INTRODUCTION
The term phimosis, derived from the Greek word meaning to muzzle, is a descriptive term referring to the natural conical shape of the foreskin in early life.
This prevents its retraction and keeps the glans of the penis covered. Additionally the inner surface of the prepuce is initially fused with the outer surface of the glans. Widening of the narrow tip of the prepuce combined with separation of its inner adhesions oc- curs during childhood to allow full retraction and uncovering of the glans by puberty.
Studies of normal infants and children have shown that the rate of this process is very variable – to the extent that in some newborns it is already ful- ly retractile, whilst in around 20% of 5-year-olds it can remain “phimotic”. The failure to recognize this normal process of development has led many doc- tors to label non-retractile foreskins abnormal and refer patients for circumcision. The vast majority of prepuces are normal, however, and will become fully retractile by puberty. In the 1% that do not, most are subject to a pathological process called balanitis xe- rotica et obliterans (BXO), which causes clinically ap- parent scarring at the preputial tip. This is rarely seen in the under fives and is usually cured by circumci- sion, for which it is the only absolute indication in childhood.
Other foreskin problems may be related to its de- velopment and non-retraction but are usually tran- sient rather than long-term problems. Thus balloon- ing during micturition and infection of the foreskin or balanitis will resolve and cause no discernable damage. Severe symptoms from these, however, do represent a relative indication for circumcision. By applying these principles several groups of British pediatric surgeons have reported circumcising only around 25% of boys referred for consideration of the operation.
There is a minority of boys whose foreskins re- main narrow or tight on retraction, in which no obvi- ous scarring can be seen. In these patients preputial- plasty or widening of the narrow tip of the prepuce can be a helpful and more conservative alternative to circumcision. Some surgeons have used this proce- dure to enable earlier mobility and facilitate the cleanliness of “late developing” foreskins, although this author now prefers to allow nature to take its course and reserves preputial-plasty for a few older boys.
The main long-term complication of circumcision is stenosis of the exposed urinary meatus, which is reported to occur in between 2 and 35% of patients.
These patients can develop voiding difficulties and even bladder dysfunction if the outflow obstruction is severe. Relief is achieved by meatoplasty.
Penile abnormality is a contraindication for rou- tine circumcision. Patients with hypospadias require a more complex re-construction, to achieve a more normal “circumcised” appearance and this is dis- cussed elsewhere in this book (Chap. 51).
The buried penis is an abnormality of peno-scro- tal fusion, in which the penile corpora are also teth- ered to the deep fascia of the lower abdominal wall. It is associated with phimosis and the appearance of the external skin suggests that the penis is small or even absent. Often the inner preputial space is en- larged and balloons during voiding, with dribbling from the preputial orifice – sometimes referred to as megaprepuce. Circumcision of the visible external prepuce in these cases does not achieve emergence of the penis and may compromise the eventual recon- struction of a more normal circumcised appearance.
An operation for this condition, to release the teth- ered corpora and remodel the shaft skin, is presented at the end of this section.
and Buried Penis
Peter Cuckow
Figure 52.1, 52.2 CIRCUMCISION
The prepuce is fully retracted behind the glans and any residual adhesions to the glans are separated carefully. If the tip is narrow or scarred a haemostat is inserted into the preputial orifice and opened in order to dilate it and allow retraction. It may be nec- essary to make a small dorsal incision in the tip of the prepuce with scissors to enable this. In a patient with severe BXO (rare in the under fives) adhesions to the glans may be dense and separation of these is trau- matic.
With the skin held under tension, retracted back over the penile shaft, a circumferential incision is made with a size 15-blade scalpel, 8 mm proximal to the glans on the dorsal surface. This is completed ventrally on each side, parallel to the coronal sulcus, where the frenulum and its artery are divided. Care is taken not to damage the urethra, which is quite superficial at this point.
The foreskin is replaced over the glans. A clip is placed on its edge in the midline anteriorly (usually the position of the midline raphe). A second is placed
opposite this dorsally and the foreskin is held for- ward, under slight tension. The second circumferen- tial incision is made just proximal to the corona of the glans, whose profile can be seen and felt through the foreskin. Care is taken to ensure that enough skin is retained to cover the shaft. The incision is angled distally towards the ventral surface, which allows for the natural angle of the coronal sulcus with the pe- nile shaft.
The clips are repositioned on the dorsal edge of the foreskin either side of the midline and a dorsal slit is made between them with scissors. This joins the inner and outer incisions. Scissors are used to di- vide the subcutaneous layers circumferentially and remove the sleeve of foreskin.
The remaining cylinder of penile skin is retracted proximally to expose the raw shaft and bleeding ves- sels. These are coagulated with bipolar diathermy.
Attention is paid to the frenular aspect of the penis and coagulation of the distal end of its artery be- neath the ventral skin cuff.
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Figure 52.1 Figure 52.2
Figure 52.3, 52.4
MEATOTOMY
A fine absorbable suture (5/0 or 6/0 Vicryl or Mono- cryl) on a round bodied needle is used to approxi- mate the shaft skin to the cuff of distal skin. A box stitch is used to reconstitute the frenulum (diagram).
A second stitch is placed in the midline dorsally and the penis is suspended between them.
Interrupted sutures are placed at 5-mm intervals along each side to complete the anastomosis. Follow- ing the operation the penis is wrapped in gauze and squeezed for 2 min to exclude haematoma and aid
haemostasis, before the boy is awakened. Any bleed- ing at this point can be stopped with a circumferen- tial gauze dressing that can be removed before the patient goes home. With effective haemostasis this should usually be unnecessary. Patients may be given topical antibacterial cream to apply for a few days post-operatively. This may reduce local infection and prevents the exposed wound sticking to underwear or bedclothes.
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Figure 52.5–52.7
The meatus is identified and a small lacrymal probe can be inserted to demonstrate it. The orifice is dilat- ed sufficiently to allow one blade of a small haemos- tat to be inserted and directed proximally. The thin ventral tissue below the meatus is crushed in the midline by closing the haemostat. This usually incor- porates at least 5 mm of tissue but does not extend more than halfway towards the corona.
The crushed tissue is now divided carefully with a fine pair of sharp pointed scissors. The crushed tis- sue maintains haemostasis at this point.
The neo-meatus is further secured with fine monofilament absorbable sutures (6/0 Monocryl).
These are placed at its apex and on either side.
The new meatus should calibrate easily to at least 14F. If it does not the ventral incision can be extend- ed by repeating the above steps. Post-operatively pa- tients are supplied with chloramphenicol eye oint- ment. The small nozzle on the applicator can be in- serted gently into the meatus to apply ointment with- in, twice daily for the next week. This gently opens the meatus and reduces inflammation as it heals.
Figure 52.3 Figure 52.4
Figure 52.5 Figure 52.6 Figure 52.7
Figure 52.8
Abnormality of peno-scrotal fusion and tethering of the penile corpora to the deep fascia, gives rise to the anomaly of buried penis. The external prepuce is small and phimotic and there may be an associated inner-preputial sac, sometimes referred to as a meg- aprepuce.
Pinching the tip of the prepuce and holding it for- ward identifies the line of demarcation between the scrotal and penile shaft skin. Deep palpation reveals normal sized corpora and glans.
A curved line is drawn along this line of demarca- tion to the apex of the scrotum. This marks the extent of what is to become the penile shaft skin. Care must be taken to ensure that this is broad enough to envel- op the penile shaft without tension.
Figure 52.9
The incision is made along this line and deepened through the dartos fascia on to the deep fascia of the penile shaft with cutting diathermy needle. The shaft skin is lifted off the dorsum of the penis and dissec- tion is continued around it using diathermy and blunt dissection with a gauze swab. It is important to expose the deep fascia of the penile shaft and to ex- tend this proximally to its base, in order to complete- ly free it.
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Figure 52.10, 52.11 BURIED PENIS
The preputial sac is opened by ventral incision into the orifice along the ventral raphe.
This allows retraction of the prepuce and expo- sure of the glans. There is a variable cuff of inner pre- puce – which may be quite extensive and rugose. A
glans suture is placed at this point to aid in retrac- tion.
The inner prepuce is pulled back along the penile shaft and circumcised 6 to 8 mm below the glans, parallel to the corona.
Figure 52.8 Figure 52.9
Figure 52.10 Figure 52.11
Figure 52.12, 52.13
The skin is lifted from the penis, by opening the cuff of inner prepuce ventrally. The dorsal flap of skin is thinned by removing some of its subcutaneous fat layer with sharp scissors. This leaves a quadrilateral flap of skin from which skin cover is obtained.
The base of the flap is secured using a deep suture of 5/0 PDS (polydioxanone), which also picks up the deep fascia over the urethra. This suture is placed at the apex of the original incision on each side.
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Figure 52.12 Figure 52.13
Figure 52.14
Ventral closure of the skin is continued distally with interrupted 6/0 Monocryl sutures. The excess skin is trimmed dorsally with a scalpel. The skin suturing is completed circumferentially. The scrotal raphe is su- tured to the proximal end of the shaft suture line, us-
ing a box stitch. The scrotal defects on each side are closed with interrupted sutures. Post-operatively, a hypospadias dressing is used, with a dripping stent, and left in situ for 1 week. Patients are given oral anti- biotics and oxybutinin during this time.
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Figure 52.14
CONCLUSION
Penile surgery should always be performed under general anaesthetic. Local anaesthetic techniques can also be used to provide good intra-and post-opera- tive analgesia and a caudal epidural is the standard.
This is probably not required for meatoplasty or
preputial plasty. Sutures for this surgery should be absorbable monofilaments such as Monocryl. The author always uses round-bodied or taper-point needles.
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SELECTED BIBLIOGRAPHY
Cuckow PM (1998) Circumcision. In: Stringer MD, Oldham KT, Mouriquand PDE, Howard ER (eds) Pediatric surgery and urology – long-term outcomes. WB Saunders, London, pp 616–624
Cuckow PM, Rix G, Mouriquand PDE (1994) Preputial plasty: a good alternative to circumcision. J Pediatr Surg 29 : 561–563
Gairdner D (1949) The fate of the foreskin. A study in circum- cision. BMJ 2 : 1433–1437
Rickwood AMK, Hemathala V, Batcup J, Spitz L (1980) Phimo- sis in boys. Br J Urol 52 : 147–150
Smeulders N, Wilcox DT, Cuckow PM (2000) The buried penis – an anatomical approach. BJU Int 86 : 523–526
