Dorsal Slit for Phimosis

CHAPTER 119 Dorsal Slit for Phimosis



Morteza Khodaee, Gary Yen


Although the exact definition of phimosis is still controversial, this condition has been recognized since ancient times. Phimosis can be physiologic, congenital, or acquired as a result of inflammation or infection. About 90% of boys have a fully retractable foreskin by the age of 3 years. American literature describes phimosis as scar formation of the foreskin secondary to any injury or inflammatory condition, with the inability to retract the foreskin over the glans penis (Wein and colleagues, 2007). Poor hygiene, diabetes, and zipper injuries are conditions that may increase the risk of phimosis. Acute phimosis may occur with infection or as a complication of various treatments for conditions such as verrucae, which can cause inflammation (e.g., 85% trichloroacetic acid, electrocoagulation).


Phimosis may lead to urinary retention or infection as well as paraphimosis (nonreducible retracted foreskin), which may require urgent or emergent intervention (Fig. 119-1). A debate exists over medical versus surgical management of phimosis. In countries in which circumcision is not widely practiced, nonsurgical and conservative surgical methods are often used. Recent worldwide studies demonstrated the efficacy of topical steroids (0.05% betamethasone cream once or twice a day for 4 to 6 weeks).


image

Figure 119-1 Paraphimosis.


Surgical options for phimosis include dorsal slit, ventral slit, preputioplasty, and circumcision. Various preputioplasty techniques (including sutureless prepuceplasty, triple incision plasty, La Vega slit) have been developed to accomplish better cosmetic results. These techniques usually involve a longitudinal incision in an attempt to release the tight prepuce ring. Dorsal slit is a simple procedure involving a single cut along the dorsal foreskin that allows rapid access to the urethral meatus and glans penis.



Indications



• To gain emergency access to the urethral meatus for bladder catheterization in the presence of phimosis

• To prevent recurrent balanitis with abscess formation

• As an adjunct treatment before circumcision or after phimotic ring incision for paraphimosis


Contraindications



• Active infection of the genitalia

• Anatomic abnormalities of the external genitalia (refer to urologist)


Equipment



• 10-mL syringe with 1-inch, 27-gauge needle

• 1% to 2% lidocaine without epinephrine

• Three small, straight hemostats

• Straight iris or small Metzenbaum scissors

• Suture scissors

• Absorbable suture (4-0) on small reversed cutting needle

• Needle driver

• Fenestrated drape

• Iodine solution or other antiseptic scrub

• Preparation bowl with 4 × 4 gauze sponges

• Adson forceps


Preprocedure Patient Preparation


Provide appropriate information to the patient about the procedure while obtaining informed consent (see the patient consent form online at www.expertconsult.com). Risks include pain, bleeding, infection, damage to the glans, poor cosmetic result, and hematoma formation. Benefits include resolution of phimosis, prevention of paraphimosis, increased ease of hygiene, decreased risk of urinary retention, and decreased pain with intercourse.


Place the patient in a comfortable supine position on an examination table in a well-lit room. Using sterile technique, surgically prepare the genital area with an antiseptic solution. Place the penis through a fenestrated drape and onto the surgical field.



Technique



Anesthesia



1 Dorsal penile nerve block or modified “ring block” is used to obtain anesthesia after preparing and draping the penis (see Chapter 179, Subcutaneous Ring and Dorsal Penile Block for Newborn Circumcision). A dorsal penile nerve block anesthetizes the right and left dorsal nerves where they branch from the pudendal nerve from under the pubic bone. The lateral and ventral portions of the penile shaft are innervated by branches arcading from the dorsal midline, radiating toward the ventral surface. The axons innervating the glans are in a constant dorsal, midline location along most of the penile shaft.

2 A 27-gauge, 1-inch needle is inserted at the base of the penis just under the pubic bone and into Buck’s fascia at the 2 o’clock and 10 o’clock positions (Fig. 119-2A and B).

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Dorsal Slit for Phimosis

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