Buried penis, hidden penis, inconspicuous, concealed or webbed penis

"Although subtly different, we consider the inconspicuous, concealed, hidden or webbed penis as minor variations of the same entity. All occur due to minor anomalies of the preputial ring. Specifically, the webbed penis represents an encroachment of the scrotal tissue onto the ventral portion of the penis. This condition results in considerable shortening of the ventral penile shaft skin compared with the dorsal skin. This can occur in two forms: (1) narrowing of the preputial ring proximal to the glans, resulting in a concealed penis, or (2) in the absence of preputial narrowing, resulting in a greater proportion of the penile shaft skin provided by he inner preputial skin than the external preputial skin (“megaprepuce”). Both of these become important when considering circumcision. In these cases, circumcision performed with a Plastibell or a Gomco clamp results in excessive removal of penile shaft skin. If the circumcising incision is made along the narrow portion of the prepuce, a cicatrix will form that will “trap” the penis. This condition (trapped penis) results in a tight, firm preputial ring that requires surgical release with a rotational flap of the dorsal inner preputial skin to the ventrum of the penis.

These conditions are all relatively common. A number of successful surgical approaches address these conditions. Our preference is to harvest a flap of inner preputial skin on its vascular pedicle, transfer that pedicle to the ventrum of the penis, and suture it in place. In this way, the natural narrowing of the preputial ring is opened and the appropriate amount of residual shaft skin and inner preputial skin can then be removed to provide for good cosmesis.

When any of these conditions are noted, it is important to refrain from newborn circumcision. Circumcision will not address the fundamental problem of proximal narrowing of the prepuce that all of these boys share."

 

Source:

Fundamentals of

Pediatric Surgery 2011

Edited by

Peter Mattei, MD, FAAP, FACS

The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Chapter 84

Penile Anomalies and Circumcision

BY Douglas A. Canning

Dr. Khan has expert in dealing with this condition and has 23 years experience in dealing this condition. 

Wound healing takes longer in adult circumcision with Shang Ring as Campare to Conventional Circumcision : Studies showed in the lietrature

Adult circumcision with Shang ring is quick procedure however wound healing takes longer than conventional circumcision in adults. 

A randomised clinical study with a Shang ring versus conventional circumcision showed wound healing time in the Shang ring groups was longer than conventional circumcision (maen +/-SD 19.86 +/-5.24 vs 13.42+/-2.35 days, p<0.001 significant) J Urol 2012

A sytematic review and meta-analysis of circumcision with Shang ring vs conventional circumcision. Urology 2015 showed  Overall, 8 randomized controlled trials involving 3314 patients were included. Compared with the Convential circumcision group, Shang circumcision is associated with shorter operative time, lower intraoperative pain score, higher satisfaction with penile appearances, less intraoperative blood loss, lower adverse event rate, and lower wound bleeding rate. Shang circumcision appears to be a safer and more effective choice in comparison with circumcision with stitches for male patients.

One long term study showed scar width is 3.7+/- 1.6 mm (clin med journal 2014)

Healing showed significant wound edges gap after removal of Shang ring and this wound heals by secondary intention, scaring with some cases.  

No study mentioned that how long adult patient feel pain after ring came off.  

Dr. Khan has performed three revision circumcisions with glue after Shang ring circumcision. Glue circumcision provide excellent cosmetic result with less pain and less complications. Patients suffered pain due to secondary healing of gapped wound for three months after Shang ring circumcision.  

This required further studies to conduct addressing this issue in Shang ring circumcision.  

 

Adult circumcision with glue and stitches under local anaesthesia at Thornhill Circumcision Centre, Luton

The widespread acceptance of adult local anaesthesia circumcision in the community remains debatable. We report outcomes (Glue and Stiches) from a dedicated GP clinic over two year period. Patient demographics, indications and postoperative complications were recorded prospectively.

Of 373 circumcisions (glue n=269 and stitches n=103), 230 patients had therapeutic indications including 63 (17%) balanitis xerotica obliterans and 11 (2.9%) had minor complications (infection n=6, bleeding n=2 and redo n=3) with no significant difference between the two groups.

Circumcision performed in adults remains a safe surgical option under local anaesthesia in dedicated GP surgeries.

Dr. A R Khan has performed 143 cases during this period. Four cases have a minor infection and one case has a minor bleeding. This means most of the cases have an excellent result after adult circumcision (Glue n=134 and stitches n=9). Glue circumcision in adults gives result with less pain and excellent cosmetic results. 

Tight foreskin - Phimosis in adult and children . Is this associated with Balanitis Xerotica Obliterans (BXO) and what is best evidence based management?

 

“No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the therapies described below have varying degrees of reported success.

1.      Topical and intralesional steroids have been used. Topical steroids can offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations with regard to the success of such treatments.

2.      Circumcision in adult and children with BXO

3.      Further treatment, or treatment of circumcised patients, is more challenging. Intraurethral steroids provide efficacious therapy for stricture disease in patients with biopsy ­proven BXO before invasive surgery.

4.      A variety of surgical techniques can be used to treat more severe penile BXO. Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow­ up care to observe any changes in involved areas suggestive of malignancy. Foreskin preputioplasty combined with intralesional triamcinolone might be a tenable alternative as against circumcision to treat BXO.

5.      Consider surgical intervention for symptoms or signs of urethral meatal stenosis.

6.      Buccal mucuosal graft for BXO ­induced urethral stricture can work.

7.      Consultations :  Consider consultation with Dr. Khan  for the following:

a.      Therapeutic circumcision

b.      Circumcision for symptomatic phimosis or paraphimosis

c.      Significant narrowing or obstruction of the urethral meatus or changes in urinary flow

d.      In some cases of male genital lichen sclerosus (BXO), painful erections may limit sexual function.”

Source: http://emedicine.medscape.com/article/1074054

London circumcision Centre, Leyton and Thornhill clinic, Luton are the best circumcision clinic to management of tight foreskin with  penile BXO. 

PATHWAY FOR PATIENTS WITH PHIMOSIS (BXO)  

1. Assessment and advice for option of treatment like steroid cream or circumcision  

2. Consultation before the circumcision  

3. Circumcision with glue because glue circumcision is better than stitches

4. Aftercare advice following the circumcision  

5. To send biopsy to confirm diagnosis and exclude any malignancy 

6. Further treatment after 6 weeks of circumcision  

7. Follow up to GP or at our clinic  

8. Long term follow up required if biopsy proven BXO found after the circumcision  

 

This is only guidance and not replacement of the professional advice by  Dr. Khan  

How to avoid bruising after adult circumcision

1. Take a rest for 24 hours  

2. Keep the bandage for 2-5 days  

3. Avoid heavy lifting for 3-4 weeks 

4. Do not take Aspirin and related medicine for 5 days before and 3 days after the operation. If you are on Aspirin for medical reason, please take an advice from from your Doctor (GP) before the circumcision 

5. Take vitamin C regularly for 10 days

6 Do not rub or scrub circumcision area when you have  had circumcision with glue

This is guidance only and will not replace the professional advice by Mr. Khan  

Adult circumcision : Are there any alternative treatments for tight foreskin in adults?

 

ADULT CIRCUMCISION:  Are there any alternative treatments to circumcision ?

Under some circumstances, other alternative treatments may be considered to keep your foreskin but adult circumcision remains the most common treatment option to relieve your symptoms of tight foreskin. Alternatives to a circumcision include:

  • Frenuloplasty – this is an operation to cut and lengthen your frenulum, which is the small tag of skin on the underside of your penis, between your foreskin and the shaft of your penis. If the frenulum is short or torn, you may have problems pulling your foreskin back. Frenuloplasty may relieve the symptoms. 

  • Dorsal slit – in this procedure the foreskin is cut on the top of the foreskin to widen and loosen it, so it can be pulled back more easily. Cosmetic result showed fish mouth like appearance. 

  • Prepuceplasty – this is a plastic operation called V-Y plasty or Z- plasty. This  procedure is more complicated than a circumcision. The foreskin is cut and stitched to widen it. This is not indicated in case of balanitis xerotica obliterans ( BXO). 

    Mr. Khan  can explain these treatments if they are suitable for you.

 

GMC issued guidance on confidentiality

GMC issued guidance on 25 April 2017 on confidentiality. 

"Our core guidance for doctors, Good medical practice, makes clear that patients have a right to expect that their personal information will be held in con dence by their doctors. This guidance sets out the principles of con dentiality and respect for patients’ privacy that you are expected to understand and follow.

This guidance outlines the framework for considering when to disclose patients’ personal information and then applies that framework to:

a disclosures to support the direct care of an individual patient

b disclosures for the protection of patients and others

c disclosures for all other purposes.

This guidance also sets out the responsibilities of all doctors for managing and protecting patient information."

London Circumcision

Royal college of Surgeons England guideline for children circumcision

Criteria to be fulfilled in performing circumcision (Royal College of Surgeons of England, 2000)

  • The operation should be performed by, or under the supervision of, doctors trained in children's surgery
  • The child must receive adequate pain control during and after the operation
  • The parents and, where competent, the child, must be made fully aware of the implications of this operation as it is a non-reversible procedure
  • This operation must be undertaken in an operating theatre or an environment capable of fulfilling guidelines for any other surgical operation
  • The person responsible for the operation must be available and capable of dealing with any complications which may arise
  • There should be close links with the patient's GP and community services for continuing care after the operation

Accurate records of all procedures and audit of results are essential. 

According to the Royal College of Surgeons of England guidance, the one absolute indication for circumcision is pathological phimosis. This is scarring of the opening of the foreskin, making it non-retractable. Other indications also involve the removal of an abnormal foreskin, including penile malignancy, traumatic foreskin injury, and severe recurrent attacks of balanoposthitis

Royal College of Surgeons of England. Male Circumcision: guidance for Healthcare Practitioners. RCSENG - communications; 2000.

 

 

What is the evidence to support early infant circumcision? Risks and benefits.

Professor Emeritus Brian J. Morris has publised an article in the medical literatutre.

"Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and “ballooning” during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical con- dition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews."

Reference: Early infant male circumcision: Systematic review, risk benefit analysis, and progress in policy 2017

ADEQUATE PERI-OPERATIVE MANAGEMENT DECREASES COSMETIC COMPLICATIONS AFTER CIRCUMCISION WITH DISPOSABLE RING IN CHILDREN

Dr. Khan will present his poster presentation at Barcelona, Spain on ESPU Meeting on Friday 21, April 2017. 

"We reviewed our experience in treating children with cosmetic complications following non-therapeutic male circumcision (NMC) with Plastibell and Circumplast devices at a community clinics ( Thornhill Clinic, Luton, Leyton Clinic, Leyton and Croydon London Clinic). This study highlights the factors leading to these complications and clinical management to improve the cosmetic appearance

A retrospective review of 3360 children who underwent Circumplast (CC) and Plastibell circumcision (PC) under local anaesthesia at the community clinics from May 2014 to October 2016. "

Dr. Khan - a member of the Independent Doctors Federation (IDF)

Dr. Khan's  application for membership has now been approved by IDF Executive Committee on 12 April 2017.

The Independent Doctors Federation (IDF) is most innovative, forward thinking and active independent medical practitioner organisation in Great Britain.  We are recognised as the nationwide voice of independent doctors in all matters relating to private medicine, their education and revalidation.

IMG_1984.GIF

Balanitis Xerotica Obliterans (BXO) - adults

Phimosis ( tight foreskin) can be caused by BXO. Recent paper which was published from Sweden showed the partial circumcision with BXO showed poor outcome. 

 " Total circumcision was a benefecial treatment for many patients, but the majority still had active BXO after this surgical procedure. Complications of BXO were commonly seen and close cooperation between the dermatologist and urologist was needed for urethral dilatation, circumcision and in cases with suspected penile cancer. However, it was reassuring to see that the disease had gone into complete remission in 27% of our patients"

Ref: Acta Derm Venereol 2017; 97: 365–369.