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

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. 

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

Phimosis or tight foreskin:  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.

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

Dr. Khan will present our results in 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. "