Irvin H. Hirsch, MD
BASICS
DESCRIPTION
• Circumcision involves the removal of the prepuce. This section addresses adult circumcision issues.
• Adult circumcision is indicated for elective treatment of balanitis (glans inflammation), posthitis (prepuce inflammation), removal of preputial lesions, and at patient request for cultural and religious preference.
• Emergent circumcision may be necessary for treatment of paraphimosis after failed attempt at manual reduction.
• Circumcision may be necessary as part of surgical procedures requiring degloving exposure of the penis (penile fracture repair or Peyronie disease).
• Circumcision is the most common operation performed worldwide.
• There is some controversy concerning the need for circumcision and potential effects on sexual satisfaction. This is weighed against the potential health benefits.
EPIDEMIOLOGY
Incidence
N/A
Prevalence
• Male circumcision, largely in newborns, is performed in 77% of US males and in 30% of males worldwide.
• Circumcision rate in newborns has declined from 83% in the 1960s to 77% in 2010.
– These incidence rates do not include out-of-hospital circumcisions
• Increasingly adult circumcision has been advocated as an important adjunct to STD and HIV prevention in developing countries (1).
RISK FACTORS
• Diabetes mellitus
• Genital lesions
Genetics
N/A
PATHOPHYSIOLOGY
• The prepuce serves as a specialized, junctional mucocutaneous tissue marking the boundary between mucosa and skin; it is similar to the eyelids, anus, and lips.
• Condition that can cause problems:
– Lack of genital hygiene
– Chronic balanoposthitis may lead to phimosis
ASSOCIATED CONDITIONS
• Diabetes mellitus
• Balanitis
• Lichen sclerosus/urethral stricture
• Penile condylomata
• Squamous cell carcinoma
• Erectile dysfunction
• Peyronie disease
ALERT
The American Urologic Association (AUA) policy statement now considers circumcision to be of a health benefit, citing a 50–60% risk reduction in HIV transmission in some African nations.
GENERAL PREVENTION
• Local hygiene measures may prevent balanitis and its sequelae.
• Although male circumcision should not be substituted for other HIV risk-reduction strategies, it has been shown to reduce the risk for HIV and some STDs in heterosexual men.
– Despite these data, male circumcision has not been demonstrated to reduce the risk for HIV or other STDs among men who have sex with men (MSM).
• Good visualization of the glans penis is crucial in all cases of circumcision to limit complications.
DIAGNOSIS
HISTORY
• Penile pain with or without erection
• Dyspareunia
• Postcoital pain
PHYSICAL EXAM
• Inability to retract prepuce (phimosis)
• Inability to reduce prepuce (paraphimosis)
• Preputial erythema or excoriation
• Glans erythema
• Malodorous secretion (smegma)
• Associated penile lesion
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• UA
• Urine culture if indicated
• STD testing if indicated
Imaging
N/A
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
• Acute and chronic inflammation
• Plasma cell infiltrate (Zoon balanitis)
• Lichen sclerosus (BXO blanaitis xerotica obliterans)
DIFFERENTIAL DIAGNOSIS
N/A
TREATMENT
GENERAL MEASURES
Circumcision for balanitis in adults should be performed after exhausting nonsurgical medical approaches.
MEDICATION
First Line
• Topical antibiotics
• Topical steroids
• Topical antifungals
Second Line
N/A
SURGERY/OTHER PROCEDURES
• General anesthesia may be utilized
• Local anesthesia is recommended when tolerated
• Lidocaine/bupivacaine combination is injected at the level of the infrapubic bone and around the base of the penis. Avoid epinephrine.
• Technique is selected based on surgeon’s preference: Sleeve technique or dorsal slit circumcision.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
• For high risk or anticoagulated patients an isolated dorsal slit may be oversewn without circumcision.
• Nonsurgical preputial compression devices are currently under investigation for HPV, HSV, and HIV risk-reduction programs in developing countries (Prepex or Shang Ring). The prepuce sloughs after 7 days.
ONGOING CARE
PROGNOSIS
Patient satisfaction is high
COMPLICATIONS (2)
• The majority of complications relating to circumcision are minor and should be easily treated
• While very infrequent, challenging complications requiring complex reconstructive surgery and should be referred to a center specializing in these reconstructions.
• Early
– Hematoma and bleeding
– Infection
– Urinary retention due to tight bandaging
– Glans necrosis
– Removal of inadequate or excessive skin
– Partial penile amputation
• Late
– Urethral injury/urethrocutaneous fistula
– Meatal stenosis
– Hypesthesia or hyperesthesia of penis
– Penile scarring and deformity
Skin bridges between the glans and penile shaft
– Concealed/buried penis
– Inclusion cysts
– Erectile dysfunction
FOLLOW-UP
Patient Monitoring
• Routine postoperative care.
• Follow for alterations in penile sensation and erectile function.
Patient Resources
www.aafp.org/afp/1999/0315/p1514/html
REFERENCES
1. World Health Organization, Department of Reproductive Health and Research and Joint United Nations Programme on HIV/AIDS (UNAIDS). Male circumcision: Global trends and determinants of prevalence, safety and acceptability WHO Press, 2007.
2. Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002;167(5):2113–2116.
ADDITIONAL READING
• Cold CJ, Taylor JR. The prepuce. BJU Int. 1999;83(suppl 1):34–44.
• Millett GA, Flores SA, Marks G, et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: A meta-analysis. JAMA. 2008;300:1674–1684.
• Summerton DJ, Kitrey ND, Lumen N, et al. EAU guidelines on iatrogenic trauma. Eur Urol. 2012;62:628–639.
• UNAIDS, WHO. New data on male circumcision and HIV prevention: Policy and programme implications: WHO/UNAIDS technical consultation male circumcision and HIV prevention: Research implications for policy and programming. Geneva: Joint United Nations Programme on HIV/AIDS and World Health Organization; 2007.
See Also (Topic, Algorithm, Media)
• Circumcision, Pediatric Considerations
• Penis, Cysts
• Phimosis and Paraphimosis
CODES
ICD9
• 605 Redundant prepuce and phimosis
• 607.1 Balanoposthitis
• V50.2 Routine or ritual circumcision
ICD10
• N47.2 Paraphimosis
• N48.1 Balanitis
• Z41.2 Encounter for routine and ritual male circumcision
CLINICAL/SURGICAL PEARLS
• These measures reduce risk of neural injury: minimize use of electrocautery and limit excision superficial to Buck fascia.
• Assure hemostasis of frenular artery.