Circumcision(Jones’CPS)
Persisting physiological phimosis (a congenital narrowing of the opening of the foreskin so that it
cannot be retracted.) resolution by apply topical application of steroid cream has reduced this need
for circumcision!
a 10-fold reduction in the incidence of UTI in circumcised males from 1/100 to 1/1000.
especially in the first year of life . Carcinoma of the foreskin does occur as a rare tumour in elderly
men with long-standing phimosis.
The penis has a very good blood supply and post-operative bleeding may occur.
In the neonatal period, any bleeding is of major concern as the blood volume of the average
newborn is 80 mL/kg, which is 240 mL for a 3 kg baby. Any blood loss over 25 mL is potentially life-
threatening. By the age of 6 months, a baby has doubled its birth weight and the tolerance for blood
loss is greater.
Infection of the open wound by coliforms in the nappy area may lead to septicaemia in the
neonatal period as the baby’s own immunity is poorly developed. By the age of 6 months, the baby
is better able to cope with infection.it may lead to meatal stenosis from scar contraction around
the urethral meatus.
The glans needs to be protected after circumcision with copious amounts of moisturising cream
applied via nappy-liner cloths for 2–3 weeks after the surgery.
It’s performed after the age of 6 months in an operating theatre under general anaesthesia, with
careful surgical technique
Indications for circumcision-
Medical (Phimosis, Paraphimosis, Balanitis ,Serious urinary tract anomaly )
Non-medical (Religious ,Social)
Complications of circumcision
Bleeding, Infection (local or septicaemia) ,Ulceration of glans or meatus, Penile deformity ,Penile
obliteration
Circumcision-Ashcrafts
It’s (removal of the redundant prepuce) one of the most frequently performed surgical procedures
in the world
the American Academy of Pediatrics (AAP) states, “Although health benefits are not great enough
to recommend routine circumcision for all male newborns.
This variation in incidence likely reflects religious and cultural differences.
The Prepuce
The prepuce is the anatomic covering of the glans involving an outer and inner layer with
attachments to both the shaft and corona
Problems with sexual dysfunction (inability to ejaculate, lacking interest, premature ejaculation, pain
during sex, not enjoying sex) appear to be slightly more prevalent among uncircumcised men
Medical Indications
The inability to retract the foreskin of a newborn is the result of incomplete keratinization of the
glans and is not pathologic
Phimosis is the inability to retract the foreskin. True phimosis is associated with a white, scarred
preputial orifice, most common just before puberty, and is an indication for circumcision
الدكتور حسن يوسف محمد الفهدواي
Balanitis xerotica obliterans is a ring-like distal sclerosis of the prepuce with whitish discoloration or
plaque formation that may involve the prepuce, glans, or urethral meatus, and is also an indication
for circumcision. Balanitis is an infection of the glans.
Paraphimosis occurs when the foreskin has been retracted behind the corona and is unable to be
brought back over the glans.
posthitis is an infection of the prepuce.
Routine Circumcision at Birth
on the eighth(8)day in the Jewish faith, traditionally by a mohel, a member of the faith trained in
circumcision. In Islamic countries, when performed, there is a wide variability in age at circumcision.
One urologic study among children without urinary complaints found a correlation between
circumcision and meatal stenosis. 20% of boys seen between 5 and 10 years of age who had
undergone neonatal circumcision were found to have meatal stenosis.
three advantages: prevention of urinary tract infections (UTIs),prevention of sexually transmitted
disease (STD), and prevention of cancer, both penile and prostate
uncircumcised individuals have an increased risk of acquiring human immunodeficiency virus (HIV),
human papillomavirus (HPV), and genital herpes
There is also evidence that circumcision is associated with a decreased risk of cervical cancer in
women.
Behavior and sexual practice still represent the greatest risk factors in STD transmission.
The inner surface of the foreskin contains Langerhans cells with HIV receptors. This explains the
rational for circumcision to decrease HIV infection in men.
The most recent two Cochrane Reviews cite a protective association between circumcision and HIV
acquisition, and recommend routine circumcision among heterosexual men while stopping short of
recommending the same in homosexual men
Other factors associated with invasive penile cancer include smoking, a history of genital warts,
penile rash or tears, multiple sexual partners, and poor penile hygiene
By 8 years, the uncircumcised group had experienced 50% more penile “problems.”
Surgical Technique
the goal is removal of an adequate amount of prepuce to uncover the glans, treat or prevent
phimosis, and eliminate the possibility of paraphimosis.
the surgeon must be familiar with and adept at the technique with a resultant low complication rate
NEWBORN CIRCUMCISION
Another study, looking at pain in relation to timing, recommended circumcision before 8 days of age
Effective relief of circumcision pain has been found with acetaminophen, topical lidocaine–procaine
cream, and local nerve blocks.
(AHMED) a Gomco circumcision(The Gomco technique), the field is sterilely prepped, and adhesions
between the glans and inner surface of the prepuce are bluntly separated. The extent of foreskin to
be excised is marked with a pen or a crush of the dorsal prepuce with a straight clamp.
Electrocautery should never be used because of transmission of the electrical current to the penis
A Plastibell (Plastibell technique)allows strangulation of the distal foreskin, with a resulting slough of
the tissue. After sterile prep and dorsal slit, the appropriate-sized Plastibell is placed over the glans
inside the prepuce, The distal foreskin remnant and ring typically slough off in 7–14 days.
الدكتور حسن يوسف محمد الفهدواي
REVISION CIRCUMCISION
the family feels the redundant, residual prepuce is unsightly, or with a postoperative phimosis, they
may seek an opinion regarding revision, the indications were primarily preputial redundancy,
residual cicatrix, preputial-glandular bridges , a sebaceous cyst, and urethrocutaneous fistula.
FREEHAND CIRCUMCISION
In older patients, circumcision is usually performed in the operating room and devices are less often
used
Complications
Bleeding and infection are the most frequent complications and are generally minor
Although adhesions between the foreskin remnant and the glans are common
serious complications can develop, including necrotizing fasciitis, sepsis, Fournier’s gangrene, and
meningitis, skin bridges.
cysts, iatrogenic hypospadias or epispadias, partial glans amputation, and catastrophic loss of the
penis
when electrocautery is used with a metal device. There can be excision of too much or too little of
the foreskin, with resultant postoperative phimosis or concealed penis
الدكتور حسن يوسف محمد الفهدواي
