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There is no operation that has had more attention paid to it than circumcision. The psychological conflict that the operation is a very good and healthy step is discussed against the opinion describing the operation as an insult on the man letting him suffer during his sexual life. Even the religions have their contradicts about it. Due to the importance of the operation both for the psychological and physical development of the man, many surgeons have developed a lot of operations` technique claiming that they will provide the best cosmetic result.
The foreskin (the prepuce) is the investing double layer of skin covering the glans of the penis (the head). It is composed of the outer normal thickness skin (partial layer) and the inner thin layer of skin (visceral layer). The visceral layer is attached to the neck of the penis in the deepening called the sulcus coronarius and is continuous with the skin covering the glans. The prepuce is in common with the skin of the penis in that it is not attached to the facial layers and the subcutaneous investment of the penis. The foreskin makes a saculation around the glans called the perpetual sac. The ventral inner area of the foreskin provides a tag of tissue which connects it to the bottom of the glans and the lower part of the opening of the urethra. On the corona of the glans and on the skin of the neck of the penis there are small minute glands called the perpetual glands which produce the smegma. The smegma is a fluid like secretion which lubricates the prenuptial sac. It is thick and yellowish white in color. The smegma may be infected leading to the symptoms of a chronic or acute infection.
Its long term contact with the glans in presence of infection and the resulting chronic irritation of the foreskin and glans may be the cause of the oncogenic changes which may lead to cancer of the penis. This is suspected because this type of cancer appears mostly in populations who do not remove their foreskin. On the contrary, it is believed that the foreskin is a naturally appearing part of the body that gives protection to the glans both from trauma and continuous sexual irritation. This leads to the preservation of the sensitivity of the glans. Consequently it is assumed that the removal of the foreskin will lead to an unpleasant continuous stimulation of the glans or by some others will expose the glans to chronic trauma and hence horrification of the glans with loss of its sensitivity and the resulting sexual pleasure on its stimulation.
Males may let the removal of foreskin (Circumcision) be done as a religious believe (Moslems and Jewish), cultural (some areas of south Asia), hygienic (USA) or as a cause of disease. The most common disease necessitating circumcision is its narrowing (phimosis). It results as a cause of accumulation of the smegma inside the perpetual sac and lack of hygiene which leads to chronic irritation of the foreskin resulting in the development of scar tissue and its narrowing. The narrowing of the skin leads to difficulty in its retraction during urination, erection or for cleansing it. The process is a vicious circle. It starts a procedure of scaring and further narrowing. In late cases some crakes appear on the edge of the skin inviting more infection until the prepuce is so narrow to be retracted. It becomes painful, difficult to clean and may be the cause of urinary tract infection or even may lead in rare cases to stenosis of the meatus or affection of the upper urinary tract.
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Before the operation
a = cut
After the operation
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Who qualifies for the operation?
The treatment of narrow foreskin is a simple procedure. Understanding the present pathology and the psychology of the patient are two important factors for the decision of circumcision. The plastic surgical skills have to be practiced here. This is because the shape of the organ and its appeal are dependant on the planning and the healing of the circumcision.
Although the operation has many techniques, it is divided into complete or partial circumcision. Most circumcisions done on cultural, ethnic or religious basis are complete circumcisions while the other opinion asks for the partial procedure because of the above mentioned arguments.
How does the operation work?
Complete (radical) circumcision:
The operation is done on out patient basis. The patient lies on his back. The body is protected with the earthing electrode of the high frequency currant applied to his thigh. The anesthesia is done according to the patient age and wish. It can be local which is suitable for elderly persons and provides a rapid recovery or it can be a mask intubation which produces some throat ache in the early post operative period.
In case of the later, the eyes are protected with an antibiotic ointment. The hair in the area is shaved. The area is generously disinfected. It is important to introduce a swab soaked with the disinfecting material in the narrow perpetual sac to disinfect it and evacuate it from the smegma. The anatomy of the foreskin is revised as it is very individual. I do only cut the skin using the scalpel as this is the only way of getting a clean cut which is important for the later cosmetic appearance. As this is the case I also perform the island flap excision method that reduces the manipulation in the area and hence the post operative swelling.
In case of radical circumcision, the edges of the foreskin opening are grasped with 2 small self retaining forceps and minimal traction is applied to the skin. The skin of the outer layer is cut just at the level of the external meatus in particular few mm before it (proximal). The skin is everted on the shaft of the penis and is cut 3-4 mm below the neck of the penis using the scalpel and maintaining the width of the visceral strip constant all round the neck. The frenulum is met at the bottom and is severed as well. The strongly bleeding frenular artery is closed with a self retaining forceps for the time being. The resulting strip of skin is then divided by the scissors ventrally and hold with 4 self retaining forceps. The island is then prepared sharply using a scissor to be excised completely. The vessels of the area are coagulated with the high frequency current forceps as they appear. Special attention is paid to the superficial vein of the penis and the frenular artery. Meticulous coagulation of the vessels under the skin edges is done.
The skin is approximated in 4 quadrants in a symmetrical manner avoiding the rotation of the skin of the penis. The edges of each quadrant are closed with fine monofilament suture in an everted way to avoid tethering of the skin or tagging of the edges during healing. The frenulum is approximated to the skin using a mattress delta suture that works as a haemostatic suture for the frenular artery. The meatus of the urethra is cleaned and cleared of blood. Iodine containing ointment is put on the skin edges. The area is dresses with a slightly tight dressing which is changed after 2 hours when the patient urinates for the first time post operatively.
Partial circumcision:
In case of partial circumcision, or when a patient wishes to preserve as much as possible of his foreskin, I define the pathologic area when the skin is everted first when this is possible.
If this is not the caser, the I grasp the edges of the foreskin opening with 2 small self retaining forcipes without applying any traction on the instruments. The skin is incised 1-2 mm above the pathologic edge. If the retraction of the skin is possible, then I define the skin island by cutting the visceral layer also 1-2 mm away from the pathologic segment. The island is removed as above. Meticulous coagulation of the vessels paying attention to the superficial vein of the penis and the frenular artery is done. The skin edges are everted and 2-4 release incisions are done on the sites of defining the skin quadrants that is to say, by 12-3-6-9 hours. The skin angels are modulated. The quadrants are closed as above the procedure is completed in a routine manner. It is rare in this case to resort to release incisions aiming at prolongation of the foreskin as this leaves scar on the penis post operatively.
I usually give the patient a medication against swelling and some drops against pain. The patients visit my office on the first post operative day to change the bandages and to look for any sign of bleeding.
Healing:
Healing of the wound is completed in one week. Usually there is a slight erection at night which does not disturb the wound or cause pain. The patient is requested to put the penis in a warm camellia bath for 15 minutes twice daily for a week after which they pay me a final visit to document absence of complications and advise him about his sexual behavior in the future.
Frequently asked questions:
- What is the function of the foreskin?
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It is a rudiment of 2 layers of skin which envelops the glans and is supposed to protect it from annoying stimulation. This belief is a ritual and there is no prove of it scientifically.
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- Is it dangerous to remove the foreskin?
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No it is not. There are millions of men who live without it and have no problem with this. The men in the middle east for example are thought to be very potent although the majority of them live without a foreskin.
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- Is the smegma a lubricant and hence an important secretion for the penis?
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It is slightly lubricant but has no importance at all for the penis. If it is infected it works as a chronic irritant that may lead to the development of pathologic changes in the penis up to the development of cancer of the organ.
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- Does the absence of the foreskin affects potency?
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No.
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- Does the absence of the foreskin reduces sensitivity of the glans?
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No. It does not increase it as well. The uncovered glans may be a little bit agonizing at the start but accommodation develops in a time to let this feeling negotiable.
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- May the circumcision lead to change in my acceptance by the other gender?
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Normally not at all. This depends sometimes on the understanding of the partner of the cause of circumcision and its benefit.
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- Does the circumcision protect me from any disease?
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Yes, According to the scientific observations, it protects from infection and may be from cancer of the skin. In this case it protects the partner from infection as well.
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- Should I perform circumcision to my son if the foreskin is relatively narrow or defected from below?
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No never. If the foreskin is defected from below and is working as a cap on the glans then it is important to exclude the presence of hypospadius first before resorting to circumcision. This is because the foreskin may be the best material for the reconstruction of the defect of hypospadius later on in life of a child.
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- What is the ideal age of circumcision for a child who have phimosis?
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The phimosis is best treated immediately. The narrow foreskin is a potential for infection and it may affect the upper urinary tract by many means. However it should be done before the school age when the children are aware of themselves and start comparison and criticism among each other which may affect the child psychologically.
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- Is circumcision a simple operation?
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Yes, it is. In spite of this it is important to note that if it is wrongly done by some inexperienced surgeon it will bring deleterious psychological problems with it in particularly psychological sexual and self-confidence ones.
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