The foreskin problems in childhood could be mainly due to a tight foreskin. 90% of newborn males have a tight foreskin. 50% of them will become retractable by the age of one year and 90% will become retractable by the age of four years. 99% of these will be become retractable by the age of 16 years.
However despite this natural history of foreskin as found by Gairdner and Gairdner more than sixty years ago, still too many circumcisions are done without any definite indication.
The only absolute indication for a circumcision is a condition called lichen sclerosus or balanitis xerotica obliterans (BXO). However even in the absence of scarring, a tight foreskin can cause symptoms like pain and recurrent balanitis. Usually this is also due to the adhesions between foreskin and the glans penis but it causes an accumulation of urine and irritation and inflammation. If this is an ongoing distressing problem, this could be dealt with by release of foreskin adhesions and if the fraenulum is tight the fraenulum could be divided or a fraenuloplasty could be done the render the foreskin retractable. If the foreskin is tight but not scarred foreskin preserving procedures may be done like prepuceplasty to widen the foreskin. Of course circumcision is the final choice if any of the foreskin preserving procedures fail or if there is evidence of thickened foreskin at the time of the procedure.
What are the foreskin preserving options of treatment for tight foreskin?
As mentioned above, tight foreskin is usually due to a combination of the adhesions between the foreskin and glans penis, a short fraenulum and also a tightness of the foreskin which is called physiological phimosis in the absence of scarring. These conditions can be dealt with by release foreskin adhesions and fraenuloplasty or division of fraenulum and prepuceplasty.
How is a prepuceplasty done?
Prepuceplasty is done by dividing the tight band after retracting the foreskin under anaesthetic. The foreskin is retracted behind the level of the cornea and the level of the tight band is identified. This tight band is divided longitudinally and closed transversely to increase the circumference of the foreskin opening. This could be dorsally or it could be done laterally on both sides. A lateral prepuceplasty offers a slightly better cosmetic outcome.
What are the implications and advantages of prepuceplasty?
The advantage of prepuceplasty is that it is a foreskin preserving operation. It does not change the appearance of the organ permanently. Particularly when this operation is done on children they have not given personal consent for an operation like circumcision which would cause a permanent change in the appearance of the penis. Implications are when children go for a prepuceplasty and release of foreskin adhesions it is very important that the parents help the children to pull back the foreskin on a daily basis and apply paraffin ointment to prevent reformation of the adhesions. If there is any infection or inflammation in the postoperative period, it is a high likelihood of scarring which could cause phimosis again. There is about a 5-10% chance these procedures could fail and the child may require future circumcision. The cosmetic appearance after prepuceplasty will not be perfect as a normal foreskin however there is slight slit like appearance which his more pronounced in the dorsal prepuceplasty and slight less pronounced in the lateral prepuceplasty. However if the foreskin is pulled back, midway through the retraction it will look slightly different and therefore a full cosmetic appearance similar to prior to the operation could not be given with any assurance at all.
What are the complications of prepuceplasty?
The complications of prepuceplasty include wound infection, bleeding and change in the cosmetic appearance of the foreskin. In the presence of infection and pre-existing very sensitive penis or extensive foreskin adhesions prior to this procedure the retraction of the foreskin can be uncomfortable. If the foreskin is not retracted regularly for the first four weeks after operation, there is a high likelihood that this procedure could fail necessitating future circumcision.
What are the advantages of advantages and implications of circumcision?
Circumcision is done for only an absolute indication of lichen sclerosus or balanitis xerotica obliterans (BXO). This is the only absolute medical indication. However the relative indications for circumcision are recurrent balanitis or a very sensitive foreskin. The circumcision involves the removal of the sleeve of the foreskin that covers the tip of the penis (glans penis). It will result in a permanent change in the appearance of the penis as though the foreskin is fully retracted. Therefore for the first few weeks after the procedure the glans penis may need to get used the undergarments and the glans penis can feel a bit oversensitive. Some men complain of numbness of the glans penis on a long term. The immediate complications are bleeding and infection which may need to be dealt with urgently.