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Concept: Phimosis

150

The traditional surgical approach to penile fracture is to perform a circumferential subcoronal degloving incision emergently to repair the injury. This approach necessitates circumcision to avoid foreskin complications. We present four men who had a delayed foreskin-sparing approach and discuss its advantages.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Masturbation, Frenulum of prepuce of penis, Phimosis, Foreskin restoration

149

This paper was aimed to compare the clinical effectiveness and safety of adult male circumcision using the Shang Ring™ (SR) with the no-flip technique compared with Dorsal Slit (DS) surgical method. A single-centered, prospective study was conducted at the West China Hospital, where patients were circumcised using the no-flip SR (n = 408) or the DS (n = 94) procedure. The adverse events (AEs) and satisfaction were recorded for both groups, and ring-removal time and percentage of delayed removals were recorded for the SR group. Finally, complete follow-up data were collected for 76.1% of patients (SR: n = 306; DS: n = 76). The average ring-removal time for the SR group was 17.62 ± 6.30 days. The operation time (P < 0.001), pain scores during the procedure (P < 0.001) and at 24 h postoperatively (P < 0.001), bleeding (P = 0.001), infection (P = 0.034), and satisfaction with penile appearance (P < 0.001) in the SR group were superior to those in the DS group. After two postoperative weeks, the percentage of patients with edema in the SR group (P = 0.029) was higher but no differences were found at 4 weeks (P = 0.185) between the two groups. In conclusions, the no-flip SR method was found to be superior to the DS method for its short operation time (<5 min), involving less pain, bleeding, infection, and resulting in a satisfactory appearance. However, the time for recovery from edema took longer, and patients may wear device for 2-3 weeks after the procedure.

Concepts: Clinical trial, Foreskin, Penis, Circumcision, Brit milah, Phimosis, Preputioplasty, Dorsal slit

136

Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder, considered the male genital variant of lichen sclerosus. Anti-inflammatory drugs are commonly used in BXO. We evaluated the effects of an innovative formulation of ozonated olive oil with vitamin E acetate (OZOILE®) on the inflammatory status and tissue remodeling in male children with BXO. The mRNA transcripts of proteins involved either in inflammation or in dynamics of tissue regeneration were analyzed by quantitative real-time PCR, in foreskins affected by BXO removed from patients untreated or treated with OZOILE®cream for 7 days before circumcision. We found a significant reduction in mRNA levels of IL-1β, TNF-α, INF-γ, transglutaminase 2 and NOS2 in foreskins treated with OZOILE®in comparison to untreated ones (p< 0.001). No significant differences were observed in NF-κB activation in the specimens obtained from treated and untreated patients. Hence, OZOILE®treatment up-regulated hypoxia-inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF) and E-cadherin gene expression (p< 0.001). The treatment with OZOILE®showed effective results in children affected by BXO by reducing the inflammatory process and stimulating mechanisms for tissue regeneration of the foreskin. A randomized clinical trial on a large number of children affected by BXO might be useful to verify the efficacy of topical treatment with OZOILE®.

Concepts: Inflammation, Cellular differentiation, Anti-inflammatory, Foreskin, Circumcision, Phimosis, Balanitis, Balanitis xerotica obliterans

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WHAT’S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. OBJECTIVES: To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample. SUBJECTS AND METHODS: The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising. RESULTS: The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft. CONCLUSIONS: This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Masturbation, Frenulum of prepuce of penis, Phimosis, Foreskin restoration

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PURPOSE: Men are particularly concerned about pain after circumcision. Concerns about pain can be a reason to decline surgery. Our aim was to assess the severity of postoperative pain and to investigate factors that may influence postoperative pain. MATERIALS AND METHODS: This was a prospective observational cohort study on patients undergoing circumcision. Patients were asked to fill in a questionnaire using visual analogue scales for pain (severity 0-10) on days 1,2,3,7, 21 and to record analgesia used, complications and time off work. Other data recorded were patient age, clinical indication of surgery, foreskin retractility, presence of adhesions and histology. RESULTS: 112 of 211 questionnaires were returned (53.1%). Mean age of patients was 46.4yrs. Commonest clinical indication for circumcision was phimosis (75%). Postoperative pain was scored as mild to moderate (means: 2.4 on days 1-3, 2.1 on day 7 and 0.5 on day 21). Patients younger than 35 yrs of age (p=0.025) and patients with wound infections (p=0.036) had higher pain scores. Only 11 patients (9.8%) had severe pains at any time during the recovery of which 8 had wound problems. The average time off work in the employed population was 6.6 days (SD-6.5), 5 days for light work and 11 days for heavy physical activity. CONCLUSION: Pain following adult circumcision under general anaesthetic administration with intra-operative penile block administration is mild to moderate. Severe pain is rare and mostly related to complications. Younger patients have more discomfort in general.

Concepts: Cohort study, Pain, Foreskin, Penis, Circumcision, Glans penis, Phimosis, Preputioplasty

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Background  In adults, human papillomaviruses (HPV), lichen sclerosus et atrophicus (LSA) and phimosis are considered to be major risk factors for penile cancer. In boys, a possible association between phimosis, LSA and HPV has been suggested. Objective  To investigate the role of HPV in the persistence of phimosis in children. Patients and methods  Out of a cohort of 420 boys presenting with foreskin problems, we prospectively sampled the preputial tissue of 82 patients during circumcision: 46 with steroid-naïve and 36 with steroid-resistant phimosis. All foreskins were assessed clinically and histopathologically with regard to appearance, inflammation, oedema, epithelial degeneration and fibrosis. The viral status of the foreskins was determined by immunohistochemistry and highly sensitive PCR, with subsequent subtyping by DNA hybridization (HPV types 6, 11, 16, 18, 31, 33, 35, 39, 42, 44, 45, 51-54, 56, 58, 59, 61, 62, 66-68, 70, 72, 73, 81-84, 90, 91). Results  The foreskins appeared normal in 62 boys and suggestive of LSA in one single case. Small cracks or white scars were present in seven steroid-naïve and 12 steroid-resistant foreskins. LSA was diagnosed microscopically in two of the steroid-naïve and six of the steroid-pretreated group. No evidence of HPV was found in any of the juvenile foreskins. Conclusions  Our prospective study has provided evidence that HPV is not usually present in the foreskin of boys with persistent phimosis after their first year of life and that topical glucocorticoid treatment failure is not associated with HPV or any specific histopathological changes.

Concepts: Human papillomavirus, Foreskin, Penis, Circumcision, Masturbation, Lichen sclerosus, Phimosis, Preputioplasty

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Although existing evidence is insufficient to recommend routine neonatal male circumcision, it is a procedure commonly performed in the United States. There are no commercially available infant penile models available for circumcision training. We improved the design of a low-fidelity penile model constructed of cocktail wieners following the one by Brill and Wallace (Fam Med 2007;39:241-243) and attached it to a high-fidelity infant simulator. Providing simulated movement and crying similar to what is encountered in routine newborn circumcisions create a more realistic training scenario.The study objectives were to (1) evaluate the educational experience of a simulated skill training program as perceived by participants based on a comparison scale and (2) evaluate the fidelity of the simulated model.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Frenulum of prepuce of penis, Brit milah, Phimosis, Foreskin restoration

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INTRODUCTION: 0.05 % betamethasone valerate cream is generally used as an alternative to circumcision for the treatment of phimosis in boys. The aim of this study is to determine whether the half-strength formula (0.025 %) of betamethasone is as effective as 0.05 % betamethasone. METHOD: All boys with phimosis seen at our institution between 2010 and 2012, whose parents complained that their children had problems of micturition, i.e., crying and ballooning, and sought for some instructions or treatments, were instructed to apply betamethasone valerate cream. Two strengths, 0.05 and 0.025 %, were randomly applied to each patient twice a day for 2 months. The patients whose parents were not willing to the conservative treatment underwent circumcision. RESULTS: Of the 47 patients, 23 boys with an average age of 16.65 ± 4.052 months (range 11-24 months) were given 0.025 % betamethasone cream, whereas the remaining 24 boys in control group with an average age of 18.42 ± 5.030 months (range 10-24 months) were instructed to apply with 0.05 % betamethasone valerate cream. Using unpaired t test, the age in both groups were comparable (p = 0.1932). There was a decrease in phimosis grade by the end of the therapeutic course in both groups. Further analysis using Mann-Whitney test revealed that the phimosis grade in the half-strength group (0.025 % strength) was significantly lower to the phimosis grade in the control (0.05 % betamethasone) group (p = 0.0003). There was no diversion from steroid application to circumcision or any side effects in the both groups. CONCLUSIONS: 0.025 % betamethasone valerate cream produced a clinical improvement. However, the half-strength formula was not effective as the conventional formula of 0.05 % betamethasone valerate cream.

Concepts: The Age, Corticosteroid, Glucocorticoid, Penis, Phimosis, Betamethasone, Valerate

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Surgery is required for phimosis with a contracted fibrous ring or when the medical treatment with steroids has been unsuccessful. Surgical teams often opt for circumcision when a conservative technique can be used. This surgery could have some psychologic consequences, and when the circumcision in not according to religious convictions, it cannot be live well for the patient and his family. Furthermore, some surgery procedures for prepuce conservation seem to give some unaesthesics aspects with cutaneous excess. The objective of this study was to evaluate our new preputioplasty technique according to the initial diagnosis (phimosis with scarred foreskin or long and narrow foreskin), in situation where circumcision is required currently. Outcome evaluated was: easy and painless foreskin retraction, absence of postoperative phimosis as well as cosmetic aspects of the penis. In this study, 90 children benefited from this technique and subsequent follow-up. The mean age was 7.9 years for the 32 children in the sclerotic phimosis group and 6.8 years for the 58 children in the long and narrow foreskin group. We observed complete foreskin retraction without any recurrence in 100% of children with a phimosis resistant to medical treatment which consisted of progressive foreskin retraction and application of topical steroids, with a mean postoperative follow-up of 1.4 years. Results showed an excellent cosmetic aspect of the penis with absence of enlarged foreskin in all our subjects. This study underlines the relevance of this surgical technique.

Concepts: Medicine, Surgery, Foreskin, Penis, Blood transfusion, Circumcision, Phimosis, Preputioplasty

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Objective: The purpose of the study was to evaluate the safety and feasibility of treatment for male circumcision using modified sleeve circumcision and subcuticular suture with the Quill™ device. Methods: From May 2011 to March 2012, 70 consecutive cases of male circumcision were performed using an alternative technique with the Quill™ device by a single surgeon in our institution. The inclusion and exclusion criteria for the selection process of this procedure were the same as for conventional circumcision. We evaluated the indications and perioperative outcomes. The circumcisions were performed as day-case procedures under local anesthesia. Results: All patients were followed up for a minimum of 3-6 months. The ages ranged from 8 to 68 (mean = 27.0 years, SD = 10). The indications for surgery were either cosmetic (n = 16, 22.9%) or medical [redundant prepuce (n = 36, 51.4%), phimosis (n = 5, 7.1%), paraphimosis (n = 2, 2.9%), balanoposthitis (n = 9, 12.9%), melanoma (n = 1, 1.4%), and condyloma acuminata (n = 1, 1.4%)] (n = 54, 77.1%). The mean operation time in this group was 29 min (19-38 min) when the Quill™ device was used. In all, 3 cases developed complications (4.3%). The final cosmetic result was satisfactory for both the patients and their spouses or parents. Conclusion: This study showed that modified sleeve circumcision and subcuticular suture were safe and reliable surgical methods of circumcision that provide a better cosmetic result. © 2015 S. Karger AG, Basel.

Concepts: Surgery, Foreskin, Penis, Circumcision, Phimosis, Balanitis, Dorsal slit