Why would a urologist be writing about adult circumcision in a country where the vast majority of men are circumcised at birth? Well, when you are dealing with an uncommon problem, finding a doctor that has extensive experience can also be difficult. That’s where my background is relevant. I am an andrologist, the urologist that specializes in the medicine and surgery of the male external genitalia. Moreover, I trained in penile cancer and the management of severe genital skin diseases like lichen sclerosus, buried penis and genital lymphedema, procedures where complex reconstruction with skin grafting may be required. I was then a consultant at the Norfolk and Norwich University Hospital where I would say about 50% of my workload was dedicated to treating penile cancer and other severe genital skin diseases. Before I left, I set up a multi-disciplinary regional referral clinic with a plastic surgeon and dermatologist so that other urologists in East of England had somewhere to refer these cases. I have since moved to the UAE and the truth is, I miss managing these conditions. It’s a strange thing to have high level of skill that you don’t get to use very often. But I have recognized that there will be men out there in the UAE and wider middle east region that would benefit from my help, even if it is rare. So, here is my adult circumcision blog….
There are essentially 4 reasons why an adult might need a circumcision:
Phimosis
This refers to whether the foreskin can slide easily back and forth over the head of the penis (glans). If the foreskin is tight and does not move freely, this is referred to as phimosis. It is completely normal in infancy for phimosis to be present. This is considered physiological phimosis which gradually improves over the years. By the age of 18 around 1-3% will still have physiological phimosis. This is different to pathological phimosis which can develop in adulthood (more on this later). Phimosis can cause pain on erection and intercourse, it can be difficult clean the glans and further inflammation or infection can occur. Sometimes the foreskin does manage to get pulled back to expose the glans. The problem here is that the foreskin can get stuck in this position. The skin of the glans starts to swell and it becomes impossible to put the skin back to its original position. This is called paraphimosis and it requires urgent surgical intervention.
Some men with uncomplicated phimosis can be managed by gentle stretching exercised. Gradually over time the tight band of skin can become wider and looser negating the need for circumcision. It is important to take it slow and not use excessive force. The main risks are developing paraphimosis, as discussed above, and tearing leading to scarring and further tightening. Another option for uncomplicated phimosis is a surgical procedure called preputioplasty in which the tight ring is widened. The main risk here is recurrent tightening and an unsatisfactory cosmetic appearance.
Recurrent Balanitis
Technically speaking the term is Balanoposthitis. Any medical term that ends in -itis means inflammation. Balanitis is inflammation of the glans, Posthitis inflammation of the foreskin, so balanoposthitis is inflammation of both. The source of inflammation dictates which type of balanitis – Bacterial, fungal, allergic, contact (zoonoid), lichen sclerosus (aka BXO). Flare ups can be managed with a variety of creams and ointments but circumcision offers a more definitive solution in the case of frequent flares.
Lichen sclerosus (BXO)
Lichen sclerosus can be a terrible condition so deserves its own section. This is a chronic inflammatory skin condition where we are not completely sure of the underlying cause. The most prevalent theory is that it is caused by urine trapping under the foreskin leading to a type of contact dermatitis. There is almost certainly a genetic component and there is a known association with diabetes, obesity and smoking.
As the disease progresses, the skin becomes thickened leading to a pathological phimosis. The skin then tears with erection leading to more scarring and thickening. Adhesions develop between the foreskin and the glans which can become inseparable. When disease affects the glans, it can spread along the urethra (the urine pipe) causing narrowing and obstruction of urine flow. There ais also a strong association between lichen sclerosus and penile cancer, a rare but devastating condition.
Because of the progressive nature of the disease, treatment should start as early as possible. Potent topical steroid + a barrier cream to stop urine contact is the initial treatment. Men will typically wash the area aggressively. This will dry out the skin. Avoid using soap and switch to an emollient wash in the shower.
Obese men with adult acquired buried penis are a special case and must be managed carefully. Often a circumcision is performed without addressing the burying. In these cases, the penis can retract further into the pubic fat, urine contact continues and the disease recurs, only this time there is less healthy penile shaft skin remaining and skin grafting is required. These men require management of the pubic fat along with circumcision.
Pre-cancer and cancer
Penile cancer is rare with an incidence of approximately 2 per 100,000 men in Europe. However, a diagnosis of penile cancer is devastating. Surgical removal is required leading to significant functional loss and psychological impact. It is therefore imperative that changes to the penile skin are not ignored. Any red patch or growth on the penile skin requires urgent assessment by a urologist experienced in these conditions. Diagnosis at the pre-cancerous stage allows optimal management while minimizing functional and cosmetic damage. Circumcision is indicated in all cases of pre-cancer. By doing this we are removing 50% of the skin that can be affected and it allows for closer monitoring of the glans.
It’s Never ‘just a circumcision’
Adult circumcision has traditionally been seen as a ‘straight-forward’, ‘simple’ or ‘easy’ procedure. One for the trainee to be left to get on with. Often, little thought is put into things like the presence of a pubic fat pad or peno-scrotal webbing. We also have to remember how much anxiety comes along with any penile problem. Fear about how it will look and feel is completely normal for a patient and should not be dismissed. The expectation of a young man with phimosis (tight foreskin) are completely different from that of an older man with severe lichen sclerosus and burying. For one, the cosmetic outcome will be of utmost importance, for the other, regaining function is paramount. Each individual needs to be counselled differently depending on their underlying condition and expectations.
The cosmetic outcome is important. I see far too many circumcisions where due care and attention is not taken when suturing. There are 2 distinct layers involved when closing a circumcision – the skin and underlying dartos layer. I close these layers separately ensuring correct anatomical realignment and wound support. For the skin I close with fine 5-0 absorbable suture making sure to take small frequent bites of skin. When this isn’t done, the suture itself can leave a scar leading to a tramline appearance. My process does make the procedure longer, but in my opinion, it is worth taking little bit of extra care and attention to get the best possible functional and cosmetic outcome.
