Adult Circumcision

CHAPTER 117 Adult Circumcision



John R. Holman


Adult circumcision is a procedure about which little is written, even in urologic literature. It is often performed for reasons that are not purely medical, yet it also has clearly defined medical indications. Some patients have their own nonmedical reasons.


General anesthesia may be necessary, but usually local anesthesia is sufficient in the outpatient setting, including the properly equipped office. Informed consent should be obtained after a thorough discussion with the patient (and partner, if appropriate), during which the indications, procedure, postprocedure care, and potential complications are explained. (See the sample patient education and consent forms online at www.expertconsult.com.) This consent is required for all patients, and it must always be documented to serve as a record of the authenticity of the patient’s presenting symptoms. Thorough documentation is important because individual physicians may vary in their judgments of surgical necessity. The physician must make sure that the patient’s reasons for requesting circumcision are medically sound and that the patient’s expectations of the results are realistic. There is evidence circumcision does not change sexual experience or satisfaction.



Anatomy


Identify normal male anatomy before proceeding. Patients with an occult hypospadias or epispadias should be referred to a urologist.



Indications



• Phimosis (tightness of the foreskin so that it cannot be drawn back from over the glans); possibly related to complaints of pain with erections and intercourse

• Paraphimosis (retraction of a narrow, inflamed foreskin that cannot be replaced)

• Penile hygiene; recurrent balanitis (inflammation of the glans penis)

• Posthitis (inflammation of the prepuce) not relieved by medical treatment

• Preputial neoplasms (e.g., erythroplasia of Queyrat, which is severe squamous dysplasia)

• Excessive foreskin redundancy

• Frenular tears

• Patient or partner preference after informed discussion

Patients may also have social, religious, or personal reasons for requesting a circumcision. Exploration of these reasons ensures a thorough understanding of the risks and benefits as well as alternatives to the procedure. Circumcision can reduce the rate of human immunodeficiency virus infection by 50% to 60% and decreases penile human papillomavirus infection. However, it does not appear to prevent other sexually transmitted infections.



Contraindications



Relative



• Psychiatric disorder or history (relative contraindication; these patients must be screened carefully)

• Bleeding dyscrasias (evaluate appropriately)

• History of penile surgery, significant trauma, or unusual-appearing or ambiguous genitalia (consider a referral to a specialist)


Absolute



• Active inflammation in the genital area

• Infection in the genital area


Equipment and Supplies



• 10-mL syringe with a 1- to image-inch, 27-gauge needle and a image-inch, 30-gauge needle

• Prep bowl with a dozen 4 × 4 gauze sponges

• Iodine solution or other antiseptic for scrub

• Ring forceps

• Pack of sterile 4 × 4 gauze bandages

• One fenestrated drape

• 6-inch segment of half-inch Penrose drain

• Six straight mosquito forceps

• One large straight forceps

• One curved Mayo scissors

• One medium-size straight Metzenbaum scissors

• One suture scissors

• 5-inch needle holder

• One Brown-Adson thumb forceps

• 4-0 or 5-0 absorbable suture (e.g., Vicryl, Dexon)

• Petrolatum gauze

• 1-inch Kling bandage

• One malleable 4- to 6-inch silver probe (optional)

• Needle-tip electrocautery unit

• Sterile marking pen


Preprocedure Patient Education and Forms


The patient should be properly counseled and evaluated before the surgery. A patient education handout is provided, and a consent form is signed. (See the sample patient education and consent forms online at www.expertconsult.com.) If the patient is anxious, a preprocedural dose of an oral, sublingual, intramuscular, or intravenous anxiolytic (e.g., diazepam 10 mg) may be administered. If such a dose is used, someone must drive the patient home after the procedure. (See the sample patient education handout online at www.expertconsult.com.)



Procedure


The patient should be supine and comfortable. Shaving and clipping of hair should be avoided to minimize the infectious complications. Surgically prepare the entire genitalia, scrotum, and pubic area with an appropriate antiseptic solution. Use a fenestrated drape.



Anesthesia



Ring Block



1 Using a 10-mL syringe filled with 1% lidocaine without epinephrine and a 1-inch, 27-gauge needle, inject 0.5 to 1 mL subcutaneously over the superficial dorsal vein so that the wheal is raised at the junction of the penis and the pubis (Fig. 117-1).

2 Without withdrawing the needle, angle it toward both sides of the dorsal vein and inject additional lidocaine.

3 Extend the needle subcutaneously downward to the deep fascia of the penis—an area of firm resistance—and continue injecting circumferentially, staying close to the deep fascia of the penis. The penile skin is loose; therefore, complete circumferential deployment of the anesthetic agent can be accomplished, and the ventral surface can be reached from both sides. This is called a ring block. Inject approximately 4 mL in this manner on each side. Do not penetrate the fascia.

4 Wait a few minutes, and then inject 1 mL of the local anesthetic subcutaneously into the frenulum using a image-inch, 30-gauge needle (Fig. 117-2).

5 Wait several more minutes and then test the depth of local anesthesia by cautiously grasping the edge of the foreskin with a mosquito hemostat. Should more anesthesia be required, use a Penrose drain as a tourniquet around the midportion of the penis. Tie the tourniquet tightly or hold the Penrose drain with a clamp to obstruct venous return. Inject an additional 2 mL of lidocaine into both corpora cavernosa just distal to the tourniquet (Fig. 117-3).

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Adult Circumcision

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