Medical Care
Daily cleaning, without forceful retraction of the foreskin, is the only treatment necessary for phimosis in patients without urinary obstruction, hematuria, or preputial pain.
Treatment with topical corticosteroids is effective in separating the loose adhesions found between the glans and the foreskin.
In 2001, French researchers Berdeu et al used data from published reports and from claims by private hospitals for children younger than 13 years. They found that topical application of clobetasol or 0.05% betamethasone cream 2 times/day to the foreskin and glans for 4-8 weeks was effective in allowing full retraction of the foreskin in 85% (range, 70-100%) of the patients who had a mean age of 5 years at inclusion. The 15% failure rate was attributed to verifiable cases of lichen scleroticas et atrophicus or nonspecific chronic inflammatory processes. Success was achieved at approximately 10% of the cost of operative circumcision; this result showed a considerable cost-effectiveness with this approach. [17]
Surgical Care
Although several techniques are used in neonatal circumcision, all of the methods involve the following common elements:
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Estimation of the amount of foreskin to be removed
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Dilation of the preputial orifice to determine the presence of a normal glans and penis without any evidence of hypospadias, epispadias, chordee, or other anomalies
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Blunt separation of the inner preputial epithelium from the glans
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Placement of a device designed to ensure hemostasis
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Removal of the foreskin
The 3 most common devices used to date are the Gomco clamp (67%), the Plastibell device (19%), and the Mogen clamp (10%). Both the Gomco clamp and the Mogen clamp are excellent instruments for infants but should not be used in toddlers who weigh more than 5 kg because of an increased risk of bleeding. Cosmetic results are excellent with any of these devices if they are used correctly.
In the authors' experience, the Plastibell technique can be used safely for office circumcisions in children up to 10 kg under local anesthesia because this technique induces tissue necrosis by means of suture compression of the foreskin over a plastic ring that protects the glans. Thus, adequate hemostasis is ensured in the older child. The skin sloughs off in 5-7 days, and the ring separates.
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Infant penis.
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Retracting the foreskin with a dorsal slit and marking the area to be incised. Video courtesy of Pamela I Ellsworth, MD.
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Sleeve technique with electrocautery. Video courtesy of Pamela I Ellsworth, MD.
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Suturing the mucosal collar to the penile shaft skin circumferentially. Video courtesy of Pamela I Ellsworth, MD.
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Circumcision complete. Video courtesy of Pamela I Ellsworth, MD.
