Circumcision
Definition:
Phimosis: stenosis of the preputal ring with
an inability to retract the foreskin.
Paraphimosis: retention of the retracted
foreskin in a position proximal to the coronal
sulcus.
Balanitis: inflammation of the foreskin.
Posthitis: inflammation of the glans.
Meatitis: inflammation of the urethral
meatus.
1
Retractability of the
foreskin
Birth 5%
6months 15%
1year 50%,
3years 90%.
2
Potential benefits of circumcision
Protection against penile cancer.
Protection against urinary tract
infection.
Protection against sexually transmitted
diseases.
Protection against carcinoma of the
3
Indications
Medical
Pathological Phimosis
White, scarred prepuce (BXO - absolute)
May cause ballooning, bleeding, dysuria or retention
Alternatives are preputioplasty / steroid cream
Recurrent Balanitis
Religious
Exclude diabetes
Urinary Tract Infection Prophylaxis
Protects against UTI in infants with VUR, PUJ, posterior
valves and hydronephrosis 1
In VUR: 63% v 19% of circumcised boys suffered UTIs
4
1 Herden CDA. J Urol 1999
Contraindications to
circumcision
Hypospadias.
Other associated genital anomalies.
Unstable or sick infant.
Family history of bleeding tendency.
5
Contraindications
Premature Infants
Congenital Penile Abnormalities
Hypospadias, episapdias, chordee, penile
webbing or concealed penis
Blood Dyscrasias
6
Complications of
circumcision.
Serious: life threatening: infection and
bleeding. Not life threatening: fistula
amputation.
Not serious: Inadequate skin removal
(incomplete circumcision). Excessive
skin removal. Inclusion cyst. Skin
bridges etc.
7
Complications
Chordee
Urethrocutaneous Fistula
Urethral injury during excision of prepuce
Necrosis
Secondary to circumcision is related to excess skin
removal
May occur secondary to surgery or infection
Only use bipolar electrocautery sparingly and never
with a ‘clamp’ device
Amputation of Glans
May occur using a ‘clamp’ device
8
Complications
Death
Bleeding (2-5%)
Suture sinus tracts
Infection (2%)
Phimosis and
concealed penis
Adhesions
Meatal stenosis
Chordee
Urethrocutaneous
fistula
Necrosis
Amputation
Hypospadias
Meatitis
9
Surgical technique
Principles: freeing the foreskin,
identifying the meatus, retracting the
foreskin, identifying the coronal sulcus.
Anesthesia: Local, General, None.
Instruments: Gomco clamp, Plasty
bell, etc.
10
The ideal circumcision
Neonatal age.
Local anesthesia.
Selective delay for those who need so.
Instruction to parents about
risks.infection, bleeding.
Follow up.
11
HYPOSPADIAS
Hypo- below, Spadon- orifice
Urethral meatus opens on ventral side of the
penis, proximal to the tip of glans penis
Incidence ……..1/125 to 1/250
12
Hypospadias
Definition: Is a congenital defect of the
penis resulting in incomplete development of
the urethra, corpora cavernosa, and prepuce.
Clinically results in deflection of the urinary
stream and abnormal appearance of the
penis.
Severe hypospadias is associated with
chordee which may result in infertility
secondary to difficulty in insemination.
Cosmetic and functional defect.
13
Subcoronal hypospadias
14
Types of hypospadias
15
EMBRYOLOGY
Cloacal membrane, genital tubercle, labioscrotal
swellings
Androgen stimulation…phallus elongation
3 phases of urethral formation
Posterior urethra formation
Anterior urethra formation
Glandular segment formation
Prepuce formation
16
PARTS OF HYPOSPADIAS
Meatus … usually non-stenotic
Stenosis more common in distal hypospadias
Megalomeatus intact prepuce
17
SKIN…..
Ventral defect & dorsal hood
Urethral delta
Hood of monk….Cobra eyes
Defects of spongiosum
Defects of cavernosa
Defective urethral plate
18
CURVATURE
Skin attachments
Bucks defect
Urethral plate
Cavernosa defects
Problems of unhealthy urethra
19
CLASSIFICATION (LOCATION)
DISTAL
Glandular, Coronal, Distal penile
MIDPENILE
Midshaft
PROXIMAL
Proximal penile, Penoscrotal, Scrotal, Perineal
20
Classification
Anterior 50%, the meatus is on the
glans, coronal or subcoronal position.
Middle 30%, the meatus is on the
shaft of the penis.
Posterior 20%, the meatus is
between the perenium and the
penoscrotal junction.
21
Associated anomalies
Undescended testis 10-30% depending on the
severity of the hypospadias.
Inguinal hernia 10%.
Utricle, remnant of the Mullairian duct system.
Urinary tract anomalies are infrequent in isolated
hypospadias.
Hypospadias alone or when associated with hernia do
not require further investigations.
Severe hypospadias, specially when associated
with undescended testis should be investigated for
possible intersex with karyotyping and endocrine
workup.
22
ASSOSIATION WITH OTHER DEFECTS
Renal agenesis, dysplasia, reflux
Prostatic utricle
Hernia
: 9%
Cryptorchidism
: 9%
Father
: 9%
Siblings
: 14%
23
Treatment
Surgery is best performed 6-18 months of
age.
Single stage versus multistage repair.
Outpatient versus inpatient.
Goal of repair: normal urethra, normal glans.
Final goal: straight shaft, normal skin normal
appearing meatus, normal skin coverage, and
normal penoscrotal position.
Correction of functional and cosmetic defect
24
is the goal of hypospadias surgery.
Operations
Utilization of local tissue, skin, tabularization,
flaps, grafts, urethral advancement.
Utilization of adjacent tissue, skin, prepuce,
penile skin scrotal skin in the form of flaps or
grafts.
Utilization of remote tissue, skin mucosa,
buccal, bladder.
Staged repair.
Operations for chordee correction.
25
Results & complications
Success rate
70-100% depends on
The severity of the hypospadias
The surgical technique
The surgeon.
26
HYPOSPADIAS & INTERSEX
? Form of androgen insufficiency
Mixed gonadal dysgenesis
Androgen insensitivity
Testosterone synthesis defects
5 alpha reductase defects
27
COMPLICATIONS
BLEEDING & HEMATOMA
MEATAL STENOSIS
URETHROCUTANEOUS INFECTION
URETHRAL DIVERTICULA
RECURRENT CURVATURE / STRICTURE
BREAK DOWN
28
