Circumcision- Standard Treatment Guidelines

Religious male circumcision is considered a commandment from God in Judaism widely practiced in Islam and customary in Christian churches in Africa. Virtually all the current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision.

The opponents to circumcision consider it a violation of human rights

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Circusion. Following are the major recommendations :

Case Definition:

The words “circumcision” is derived from the Latin circum (meaning “around”) and coedre (meaning “to cut”). Male circumcision is the removal of some or the entire foreskin (prepuce) from the penis

Medical Indications :

• In infants and young boys – true phimosis caused by BXO (Balanitis xerotica obliterans)


• Recurrent balanoposthitis


• Recurrent UTI’s with an abnormal upper urinary tract


• Phimosis may result from misguided attempt by parents to expose the glans forcibly


• In adult – inability to retract prepuce for intercourse


• Splitting of an abnormally tight frenulum


• Balanitis


• Before radiotherapy for carcinoma penis


• Paraphimosis


• Diabetes mellitus with recurrent balanoposthitis


• HIV


• UTI

Incidence :

Proportion of males circumcised worldwide vary from one sixth to a third Circumcision is most prevalent in the Muslim countries of the world

In India too, it is nearly 100% among Muslims

Prevention And Counselling

Physiological adhesion between the foreskin and glans penis may persist until 6 years of age and be mistaken for phimosis. Forcible retraction of the skin is not recommended in physiological phimosis.

At 4-5 years of age, topical corticosteroid cream may be used for 6 weeks if phimosis continues to exist.

Circumcision – is done if it is

• Resistant to topical steroid therapy


• If patient requires treatment for balanitis


• When there is urinary obstruction due to very high prepuce

Carcinoma penis should be ruled out. When confined to prepuce, circumcision may be adequate treatment but regular follow up is necessary

Similarly chancre which may present as phimosis should be ruled out

Balanitis xerotica obliterans – normal foreskin becomes thickened and does not retract

Has increased susceptibility to carcinoma and hence requires early treatment

Treatment is circumcision

Optimal Diagnostic Criteria

Phimosis is diagnosed by inability to retract the prepucial skin

SITUATION 1:

1. PHIMOSIS: clinical features

• Inability to retract the prepuce


• Ballooning of prepuce (second bladder) in children


• Balanoposthitis because of inability to clean the glans

2. PARAPHIMOSIS: clinical features

Retracted prepuce cannot be pulled forward; forms a tight ring and acts as constriction. Venous congestion increases with swelling of glans and can result in ulceration and gangrene of the glans

3. History of diabetes with recurrent attacks of balanophosthitits

4. History of bleeding and short duration of lack of retractibility would suggest carcinoma

5. History of STD; sexual history to r/o chancre

Differential Diagnosis

1. Chancre

2. Cancer

3. Meatal stenosis (masked by prepuce)

Investigations:

Simple phimosis is a clinical diagnosis and requires no investigation for confirmation

Routine investigation before surgery such as

Blood sugar

Haemogram Urine r/m

X Ray and ECG may be done as per anaesthetic indication

Biopsy of underlying lesion if any

USG of the abdomen and pelvis to evaluate the entire urinary tract in cases of UTI

Treatment:

Medical treatment in children 5-6 years with congenital phimosis – topical steroid cream

Surgical treatment – circumcision

Procedure :

In infant:

Applying a clamp (or bone forcepts) across the prepuce distal to the glans with blind division of the foreskin is to be condemned

Perform a proper circumcision under direct vision as in an adult

Anaesthesia -

GA – in children, infants and neonates

Dorsal penile nerve block, Ring block and / or EMLA (lidocaine/prilocaine) topical cream may be used in adults

Razmus et al reported that newborns circumcised with the dorsal block and ring block in combination with oral cucrose had lowest pain scores

Wg et al found EMLA cream in addition to local anaesthetic effectively reduces the sharp pain induced by needle puncture

In adults frenular stretch must to avoid bleeding from frenular artery

Histopathology: should be done when there is suspicion of malignancy or other associated conditions

POST OP:

Analgesic

Antibiotic: perioperative dose

Abstinence for 4-6 weeks in adults

The patient should be reviewed 5-7 days post op

Retract and clean any skin covering the glans to prevent adhesion

Complication of Ciricumcision :

• Bleeding most common


• Infection


• Scar


• Meatal stenosis


• Phimosis in later life – if insufficient skin is removed in a child during the first sugery


• Skind bridge formation in infants

SOP: Day care

Referral criteria:

The patient should be referred to a higher centre for treatment of associated conditions if any, such as malignancy

Patient with bleeding disorders and co morbidities may be safely operated in a higher centre

SITUATION 2:

Differential Diagnosis

1. Chancre

2. Cancer

3. Meatal stenosis (masked by prepuce)

Investigations:

Simple phimosis is a clinical diagnosis and requires no investigation for confirmation

Routine investigation before surgery such as

Blood sugar

Haemogram Urine r/m

X Ray and ECG may be done as per anaesthetic indication

Biopsy of underlying lesion if any

USG of the abdomen and pelvis to evaluate the entire urinary tract in cases of UTI

HbA1C

Coagulation profile if bleeding disorder is suspected

Treatment:

As in situation 1

Additional procedures:

Devices are available for infant circumcision – Plastibell, Gomco clamp, or Mogen clamp used together with a restraining device

1. Frenulum may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed

SOP: Day care

WHO DOES WHAT? AND TIMELINES

Doctor

• Clinical examination


• Diagnosis


• Planning surgery


• Surgery


• Post op care


• Anesthesia

Nurse

• Pre & post operative care


• Assisting during surgery

Technician

• Pre op equipment and drugs to be cechked and kept ready


• Assist anaesthetist in the OT


• Assist the surgeon

Resources Required For One Patient / Procedure (Patient Weight 60 Kgs)

Guidelines by The Ministry of Health and Family Welfare :

Dr Ajit Sinha Department of Surgery Safdarjung Hospital New Delhi