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Patient Advice and Information

Tight Foreskin in Boys & Adult Circumcision
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

A. Tight Foreskin in Boys

1. Does my boy have a tight foreskin?

When a boy is born, the foreskin [prepuce] is long with a tight tip. Retraction is no possible in almost all infants, as the inner lining of the prepuce is fused with the surface of the glans penis. This is sometimes improperly called phimosis [a pathological condition characterised by hardening of the tip of the foreskin] and the fusion is improperly called “adhesions”, as the fused foreskin will often separate by the age of 3-5; sometimes it takes longer. This maturing is a normal stage of development and may require years to complete. Each boy matures at his own rate and he maturation of prepuce continues beyond puberty.

You should remember that the appearance of an infant penis does not reflect on the appearance of the adult penis!

By the age of 3, the skin is retractable in 75-90% of boys, but even till puberty, by the age of 11-15 years, up to 35% of boys may have some degree of inretractability. 

2. What should I do about my son’s foreskin?

·    Leave it alone; wash only what is external and readily visible.

·    Never forcibly retract your son’s foreskin and do not permit anyone else to do so. The fortunate foreskin of an infant boy should be left alone by everyone but its owner.

·    When teaching your child to bathe and care for himself, let the child retract his own foreskin if he wants to. He will not retract it beyond the point of discomfort. As a boy becomes more aware of his body, he will most likely discover how to retract his foreskin.

·    A child’s foreskin should not be retracted regularly for cleaning until the end of puberty.

3. What about spegma and irritation/itching?

Spegma is a natural oily, waxy lubricant formed between the foreskin and the glans. It forms rarely in children whose foreskin has not been forcibly retracted. Any accumulation of such whitish lubricant can easily be cleansed during the boy’s shower or bath.

If there is irritation and redness of the foreskin simply apply a protective healing ointment such as A&E ointment, vitamin E or antibiotic ointment. When dirt or sand [in active, older boys] caused the irritation, you should gently rinse the area with warm water.

4. When is treatment necessary?

·   If there is true phimosis

·   If the stream of urine is never heavier than a trickle

·   If your son has discomfort passing water

·  If there is infection of the penis and skin or recurrent urinary tract infections

·   If there is stenosis [the skin balloons on urination]

5. Which treatments are available?

a. Conservative.

The topical application of steroids [0.05% betamethasone cream] is quite effective and is recommended by all paediatric societies. The success rate is 80-90%. Thus, the foreskin and all its protective, sensory and physiologic sexual functions are preserved.

b. Stretching and dilatation

The skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time.

Stretching is actually imitating the natural development.

c. Surgery

Surgery is indicated in true phimosis or true stenosis, demonstrated by urine tickle, repeated infections and ballooning.

About 2-4% of children with tight foreskin will require surgery.

6. What type of surgery is to be performed?

a. Circumcision which is the surgical removal of the foreskin. There are two types of techniques, the dorsal slit and the sleeve technique. The redundant and tight foreskin is excised and the wound is stitched by interrupted dissolvable stitches [they take about 3 weeks to dissolve].

b. Preputioplasty and other types of plastic repairs like the multiple V-Y plasty are used increasingly as they preserve the functional foreskin, they have a more rapid and less painful recovery and significantly less morbidity.

7. How is the operation carried out?

The operation is usually done under general anaesthetic. It is usually performed as a day case. Day case surgery means that after surgery, when your son recovers from anaesthesia [3-4 hours if general, 1-2 hours after local anaesthesia] you will take him home, with all instructions given to you before [by the surgeon] and after surgery [by the nursing staff].

8. Coming into hospital

You will be asked to bring your son in the day of your operation without letting him drink or eat anything at least for the last 4 hours. A nurse will receive you in the ward and she will note down your details. Please do not hesitate to ask her about any concern you may have. The surgeon and the anaesthetist will also see you prior to surgery and you will be asked to sign a consent form that the procedure has been explained to you and you agree to go ahead.

9. The operation

You will come will your son in the anaesthetic room and you will be there till the anaesthetist uts him to sleep. Then he will be transferred in the operating theatre, where the area will be cleaned and sterile drapes will be placed to guard against infection.

The type of the procedure performed [circumcision or perputioplasty] depends partially on the decision you and the surgeon have made and partially on the operative findings.

A small dressing with petroleum gauge and a sterile gauge may cover the penis, but quite often no dressing is applied.

As with any surgical procedure, bleeding and infections are probably the more common complications, but the risk is minimal [0.2-0.6%].

10. What about care after surgery?

The effects of anaesthesia take some time to pass, time during which a nurse will make regular observations of his condition. Once his condition allows im [3-4 hours] he will be able to drink and eat something light. After the wound has been inspected, you will be discharged home the same evening or the next day. Usually there is no need for antibiotics and pain-killers.

If the dressing falls, there is no need to replace it. Otherwise, it should be removed 24-48 hours after surgery. Your son should then wear loose-fitting briefs [or panties if he is an infant] and you should gently wash the wound daily for the next 3-5 days.

The penis [especially after circumcision as the foreskin fusion to the glans is mobilised] will often swell and look red. This is quite normal. It s also normal for the tip of the penis to ooze some fluid and form a scab over it for the next 3-4 days, that will flake off.

He may also experience a burning sensation when you pass water, but this subsides quickly.

Your son can return to his normal activities when he feels sufficiently well, generally after 12-48 hours.

B. Adult Circumcision

1. What is circumcision?

Circumcision is the surgical removal of the foreskin.

It is usually performed for:

·     extreme tightening of the skin that does retract to reveal the glans [phimosis],

·     ballooning when passing water, repeated infections [balanitis, posthitis],

·     acute swelling of the glans due to tightened foreskin behind it [paraphimosis] or

·         bleeding and painful intercourse.

2. How is the operation carried out?

The operation is usually done under general anaesthetic but can under certain circumstances be done under local anaesthesia. It is usually performed as a day case. Day case surgery means that after surgery, when you recover from anaesthesia [3-4 hours if general, 1-2 hours after local anaesthesia] your escort will take you home, with all instructions given to you before [by the surgeon] and after surgery [by the nursing staff].

3. Coming into hospital

You will be asked to come in the day of your operation without drinking anything at least for the last 4 hours, if you are to have surgery under general anaesthesia. Please bring with you all the medicines you are taking to show to the doctor. A nurse will receive you in the ward, will note down your details and will ask about any other conditions you suffer from. The surgeon and the anaesthetist will also see you prior to surgery and you will be asked to sign a consent form that the procedure has been explained to you and you agree to go ahead.

4. The operation

You should wash the area thoroughly before surgery.

The anaesthetist will put to sleep and you will be transferred in he operating theatres. Sterile drapes will be placed over you to guard against infection and if local anaesthetic is to be administered it is given by injection at the base of the penis or around the shaft.

There are two types of techniques, the dorsal slit and the sleeve technique, with small differences between them.

The redundant and tight foreskin is excised and the wound is stitched by interrupted dissolvable stitches [they take about 3 weeks to dissolve].

A small dressing with petroleum gauge and a sterile gauge may cover the penis, but quite often no dressing is applied.

5. What are the possible complications?

As with any surgical procedure, bleeding and infections are probably the more common complications, but the risk is minimal [1-2%].

Poor cosmesis due to scarring is a late complication.

6. What about care after surgery?

The effects of anaesthesia take some time to pass, time during which a nurse will make regular observations of your condition. Once your condition allows you [3-4 hours] you will be able to drink and eat something light. After the wound has been inspected, you will be discharged home the same evening or the next day. Usually some antibiotics and pain-killers are prescribed for the first days following surgery.

If the dressing falls, there is no need to replace it. Otherwise, it is removed 24-48 hours after surgery. You should then wear loose-fitting briefs and you should gently wash the wound daily for the next 5-7 days.

The penis will often swell and look red. This is quite normal. It s also normal for the tip of the penis to ooze some fluid and form a scab over it for the next 3-4 days, that will flake off.

You may also experience a burning sensation when you pass water, but this subsides quickly.

Sexual intercourse and masturbation should be avoided for the about 4 weeks following surgery to prevent wound breakdown. There are drugs that can be used to abort erections that occur during the recovery period [inhaled amyl nitrate] but it not usually required.

7. Return to normal activity?

You can return to work when you feel sufficiently well, generally after 2-4 days. Heavy work should be avoided for a week and thereafter activity should be judged in relation to any discomfort present.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

 
 

This page was last updated on 01/10/2006

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures