Phimosis, Adult Circumcision, and Buried Penis Treatment & Management

Phimosis

Applications of steroid creams (0.05% betamethasone) have been used to manage phimosis medically. ^[35]  The usual regimen is application of the steroid cream once or twice daily for 4-6 weeks. Studies have shown a success rate of 87% with this treatment. Higher rates of success have been reported with concomitant preputial stretching exercises.

If a patient has concomitant balanitis or balanoposthitis, depending on the etiology, he may be treated with topical antibiotics or antifungals. Patients with diabetes mellitus should be advised on proper serum glucose control.

Buried penis

Buried penis cannot be treated medically. The separate entity of trapped penis following neonatal circumcision has been successfully treated with topical betamethasone and manual retraction.

Phimosis

In the United States, circumcision is the surgical treatment of choice for correction of phimosis. In European countries, however, preputioplasty is often used. Although these techniques are outside the scope of this discussion, patients should be aware that these prepuce-preserving methods exist.

Adult circumcision can be performed under local or regional anesthesia and commonly involves either the dorsal slit or the sleeve technique. In China, however, standardization with a device known as the Shang Ring has proven effective, with a substantial decrease in both operative time and anesthetic requirements. ^[36] The dorsal slit is often useful in patients with phimosis, and the sleeve technique may allow for better hemostasis in patients with large subcutaneous veins.

A properly performed circumcision eliminates phimosis, as well as the risks of paraphimosis and frenular tears or bleeding associated with sexual intercourse.

Buried penis

Numerous techniques have been described for repairing the buried penis. Variations have been proposed for different presumed etiologies and to simplify the procedure. Recurrence and the need for subsequent procedures are possibilities. While the challenge of repair may seem daunting for most general urologists, reconstructive experts have reported unanimous success of a lasting nature. ^{[37, 38, 39, 40]}

 

Obtaining proper informed consent before the procedure is critical. In particular, inform patients of potential risks, which include bleeding, hematoma formation, infection, suture disruption, inadvertent injury to the urethra or glans, removal of too much or too little skin, and a change of sensation during intercourse.

With regard to surgery for the buried penis, patients should be aware of a 1-15% chance of recurrence (secondary concealment) that may necessitate reoperation. Risk factors specifically relating to the correction of a buried penis in adults include a predisposition to erectile dysfunction and loss of sensation over the skin-grafted area for those presenting with eroded penile shaft skin secondary to inflammation and bacterial infections. ^[27]  

Patients undergoing circumcision for recurrent balanitis should be free from infection before the procedure.

Surgical repair for phimosis

With the patient in a supine position, the genital area is prepared with povidone-iodine solution. Shaving or clipping of the pubic hair is usually unnecessary.

A general anesthetic is recommended in children. A local anesthetic may be used in adults. Local anesthesia is accomplished by administering a dorsal penile nerve block followed by a ring block.

A mixture of equal volumes of 0.5% bupivacaine (Marcaine) and 1-2% lidocaine (Xylocaine) without epinephrine is common. A potential complication of epinephrine use is local tissue ischemia. The maximum recommended dose of lidocaine without epinephrine is 4.5 mg/kg, or 315 mg in a 70-kg male.

Dorsal slit circumcision

To perform the dorsal slit circumcision, clamp the foreskin at the 12-o'clock position with 2 straight hemostats to limit bleeding. See image below.

Sharply incise the tissues between the 2 clamps perpendicular to the corona. Make the proximal circumscribing incision. See images below.

Excise the foreskin at its base (approximately 1 cm proximal to the coronal sulcus) with scissors to produce a cosmetically attractive circumcised penis. The amount of skin left below the coronal sulcus should be no more than 1 cm long to prevent edema, adhesions, and, occasionally, paraphimosis. See image below.

Ligate superficial veins and obtain hemostasis with electrocautery.

Circumferentially approximate the proximal and distal edges of the foreskin with 4.0-5.0 absorbable sutures (children) or 3.0-4.0 absorbable sutures (adults) in an interrupted fashion. See image below.

During the circumcision, the use of a thin tapered (noncutting) needle is recommended because it is less traumatic to the tissues and causes less bleeding.

Bacitracin ointment is used to lubricate the suture material (eg, chromic) to facilitate passage of the suture through the delicate skin tissues. This is especially helpful in the pediatric population. Alternatively, mineral oil may be used as a lubricant.

Sleeve technique

The sleeve technique is an attractive alternative for circumcision.

After proper anesthesia has been achieved, mark the redundant foreskin with a marker.

Before making the initial incision, take care to measure out the correct amount of foreskin to be removed. This is accomplished by gently stretching out the penis with an index finger applied to the penoscrotal junction and noting the indentation of the coronal sulcus through the penile skin.

Outline the coronal sulcus with a marker. This is the proximal skirt of the circumscribing incision. The distal skirt of the circumscribing incision is approximately 1 cm proximal to the corona. When this is properly performed, a sleeve of foreskin is present between the 2 incisions, and the remaining penile skin does not remain too short or too long. See images below.

Clamp the redundant foreskin between the circumcision incisions at the 12-o'clock position and incise it. See image below.

Remove the sleeve by using electrocautery. See image below.

Obtain hemostasis with cautery and ligatures. If circumcision has been performed properly, the proximal and distal skirts should approximate well without tension. See image below.

Once hemostasis has been achieved, circumferentially approximate the edges of the foreskin with 3.0-5.0 absorbable sutures in either a running 4-quadrant closure or an interrupted fashion. Admittedly, while a sutured closure is most commonly used, 2-octyl cyanoacrylate (2-OCA; Dermabond, Ethicon) represents an alternative. ^[41] Correct technique allows for proper cosmesis. See images below.

Surgical techniques for buried penis

In pediatric cases, sources have described the essential nature of dividing dysgenetic dartos bands and fixation of the dartos fascia to the Buck fascia dorsally in the midline, ventrally over the corpus spongiosum, and proximally along the penile shaft. Care must be taken to avoid injury to either the urethra or the neurovascular bundles.

Defatting of the mons pubis is an essential step in buried penis repair in adult patients, but opinions vary as to the value of its removal in children. This can be achieved by excisional lipectomy, liposuction, or a combination thereof. ^[42] The same controversy exists regarding whether or not to take down the suspensory ligament. In the authors’ experience, this is rarely necessary and may lead to instability of the erection.

In 2004, Frenkl et al described a simple technique for the repair of buried penis in children, as follows: ^[43]

• First, a traction suture is placed in the glans, and local anesthetic is instilled along the subcoronal circumference.
• A circumcision incision is then used, and, using the Buck fascia as the dissection plane, the penis is degloved to the penopubic junction.
• As the next step in the operation, numerous authors describe sharp dissection of dysgenetic dartos fibers.
• Fixation is then performed between the Buck fascia and the dermis at the base of the penile shaft with 5-0 sutures at the 3- and 9-o'clock positions.
• The circumferential incision is then reapproximated at its origin with interrupted absorbable suture.

Cromie et al (1998) applied a similar technique in adults for correction of buried penis that involved making a circumferential incision of the inner preputial skin layer proximal to the corona, unfurling the incised skin from the penile shaft, and leaving a coronal collar of approximately 1 cm. ^[44]

Brisson et al (2001) add a longitudinal incision on the penile shaft ventrally, along the median raphe. They utilize this exposure to allow for additional points of fixation between the skin and the tunica albuginea. ^[30]

In 1998, Donatucci and Ritter reported their technique for correction of buried penis in adults as follows: ^[45]

• If a pannus is to be resected, the amount to be removed is estimated with consideration of avoiding undue tension upon closure. Both liposuction and panniculectomy have been used in these operations. Generally, if excess skin with poor tone is present, panniculectomy should be performed instead of liposuction.

• Resection is done in an elliptical fashion down to the mons pubis, which is mobilized to the base of the penis. The mons pubis is then resuspended with sutures between the superficial fascia at the penile base and the deep fascia of the abdominal wall. The wound is closed over a drain with gentle pressure over the pubic area.

• A traction suture is placed in the glans to facilitate dissection, and a Foley catheter is used to protect the urethra. The scar contracture is released, and the penis is degloved to the base along the Buck fascia, with preservation of neurovascular bundles. Adhesions are separated as they are encountered, and chordee is corrected.

• Artificial erection is used to confirm chordee correction and to determine tissue needs for optimal construction. This maneuver is performed using a Penrose drain as a tourniquet at the penile base and injecting 50-100 mL of sterile saline into the corpora cavernosa with a 21-gauge butterfly catheter. If adequate length is not obtained, the suspensory ligament is divided and resuspended from the symphysis pubis with 1-0 silk sutures with the penis in traction.

• If a patient has a minimal deficiency of longitudinal penile skin, a plasty rearrangement of this skin can often be accomplished. If a severe deficiency of skin is appreciated, a split-thickness skin graft may be used, either from a panniculectomy specimen (if available) or from the lateral thigh. ^[46] (Other authors, such as Chopra et al [2002], feel that a full-thickness skin graft is more appropriate. ^[47] ) Once fixation between the skin, dartos, and tunica albuginea at the base of the penis has been performed, as described above, skin grafts are applied in spiral fashion. If the wound bed is inadequate for grafting because of scarring, the use of flaps may be considered.

• A penile block at the conclusion of the procedure may provide better postoperative pain control.

A more recent description has described a W-shaped excision that may allow for minimal dog-ear deformity. ^[48]

Adult circumcision

Following adult circumcision, many urologists choose not to use a dressing. However, either petroleum jelly and sterile gauze or Xeroform petrolatum gauze may be wrapped around the penis circumferentially, followed by application of sterile gauze and a nonadhesive elastic wrap.

In adults who have undergone circumcision, discharge medications should include oral narcotics. The dressing is removed 24-48 hours after surgery. The patient should wear loose-fitting briefs after surgery, and he may shower but should wash gently around the incision site.

Full recovery may require 4-6 weeks of complete sexual abstinence.

Buried-penis surgery

Following surgery for buried penis with skin grafting, the authors’ preference is to use a vacuum-assisted closure, negative-pressure dressing in addition to an indwelling Foley catheter. Pressure of 75 mm Hg is maintained for 5 days, with the patient on bed rest. Upon removal, the patient is discharged with a regimen of petroleum gauze dressing changes.

In patients who have undergone panniculectomy, a pressure garment may be worn over the surgical site for 4-6 weeks. In patients who have undergone liposuction, a pressure dressing is left in place for 7 days.

Children have few restrictions after surgical correction of the buried penis. Adults, however, must refrain from strenuous activity, heavy lifting, and sexual activity for 6 weeks after operation. Despite avoidance of sexual activity, erections are encouraged to avoid subsequent restriction by graft contraction.

Circumcision

Circumcision is a safe surgical procedure that is well tolerated in nearly all patients. However, as with any surgical procedure, complications are possible although uncommon. In a study of nearly 8000 adult men who underwent voluntary medical male circumcision (VMMC), fewer than 1% reported adverse effects and all of those effects resolved without long-term sequelae. ^[49] Possible complications include bleeding, infection, hematoma, swelling/lymphedema, pain, and poor cosmesis. Even given the low risk of adverse events, circumcision should be performed only by competent medical professionals, as cases of self-circumcision by members of the general public have produced tragic outcomes. ^[50]

Postoperative bleeding is the most common complication. It usually occurs when a scab is pulled off as the dressing is being removed. However, sutures can also be torn by erections before healing is completed. Bleeding can often be controlled with direct pressure. Rarely, electrocautery or ligature is required.

Infection after circumcision is uncommon and, if encountered, may be treated with local or oral antibiotics.

Urethral injury is extremely rare. A urethral injury that can result from circumcision is a subcoronal urethrocutaneous fistula. This condition necessitates surgical correction.

Suture sinus tracts can occur if a simple suture becomes epithelialized before suture absorption. These frequently go unnoticed and are likely inconsequential.

Postoperative adhesions may lead to formation of skin bridges between the circumcision incision and the glans. These adhesions are typically on the dorsal surface and therefore may present an obstacle to proper hygiene.

The most devastating complication associated with circumcision is amputation of the penile shaft. One report detailed repair of such complications by corporal advancement with accompanying fat flap interposition and skin grafting. ^[51] It is also possible to inadvertently remove an excessive amount of foreskin, requiring either grafting or a flap reconstruction. Another postcircumcision complication, although rare, is keloid formation. While topical application of steroids has been used, surgical excision remains the standard modality of treatment. ^[52]

A study by Fink et al (2002) examined the sexual effects of adult circumcision. ^[53] They found that circumcision in the adult appears to result in worsened erectile function and decreased penile sensitivity. However, sexual activity did not change, and satisfaction was actually improved. Given that 93% of the patients in that study underwent surgery for pathology, circumcision may have alleviated enough sexual apprehension to allow unmasking of previously unidentified erectile dysfunction. Although many investigators feel that circumcision reduces penile sensitivity, an increase in ejaculatory latency time may, in some cases, be considered an advantage.

Some have speculated that the mucosal cuff length following circumcision may be associated with premature ejaculation. However, an evaluation of 84 men found no association between these entities and concluded that circumcision has no deleterious effect on sexual function. ^[54] Furthermore, reports of a direct comparison between circumcised and uncircumcised men found no difference in genital sensitivity. ^[55]

In evaluating the effect of circumcision on a woman's sexual enjoyment, O'Hara et al (1999) reported that the women surveyed preferred intercourse with uncircumcised men. ^[56] The authors suggest that coitus with a circumcised partner reduces vaginal secretions and decreases continual clitoral stimulation. However, a number of the women surveyed were recruited via the newsletter of an anticircumcision organization.

Buried penis

Correction of the buried penis is a simple and effective procedure with few recurrences or complications. Two series that reported on the long-term outcome of pediatric cases found that the correction resulted in excellent long-term cosmetic results. Higher success rates were found in patients who had the correction as toddlers than in those who had the correction as adolescents. Herndon et al (2003) found that most parents felt that the surgery eliminated associated negative feelings and that it enhanced penile appearance and facilitated better hygiene. ^[57]

Most of the complications reported after surgery for buried-penis correction are temporary. Reported rates of recurrent retraction, however, range from 1-15% and often require additional surgery. Observation is a viable option for mild cases. Ventral edema has been reported in 1-11% of cases and usually resolves spontaneously. Dissatisfaction with cosmesis is possible, but the physician should preoperatively assess for unrealistic expectations. Postoperative sexual dysfunction has been reported, but conditions predisposing to buried penis often carry a higher likelihood of erectile dysfunction.

Studies in an animal model show that buried penis may induce microscopic changes related to erectile dysfunction, including decreased activity of nitric oxide synthase and loss of smooth muscle. ^[58] These changes seem to be directly related to the duration of the condition. Pain upon erection may be seen with suturing of the Buck fascia to the pubic periosteum. Additionally, it needs to be recognized that the area of the skin graft will be insensate.

Patients who have undergone penile reconstruction may present with poor graft healing, flap necrosis, or complaints of decreased sensitivity in the grafted area. Patients may also present with persistent redundancy of the penile skin or reaccumulation of the abdominal fat pad.

Adult patients undergoing surgery for a buried penis are often obese (BMI >30), even with substantial weight loss or weight loss surgery, the overhanging suprapubic pad that is secondary to obesity remains in adults. Whether or not the overhanging panniculus will be removed with weight loss, it is still imperative to educate and advise these patients on increasing physical activity, improving diet, and achieving weight loss before surgery to minimize obesity-related surgical complications. ^[27]  

Routine follow-up after adult circumcision is advisable, but not mandatory. Patients may be seen 2-3 weeks after the operation so that the incision can be examined to see if it has appropriately healed. Following buried-penis repair, both pediatric and adult patients may be seen at 2 and 6 weeks after surgery.