Pediatric and Adult Circumcision

Circumcision is the removal of the prepuce (foreskin) that covers the glans penis (head of the penis).

In an adult, there are a few reasons that a circumcision might be performed.

1. Phimosis: This means that the opening of the foreskin has scarred down and consequently, the patient cannot pull it back properly, or in some cases, at all. This may result in poor hygiene, and in extreme cases, interfere with urination.
2. Balanitis or Posthitis: This means that the head of the penis or foreskin becomes infected. Patients who have this once are more likely to have problems with recurrent infections.
3. Elective: In these cases, an individual may tell the urologist that he wants a circumcision for cosmetic or religious reasons.
4. Discomfort with Intercourse: In rare instances, a patient can have a prominent frenulum. This is the web-like tissue on the undersurface of the penis that goes from the shaft to the head of the penis. In some males, this can be tight and cause a pulling sensation during sexual intercourse.

*Diabetic patients are at very high risk for severe infection if they have phimosis and consequently poor hygiene. Diabetics with recurrent infections may be advised to undergo circumcision.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners"). The most common of these medications are aspirin and all related pain reliever or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, mention it anyway so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure usually takes less than one hour. Adhesions (tissues stuck to one another) from phimosis or prior infection may add to the operative time. Circumcisions can be performed with local anesthesia only (injection directly into the skin and nerves around and on the penis) or local injection in conjunction with sedation (a very light twilight sleep). Sometimes, sedation alone is adequate. They can also be performed under general anesthesia (complete sleep) or with a spinal.

There are many different methods to perform circumcisions. In most cases, it is the surgeon's choice. After you are sufficiently numb and/or asleep, the foreskin is cut and removed. Bleeding vessels are cauterized (burned with a heat scalpel) or tied with a suture. Sutures are then placed in the skin around the full circumference of the penis. If there is a tight or pulling frenulum (web of tissue on the undersurface of the penis), this is sometimes cut and sutured to allow the foreskin to be fully pulled back. Antibiotic ointment may be placed around the incision and a gauze dressing may be wrapped around the incision.

Post Procedure

You will be in the recovery room for a short time before being sent home. You may have discomfort over the incisions. There may be small blood staining that soaks through the gauze. If the dressing becomes soaked, or you see active blood oozing, please contact us. Sometimes, the bandage falls off before the following day. If there is no active bleeding, there is no need for concern. Otherwise, we will usually instruct you to remove the dressing the following day and take a shower. You should avoid a bath or swimming for the first few days unless otherwise instructed. Some surgeons may ask you to take warm baths a couple of times per day a few days after the surgery. Often, we suggest that you apply ice compresses (as directed) to the penis when you arrive home. We ask that you refrain from any strenuous activity until your follow up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. We encourage you to take the following day off of work and perhaps more if your occupation requires very strenuous activity or heavy lifting. In the first 24 hours, it is to your advantage to minimize activity. Some patients have almost no discomfort while others are a bit uncomfortable for a few days. We may provide you with a prescription for pain medication but you certainly may take an over-the-counter pain reliever medication to which you are not allergic. The sutures we use are self-dissolving, and therefore just fall out on their own within 2-3 weeks after surgery.

*You absolutely must abstain from any type of sexual activity until we tell you that you may resume. This period is typically for 3-4 weeks but may even be longer in diabetic patients who often heal more slowly.

Expectations of Outcome

The swelling may take several weeks until it is fully resolved. The suture line may seem very obvious for weeks or months but typically beings to fade and flatten out. If there were significant adhesions of the skin to the head of the penis, the head may be red, and sting. Sometimes, a scab can form over the next few days. You should not peel these scabs off. Possible Complications of the Procedure ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation.

While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes, which may include, but are not limited to:

• Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising because the blood may be caught under the suture line. This almost always resolves over time with compresses...much like any bad bruising or swelling. If the hematoma is cumbersome or painful or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required. In other words, we may have to open the incision to allow drainage.
• Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage. Infections are far more common in diabetic patients. The signs of infection are unusual redness, increased pain, and/or whitish to yellowish discharge from in between the sutures. Please call the doctor if you note signs of an infection.
• Injury to the Glans Penis: This can be seen in patients with severe phimosis (complete inability to pull the foreskin back) and a history of infections. The foreskin can be stuck to the glans. Although we take every precaution to carefully separate the two, we can sometimes cause an abrasion (scraping) or laceration (cut) to the glans. It is very rare that we would need to suture the area. In almost all cases, the area heals with antibiotic ointment and time. This area may be quite tender for a few days. We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

CALL THE OFFICE FOR: Fever greater than 101 Fahrenheit, nausea, vomiting or uncontrolled pain 970-368-6247. If after hours present to the closest Emergency Room.

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