Phimosis in adults

Phimosis in adults

Scarring in adults occurs as a result of balanitis (inflammation of the glans penis), posthitis (inflammation of the foreskin) or LS. In LS ( Figures 85.14 and 85.15 ) the normal pliant foreskin becomes thickened, typically whitish in appearance and forms a constricting band that prevents retraction. As a consequence, it is di ffi cult to keep the penis clean and there may be recurrent attacks of balanitis. Treatment In physiological phimosis, no treatment is necessary or appro priate. True phimosis causing symptoms requires circumcision. In emergency situations, such as when catheterisation is required, a dorsal slit under local anaesthesia ma y be required. - ). Circumcision Circumcision has been practised since as early as 4000 /uni00A0 /b.sc/c.sc/e.sc . Circumcision should not be performed in the presence of hypospadias, penile curvature or buried penis. - In infants and young boys, circumcision is usually performed at the request of the parents for social or religious reasons. Medical indications for circumcision in boys include true phimosis, LS (rare under the age of 5 y ears), recurrent

(b) Figure 85.14 (a) Active phase of lichen sclerosus (LS). (b) Burnt-out phase of LS. Indications.

attacks of balanoposthitis and recurrent UTIs with abnormal ities such as high-grade vesicoureteral reflux. In adults, circumcision is indicated when there is inability to retract the foreskin for intercourse, for splitting of an abnor mally tight frenulum or for recurrent balanitis. Recently , evidence has emerged that circumcision protects against the spread of human immunodeficiency virus (HIV). The virus dies quickly on a dry penis. A large-scale programme of adolescent circumcision under the auspices of the World Health Organization is ongoing in some African countries. Under anaesthesia the prepuce is held in artery forceps and put on a gentle stretch. A circumferential incision in the penile skin is made at the level of the corona using a knife. The prepuce is then slit dorsally in the midline to within 1 /uni00A0 cm of the corona. (An alternative technique slits the prepuce first.) This converts the foreskin into two flaps. When the undersurface of the prepuce has been separated from the glans, the inner layer of each flap is again marked with a pen and then incised with a second circumferential inci sion, leaving about 0.5 /uni00A0 cm of the inner layer of the preputial skin. Cutting the remaining connective tissue completes the excision ( Figure 85.16 ). V essels should be preferably secured with bipolar dia thermy or with absorbable sutures. The cut edges of the skin are approximated using interrupted sutures, making certain that the frenular vessels are ligated. In LS, the separation of prepuce from foreskin is at times di ffi cult. The excised skin should be sent for histology . Summary box 85.6 Circumcision /uni25CF /uni25CF /uni25CF Walter Hermann von Heineke , 1834–1901, surgeon and Professor of Surgery in Erlangen, Germany . Jan Mikulicz-Radecki , 1850–1905, surgeon and Director of Surgery in Krakow and Wroc ł aw , Poland. (c) - (d) (e) -

Figure 85.15 Lichen sclerosus is a genital skin disease and can involve the skin of the genitalia. Technique. Commonly performed for religious and cultural reasons Physiological phimosis does not need circumcision Symptomatic phimosis is treated by circumcision Figure 85.16 (a–e) Stages in circumcision.