In a region where the vast majority of men are circumcised during infancy for cultural reasons, it is fair to ask: why would a urologist dedicate an entire blog to adult circumcision?
The answer is simple. Although adult circumcision is relatively uncommon, the health conditions that potentially lead to it can be quite complex, and finding a specialist with the right experience in managing them is not always straightforward.
As an andrologist, I specialize in the medical and surgical management of disorders affecting the male reproductive and genital systems. My training and clinical practice was not limited to routine andrology procedures but also included some of the most challenging conditions affecting the male genital organs, such as penile cancer, lichen sclerosus, buried penis, and genital lymphoedema. In a lot of these cases, treatment extends far beyond circumcision and may require advanced reconstructive techniques, including skin grafting.
Before moving to the UAE, I worked as a Consultant Urologist at the Norfolk and Norwich University Hospital in the United Kingdom, where a significant proportion of my clinical workload had focused on the management of penile cancer and complex genital skin conditions. Recognizing the need for very niche and specialized treatment pathways, I set up a multidisciplinary regional referral clinic alongside colleagues in plastic surgery and dermatology, providing a full-fledged and dedicated center for the assessment and treatment of these challenging conditions across the East of England.
Since relocating to the UAE, I have come to appreciate that although these conditions are not commonly discussed, they certainly do exist. Men across the Gulf region and the Middle East continue to experience medical problems affecting the foreskin, penile skin, and external genitalia, many of which can have an adverse impact on quality of life and may require assessment and treatment by a specialist.
Drawing on years of experience managing both routine and highly complex cases, my goal is centered around helping men better understand these conditions, recognize when to seek medical advice, and become aware of the treatment options available to them.
So, whether you are considering circumcision for medical reasons, have concerns about changes affecting the foreskin or penile skin, or are simply looking for reliable information, this blog is for you.
There are four reasons why an adult man may need a circumcision.
Phimosis occurs when the foreskin is too tight to be pulled back comfortably over the head of the penis (glans).
In babies and young boys, this is typically quite normal and is known as physiological phimosis. In most cases, the foreskin becomes more retractable with time, as a child grows. However, a small percentage of men continue to experience tightness in the foreskin until adulthood. This isn’t similar to pathological phimosis, which develops later in life due to scarring, inflammation, infection, or an underlying skin condition.
A tight foreskin can result in discomfort during erections or sexual intercourse. It may also make proper cleaning beneath the foreskin difficult, increasing the risk of irritation, infection, or inflammation.
In some cases where the foreskin can be pulled back, it may become trapped behind the glans and swelling can develop, making it impossible to return the foreskin to its normal position. This condition, known as paraphimosis, is considered a medical emergency and typically requires urgent treatment.
Not all men with phimosis will require circumcision. In certain cases, gentle stretching exercises may gradually help to improve foreskin tightness over time. It is important to avoid excessive force, as this may cause small tears, scarring, and further tightening of the foreskin.
Another option for some men is preputioplasty. This procedure involves widening the tight area of the foreskin while preserving it. This can be an effective alternative to circumcision, however, there is a possibility of recurrent tightening, and some patients may not be satisfied with the cosmetic outcome.
In technical terms, the condition is known as Balanoposthitis, indicating inflammation. Balanitis is the inflammation of the glans, while Posthitis is the inflammation of the foreskin, therefore, the term balanoposthitis refers to the inflammation of both.
The cause of inflammation dictates the type of balanitis – Bacterial, fungal, allergic, contact (zoonoid), lichen sclerosus (also known as 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, also known as balanitis xerotica obliterans (BXO) is a chronic inflammatory skin condition affecting the penis. It deserves special attention because of the significant complications it can cause if left untreated.
Although the exact cause remains unclear, several factors are presumed to be contributing to its development. One of the leading assumptions is that prolonged contact between urine and the skin beneath the foreskin triggers chronic inflammation. Genetic predisposition is also evident, as the condition is more commonly seen in men with diabetes, obesity, and a history of smoking.
As lichen sclerosus is progressive, the foreskin can gradually become thickened, scarred, and less elastic, resulting in pathological phimosis. Over time, erections may cause the tightened skin to split, leading to further scarring which aggravates foreskin tightness. In some cases, adhesions may develop between the foreskin and the glans, causing their separation to become difficult or impossible.
The condition can also affect the glans and extend into the urethra, the tube carrying urine out of the body. This may result in urethral narrowing, leading to urinary difficulties and, in some cases, significant obstruction to urine flow. Lichen sclerosus is also associated with an increased risk of penile cancer, highlighting the importance of early diagnosis and treatment.
Due to the progressive nature of the condition, treatment should start early. Initial management typically involves an effective topical steroid combined with a barrier cream to minimize skin contact with urine and control inflammation. Many men instinctively wash the area very often, but this can cause more skin dryness and irritation. Soap should be avoided in all cases and replaced with a gentle emollient wash.
Men with adult-acquired buried penis will particularly need careful assessment. In certain cases, circumcision is performed without addressing the underlying burial of the penis within the surrounding pubic fat. This can lead to constant trapping of urine and persistent skin irritation, resulting in recurrence of lichen sclerosus despite surgery.
Recurrence occurring after circumcision often leaves less healthy penile skin available for reconstruction, making more complex procedures, including skin grafting, necessary. For this reason, the ideal treatment plan should address both the diseased foreskin and the underlying buried penis, in addition to managing the excess pubic fat when appropriate.
An early assessment by an experienced specialist can help prevent disease progression and reduce the risk of long-term complications.
Penile cancer is a rare condition, affecting almost 2 in 100,000 men in Europe. However, its impact can be life-changing. Treatment requires surgery, which may have significant physical, functional, and psychological implications. Therefore, any persistent change to penile skin should be taken very seriously. Red patches, abnormal growths, non-healing lesions, or other unexplained skin changes should be assessed urgently by a urologist with experience in penile skin disease and penile cancer.
Early diagnosis is key, as detecting abnormalities at a pre-cancerous stage often leads to more effective treatment while preserving both function and appearance. Here, circumcision plays a key role in the management of penile pre-cancerous lesions. Besides allowing for the removal of a significant proportion of the tissue at risk, it helps improve visualization and monitoring of the glans, making the early detection of any future changes possible.
Adult circumcision is traditionally viewed as a straightforward procedure. However, achieving the best possible outcome requires careful consideration of other factors such as excess pubic fat, a buried penis, or penoscrotal webbing, all of which can influence both the surgical approach and the final result. Not addressing such underlying issues may compromise functional and cosmetic outcomes.
Penile conditions often bring significant anxiety that needs to be recognized and managed. Concerns about appearance, sensation, sexual function, and recovery are quite understandable and shouldn’t be dismissed. Patients attend their consultations with differing expectations and priorities. For example, a younger man with uncomplicated phimosis, may be primarily concerned about cosmetic appearance, whereas an older man with severe lichen sclerosus and a buried penis is focused more on restoring function and improving quality of life. For this reason, treatment planning and counselling need to be tailored to the patient’s condition, objectives, and expectations.
The cosmetic outcome after a circumcision matters. Although this surgery is often considered minor, attention to detail is a key factor in determining the final appearance and healing process.
In my practice, meticulous wound closure is an essential part of the procedure. Circumcision involves sealing two layers: the underlying dartos tissue and the skin itself. These layers are repaired separately to provide proper wound support, restore normal anatomy, and support optimal healing.
The skin is then closed using fine absorbable sutures put in place with precision and care. Taking small, closely spaced bites of tissue helps reduce scarring and the risk of the visible “tramline” effect that can occur when sutures are not placed with enough care.
Although my approach may take longer than a standard closure, I believe the additional time and attention are worthwhile. My ultimate goal is not simply to remove the foreskin, but to achieve the best possible functional and aesthetic outcome for each patient.
