activity for as erections may be uncomfortable or painful, or cause a suture tear
Alternatives to circumcision
Topical steroids for phimosis
Applications of steroid creams have been used to manage phimosis medically. The usual regimen is application of the steroid cream once or twice daily for 4-6 weeks. Higher rates of success have been reported with adding foreskin stretching exercises.
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