BXO management - reported in JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY 27 July 2017 University College London Hospitals, London, UK

Our approach to the treatment of Balanitis Xerotica Oliterans (BXO) is aimed at eliminating occlusive contact of skin to urine, minimising urinary and sexual morbidity, abolishing the risk of progression to penile squamous cell carcinoma (PSCC) (by curing the inflammatory and scarring disease), with preservation of the foreskin if possible  If the condition is diagnosed early and interventions instituted promptly, disease progression and morbidity can be halted, and normality can be restored. Our medical treatment protocol involves avoidance of contact with urine by assiduously emptying the urethra after micturition (by shaking, squeezing, dabbing, and using barrier preparations), regular use of soap substitutes and barrier emollient creams and application of ultrapotent topical corticosteroids for a fixed, monitored period of time (usually clobetasol propionate). In addition, the short trimming of pubic hair is recommended in order to eliminate penile abrasion, irritation and inflammation. We avoid using topical calcineurin inhibitors due to the theoretical link with progression to SCC, but accept that this is controversial in BXO The mainstay of surgical management is circumcision.

If the above medical treatment regiment fails then circumcision is offered. Some patients may require further urethromeatal surgery. The success rates with medical therapy previously reported in the literature by us and others are in the range of 50-60%, whereas circumcision is thought to lead to cure in >75% of patients. Our results confirm the above; in isolated BXO, 50% of patients were treated successfully with medical therapy and foreskin preservation. The validity of the above treatment protocol is vindicated further by the outcomes of this study, with 91.7% having achieved resolution of symptoms, and the remaining either receiving ongoing medical therapy (4.8%) or waiting to undergo circumcision (3.5%). Side effects were minimal and mainly related to surgery.

Ref:

Journal of the European Academy of Dermatology and Venereology, Version of Record online: 16 AUG 2017

Plastibell circumcision and complications.

Abstract

Introduction

The World Health Organization's manual on male circumcision listed Plastibell technique as a well-proven paediatric method with respect to the results and complications. Although, literatures abound on its wide acceptability, there are few multi-centered reports from this environment. The objective was to evaluate the cases of infant circumcision by Plastibell device from two medical institutions.

Methods

All consecutive infants who had Classical Plastibell Circumcision (PC) at the Federal Staff Medical Centre, Abuja and the Lagos State University Teaching Hospital, Ikeja between February 2011 and June 2015 were included in this cross-sectional study. The procedures were performed by surgical registrars and medical officers after ninety minutes of topical anesthesia to the penis. Data harvested from the standard proforma were analysed using Statistical Package for Social Science 20.0 for window.

Results

A total of 2,276 infants had classical PC within the study period. Their ages at circumcision ranged from 4 days to 3 months with a mean age of 17 days. Majority of the boys were circumcised at second week of life (n=1,394,61.2%). All the cases were performed for religious (53%) and cultural (47%)reasons. The most common Plastibell size deployed was 1.3cm (n=1,040, 45.7%) while 1.6cm was the least commonly used ring (n=10, 0.4%). The mean time for device to fall-off was 6 days (range 4-12 days). There was no correlation between the age at circumcision and Plastibell size. We recorded an overall complication rate of 1.1% with postoperative bleeding leading the pack (n=12, 48%). No case of urethrocutaneous fistula was seen. We detected 17 cases (0.7%) of distal hypospadias in whom circumcisions were postponed till the time of hypospadias repairs.

Conclusion

The main indication for infant circumcision in our environment was religious. The PC has good safety profile with few easily correctable early complications. Detailed attention to placement of ligature, selection of appropriate Plastibell size and adequate parental education are key to preventing post-procedure mishaps.

 study adds to the literature: 

  • We found out that the main indication for infant circumcision in our environment was religious.
  • The study reinforced the need to pay detailed attention to selection of appropriate Plastibell size, placement of ligature and parental education in reducing post-procedure complications.

Dr. Khan comments on this study: 

1. Mobile contact to the parents  for any postoperative question. 

2. Anbiotics used in all cases. In our cases, we used antibiotics in 1:20 cases only  

3. Infection can still accured inspite  of antibiotics  

4. Bleeding is 1.1% which may require intervention 

5. Age is 1 to 3 months. Most common is second week of life (62%). Ideal  age of circumplast or plastibell is under one month as it has been shown in our experience

6.  Ring falls off day 6 (4-12 days)

7. plastibell 1.3 is commonly used. 

8. Parent education of aftercare is important part of aftercare  

Reference: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856486

 

London Children Safeguarding Board Policy about Male Circumcision

Dr. Khan is trained in children safeguarding Level 1-3 ( last September 2017) and follows GMC good medical practice and London safeguarding board policy regarding male circumcision. 

Please see link for further information:  

http://londoncp.co.uk/chapters/male_circum.html

Adult Male Circumcision

Please see dedicated website for adult male circumcision at London Clinic ( Circumcision, Frenuloplasty and Preputioplasty ) 

http://adultcircumcision.strikingly.com/ 

 

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Revised foreskin conditions commissioning guide-republished 2016

Royal college of Surgeon, England has published following documents for doctors and surgeons for commissioning foreskin conditions. 

In the financial year 2013/2014, activity and cost rates for Foreskin Conditions procedures in patients aged 18 years and below in England were as follows:

Procedure

  • Circumcision
  • Frenuloplasty
  • Prepucioplasty
  • Freeing of adhesions of prepuce,
  • Dorsal slit on prepuce, stretching of prepuce,
  • Other procedures Activity

In children <18 years, pathological phimosis must be distinguished from physiological adherence of the foreskin to the glans, which is normal.

In the adult population there is a wide differential diagnosis including STDs and skin diseases such as eczema, psoriasis, lichen planus, Zoons balanitis, carcinoma in situ (CIS), and frank squamous carcinoma. Circumcision in an adult may also be undertaken for premalignant conditions, CIS and for biopsy where disease other than lichen sclerosus cannot be excluded.

Balanitis refers to inflammation of the glans penis and posthitis refers to inflammation of the inner layer of the foreskin/prepuce. Balanoposthitis refers to inflammation of both
Balanoposthitis can be and often is chronic, not just acute.

In children up to and including 18 years of age, pathological phimosis (non-retraction) must be distinguished from physiological adherence of the foreskin to the glans, which is normal.

Non-retractile ballooning of the foreskin and spraying of urine do not routinely need to be referred for circumcision although not all ballooning is related to physiological phimosis and spraying can be due to lichen sclerosus.

The proportion of partially or fully retractable foreskin by age is:

  •   Birth 4%
  •   6 months 20%
  •   1 year 50%
  •   3 -11 years 90%
  •   12-13 years 95%
  • 14+ years 99%

 

Parents and patients should be made aware of the risks and benefits of circumcision.

Referrals from primary care for physiological phimosis account for a significant clinical workload in consultation time that could be avoided.

Conservative management of the non-retractile foreskin is under-recognised and practiced in some regions. This is of particular importance in the paediatric population where too many circumcisions are undertaken for physiological phimosis thereby incurring avoidable morbidity.

Currently, paediatric surgeons, paediatric urologists, adult general surgeons or urologists with a dedicated paediatric practice, paediatricians or specially trained clinical nurse specialists see outpatient referrals to regional centres.

Only a minority of children will have pathology and be subsequently listed for circumcision.

Indications for circumcision

  •   Pathological phimosis: The commonest cause is lichen sclerosus, balanitis xerotica obliterans BXO is an old fashioned descriptive term (BXO)
  •   Recurrent episodes of balanoposthitis
    Relative indications for circumcision or other foreskin surgery
  •   Prevention of urinary tract infection in patients with an abnormal urinary tract
  •   Recurrent paraphimosis
  •   Traumatic (e.g. zipper injury)
  •   Tight foreskin causing pain on arousal/ interfering with sexual function
  •   Congenital abnormalities

Non-therapeutic circumcision is not within the scope of this document although doctors or others who undertake circumcisions for non-medical indications (in hospitals or the community) are scrutinised in the normal way, as per any aspect of medical practice. If their practice is criticised, they can defend themselves against litigation providing they are able (i) to show that their practice is considered reasonable by their peers (in the form of an expert opinion) and (ii) that the expert opinion is viewed by a court as being able to survive logical scrutiny. 

Please read further as link below: 

Resource: 

https://www.rcseng.ac.uk/-/media/files/rcs/standards-and-research/nscc/revised-foreskin-conditions-commissioning-guide-republished.pdf?la=en

Feedback on "I want great care" at London circumcision clinic

"I really appreciated his professional work. He explained the process clearly and easily. He answered all our questions nicely and clearly. I recommending to my family and friends to go the clinic and use the service with Dr Khan."

Simret and Michael

August 2017  

At Leyton Healthcare, Leyton, London