Cracks on the foreskin

Cracked foreskin presents with mild burning, itching, swelling and red patches, and with tight foreskin (phimosis)

Cracks or fissures on the foreskin may be due to Inflammatory conditions of the foreskin (called posthitis) or head of the penis (balanitis) or both (balanoposthitis). These cracks could be painful and associated with fungal or bacterial infection, scarring conditions called lichen sclerosus (BXO), and tight foreskin (phimosis and Paraphimosis).

Fungal infections are usually responsible, most commonly involving the yeast called Candida albicans, which is associated with a bacterial infection. Foreskin yeast infection is generally called “candidiasis” or “thrush” and is not common in healthy individuals but in cancer, immunocompromised, and diabetic individuals.

Bacterial infections, especially Streptococcus organisms, are the second most common cause of balanitis. The sexual health clinic needs to exclude sexually transmitted infections (STIs). The most common STIs are Chlamydia trachomatis, genital mycoplasmas, and Neisseria gonorrhoeae. These can produce cracks and red foreskin.

Poor hygiene due to a tight foreskin can cause cracks on the foreskin and irritant balanitis.

Diabetic patients with uncircumcised men have a high (35%) prevalence of balanitis, which gives them cracks to the foreskin. Among men with an acquired tight foreskin, 26% had a history of diabetes. Tight foreskin (phimosis) in men with diabetes increases the risk of infection of the foreskin and glans.

Balanitis xerotica obliterans (BXO) is a chronic, progressive, and sclerosing inflammatory foreskin disease of unknown cause. BXO will produce scars and cracks.

Treatment of the cracks is medical (antifungal, antibiotics and steroids) and surgical (dorsal slit, preputioplasty or circumcision). Control of sugar in diabetes patients is critical to managing the above treatment.

If cracks of freoskin are associated with tight foreskin (phimosis)

The treatment of phimosis depends on several factors, including age and the degree of tightness. Here are the available options:

1. Steroid Cream or Ointment: These reduce inflammation and improve foreskin elasticity.

2. Stretching Exercises: Beneficial, especially in the early stages of Phimosis.

 3. Stretching Rings (Phimostretch): Devices that aid gentle foreskin stretching.

If cracks of freoskin are associated with diseased freoskin (BXO)

We provide circumcision, dorsal slit or preputioplasty at our centre
Please get in touch with us for professional and expert advice by calling the mobile number below to the doctor directly.

Please call us at +447527314081 to discuss this further and get advice from our specialist team.

• Dr Nkwam: Consultant Urologist

• Dr Sanndher: Consultant Urologist

• Dr Khan: Paediatric Surgeon/Urologist

• Dr Safdar: Experienced Surgeon

London Circumcision Centre, Leyton and South Woodford Clinics, London

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Can I be circumcised as an adult

incidence of circumcision 

In the USA, 75% of men are circumcised; however, 6% of men are circumcised in the UK. Jews and Muslims are circumcised as a part of their religious obligation. Historically, Christianity has had periods of both pros and cons. In most societies, males are circumcised at birth. Adults are circumcised if they have medical problems or cultural or personal reasons in our London clinics. 

Indications of adult circumcision 

General Indications

Several medical indications for adult circumcision are phimosis, paraphimosis, and Balanitis, and non-infectious causes include lichen sclerosis (also called BXO - balanitis Xerotica Obliterans), allergic dermatitis, trauma, and Zoon’s balanitis.

 
Phimosis is a condition in which the foreskin (also called prepuce) is unable to be reduced over the head of the penis (glans penis). This can result in pain with erection and intercourse. 

Diabetes is a risk factor for phimosis, recurring balanitis and BXO. 

Paraphimosis is a condition in which the foreskin can be retracted over the glans but stuck or tight behind the head of the penis. When there is a partially tight band at the inner skin of the foreskin, and the foreskin does not reduce naturally over the glans, the tight band acts like a constricted ring over the shaft of the penis. A history of recurring paraphimosis may result in a more tight foreskin, leading to swelling of the glans and significant pain. This may require urgent medical treatment. 

Balanitis is also a medical indication for circumcision. Balanitis is the infection of the glans penis. Balanitis may occur along with infection of the foreskin. This combination of infections is called balanoposthitis. 

The combination of phimosis and diabetes is a recognised risk factor for balanitis. Balanitis can be caused by both infectious and noninfectious causes. In the case of phimosis, fungal infection is also expected along with bacterial infection. Non-infectious causes include allergic dermatitis, trauma, and Zoon’s balanitis.

Sexually transmitted disease (STD) Prevention

Circumcision is a preventative measure against the spread of HIV and AIDS, as shown in many African studies. The inner preputial skin has special cells called Langerhans cells, which contain receptors for HIV. Removing most of the inner preputial foreskin by circumcision may prevent to prevent HIV viruses. Additionally, the inner preputial skin contains a little protective keratin layer relative to the outer foreskin, making it less mechanically resistant to injury, which may be a source of HIV. 

Lichen Sclerosis or Balanitis Xerotica Obliterans (BXO) 

Lichen sclerosis (LS) can affect both children and adult populations. LS has been known as lichen sclerosis or balanitis xerotica obliterans (BXO). The typical peak ages of presentation of BXO are 8–10 years of age and 30–50 years of age. The clinical presentation can be variable; however, the advanced classic appearance is atrophic white scarring. Purplish scaly scars, red abnormal blood vessels, tears, splits, and ulcerations have also been documented. The foreskin is the largely common site of involvement; however, it can affect the glans, wee hole (meatal opening), and wee tube (urethra).  Symptoms can vary according to the different areas of involvement. Please see further information for BXO. Circumcision in men is a medical indication for BXO symptoms. 

Circumcision for medical reasons is available in the NHS.  However, there is a long waiting list for urological consultation and circumcision in the NHS hospitals. 

Surgical Techniques

Although circumcision is done in our London clinic, the best method of circumcision is with the glue with different circumcision styles. We do circumcision with stitches and surgical staplers (ZSR or CircCurer (LangHe) staples suture device). Adult circumcision costs £680 with glue at our London Circumcision Centre. Circumcision cost in the UK depends upon the technique and methods of circumcision. Circumcision is a low-risk surgical procedure, at least in our hands. History of bleeding disorders needs to be excluded, and all medications affecting platelet function (aspirin, clopidogrel, warfarin ) should be stopped 5 days before adult circumcision after a discussion with your doctor. 

Anaesthesia

Circumcision can be performed under local or general anaesthesia. Most patients are suitable for local anaesthesia, which involves injections into the skin. 

Informed Consent

We provide the patient with all the information about the circumcision, and consent is taken before the procedure in our centre. Circumcision is an irreversible procedure and exposes the glans permanently. 

Forceps-guided method, sleeve technique and Glue circumcision are standard techniques used. 

The most common method is the glue circumcision technique. It has been reported that the stretched length of the penis is the equivalent length of the erect penis. By having the penis on stretch, we make sure that no excessive shaft skin is excised, which would produce penoscrotal webbing due to underneath skin deficiency and hairy skin from the pubic area pulled to the shaft of the penis due to less shaft skin, especially during erection. 

Complications

Risks are bleeding, bruises, haematoma formation, infection, removal of too much or too little skin, lymphoedema,  displeasing results that require revision circumcision and a change of sensation during sexual activity.

Sexual Dysfunction

Change in sexual function after circumcision is very controversial. Studies investigating sexual dysfunction have shortcomings of self-reported variables, non-validated questionnaires, small population studies, and the investigation of patients with prior foreskin disease. 

Summary 

Adult circumcision is a safe surgical procedure with uncommon complications. Adults have circumcision due to tight foreskin (phimosis, paraphimosis), infection (balanitis), and scaring due to lichen sclerosis (BXO). A lot of African studies also reported that circumcision can be preventative in HIV and AIDS transmission and some sexually transmitted infections. Several methods of performing an adult circumcision exist at the London circumcision clinic, but glue circumcision remains our method of choice. Although sensation appears to be different in circumcised adults in the first 6-12 months, studies have not proved if there is any difference in sexual function as compared to uncircumcised men. The benefits of circumcision are well-reported in the literature. Men can be circumcised in our London circumcision Centre.

This is for information about purposes that can not replace professional advice. Please contact Dr Khan or a consultant Urologist for further details. 

Skin bridge and Preputial adhesion after circumcision

A penile skin bridge can occur in circumcised males after their childhood period. These bridges cause pain or discomfort and may require correction.

A penile skin bridge requires operative correction as it is a thick skin attachment from the shaft skin of the penis to the head of the penis (glans).  It causes pain and discomfort during Erection due to tethering of skin.  . These will not be resolved on their own and is actually more uncomfortable and bending of the penis with penile growth

What is a penile Skin Bridge?

When the incision heals improperly to the gland in a circumcised male, the shaft skin becomes permanently attached to the glans. The. penile skin bridge develops. 

Penile skin bridge can occur in childhood right after the infant circumcision. But adult may not realise it until he is sexually active and feels a pulling the head of the penis when he has sexual activities and erection. 

Operation for a Penile Skin Bridge 

• A urologist usually carries out the procedure under a local anaesthetic.

• Local anaesthetic nerve blocks also provide post-operative pain relief

• He divides the skin on the top of the head of the penis and both skin edges.

• He uses dissolvable stitches throughout which usually disappear within two to three weeks.

• He applies and seals the wound with glue which sloughs off within 10 days.

• we normally wrap the penis in a loose bandage which you can remove after 1-2 days.

• Some patients may require a circumcision revision if the patient has more scarring with multiples skin bridges.

• The underlying colour of the skin may different colour than the rest of the skin of the shaft and head of the penis.

What can I expect when I get home?

• You will get some swelling and bruising of the penis which may last several days

• All your stitches will disappear, usually within two to three weeks, but may sometimes take a little longer

• Simple painkillers such as paracetamol or Ibuprofen are helpful if you have any discomfort

• Any dressing should fall off within 24 hours; if it does not, or if it becomes soaked with urine, it should be removed

• Keep the area dry for 48 hours; avoid soaking in a bath

• You should not swim or any exercise for two weeks

• Try to keep your wound clean and dry after passing urine

• Apply a little Vaseline to the tip of your penis and around the stitch line to stop it from sticking to your clothing

• Wear tight-fitting clothing for two to three days

• You should retract your foreskin on a daily basis to maintain the benefits of the surgery after 3 days 

• You will be given a copy of the letter which should be given to your GP

• Any antibiotics or other cream, you need to get from any pharmacy

• You should refrain from sexual activity (intercourse and masturbation) for up to four to six weeks 

If you notice any re-attachment happening, please contact us for an assessment

What are the risks, consequences and final outcome?

Most operations are straightforward; however, as with any surgical procedure, there is some chance of side-effects or complications such as:

Bruising and swelling generally happen. Significant swelling of the bridge incision will develop during the first few days. This swelling may last for 2-3 weeks or longer.  bleeding from the wound site (occurs in 2 - 3% of patients) but is usually minimal and settles quickly. Infection can arise and is usually minor but can be possibly serious with an incidence of less common.  Tenderness of the scar at the wound. Dissatisfied with the cosmetic result. Failure to improve your symptoms may result in the need for full revision circumcision. 

Contact us for further consultation