Circumcision is the amputation of the foreskin, resulting in a permanent alteration of the anatomy and histology of the penis 1–3. It is a very common procedure in the USA, where up to 85% of boys and men are circumcised, while it is not so frequent in Europe 3. Usually, boys and appreciably fewer adult men are circumcised for three reasons: first of all, it is considered a religious ritual; second, it is a prophylactic measure against future ailments (reducing the risk of penile cancer, urinary tract infection, and sexually transmitted diseases); and third, it is performed for medical indications 4. The latter reason represents the subject of this article. Phimosis is defined as an abnormal tightness of the foreskin, preventing it being retracted over the tip of the penis. Pathological phimosis due to balanitis xerotica obliterans (BXO), affecting 0.8–1.5% of boys 5,6 and recurrent balanoposthitis, involving about 1% of boys 7 are reported as indications for circumcision. For these indications, less than 2.5%, by a generous estimation, of boys requires circumcision.
It is known that the foreskin is a primary, erogenous tissue necessary for normal sexual function 8. In this way, surgical amputation of the foreskin removes many of the fine-touch corpuscular receptors from the penis. Moreover, the residual exposed glans mucosa becomes abnormally keratinized with an increase in the number of cell layers in granular mucosal epithelium, reducing sensitivity.
Research exploring sexual functioning across circumcision status has produced mixed results 9. In this regard, the absence of fine-touch receptors, a desensitized glans, and the impossibility of an erogenous mobility of the prepuce might necessitate inordinate stimulation of residual penile nerve endings to achieve pleasure and orgasm 9–11. Furthermore, many circumcised men reported that restoration of the foreskin resolved the unnatural dryness of the circumcised penis, which caused abrasion pain or bleeding during intercourse and that restoration offered unique pleasures, which enhanced sexual intimacy 9,12,13. Moreover, 0.9–7.29% of circumcised men complained of meatal stenosis 14,15.
Some authors developed alternative procedures to circumcision for men who required surgery for phimosis, such as preputioplasty 16–19, to preserve corpuscular sensory receptors, dartos muscle, and complete function of the penis, thus avoiding abnormal exposure and keratinisation of the glans. However, for BXO-related phimosis, preputioplasty is not indicated as the affected foreskin is not removed. We have developed a technique of modified partial circumcision for paediatric patients affected by ‘pathological’ phimosis, removing the stenotic region and the internal layer of the foreskin but almost completely preserving the foreskin. In our opinion, this technique allows a cover for the glans, maintains the function of the foreskin, and avoids recurrence of phimosis with good cosmetic results.
Patients and methods
The study was approved by the Institutional Review Board. Between January 1998 and August 2009, 360 consecutive patients with ‘pathological’ phimosis underwent modified partial circumcision at our institution. After informed consent of parents, all the patients underwent surgery as day cases under both general and locoregional infiltration anaesthesia (bupivaine 0.5% plain). The mean age of the boys was 8.9 years, range 5–15 years. In 145 (40.3%) cases, the indication for surgery was the clinical suspicion of BXO as a cause of troublesome phimosis. In 215 (59.7%) cases, the indication for surgery was the fibrotic scar of the preputial orifice after attempts to shift the foreskin with its radial laceration and fibrotic scar formation (chronic inflammation of the prepuce).
After dilation of the stenotic preputial hole using clips and exposing the glans (Fig. 1), a frenulectomy using a bipolar is performed. Then, the foreskin is retracted, and a circumferential incision is made 0.5–1.0 cm proximal to the coronal sulcus, depending on the penile length (Fig. 2a and b). Two Allis’ forceps are located on the edge of the prepuce, performing a light traction and a demarcation of the fibrotic preputial tissue that needs to be removed is carried out using a forceps (Fig. 3a and b). Thus, the foreskin is excised circumferentially with monopolar diathermy (Fig. 4a and b). Then, the foreskin is retracted, and the remnant mucosal epithelium is excised circumferentially (Fig. 5a–d). If necessary, the bleeding vessels are gently cauterized or tied off with 6–0 absorbable sutures.
The residual preputial skin is then sutured to the distal mucosal skin with a stitch in the dorsal midline and two ventral stitches on each side of the frenulum. These sutures can be used for gentle traction. The remaining preputial skin is sutured to the distal mucosal skin with 5–0 absorbable interrupted sutures (Fig. 6a and b). The reconstructed foreskin is gently pulled up to allow cover of the glans. In this way, the suture line lies on the internal part of the preputial sac (Fig. 7a and b). The removed prepuce is sent for histological examination. The patients were discharged the same day of the surgical procedure with topic antibiotic therapy for 7 days. In all patients with histological diagnosis of BXO, a local treatment with 0.05 clobetasol propionate was performed, according to the Pugliese et al. protocol 20. In particular, one application per day for 4 weeks, then one application every 48 h for another 4 weeks and, subsequently, two applications per week for 1 month was followed.
In all the cases, the postoperative period was uneventful, and no complications were reported. An outpatient follow-up was carried out at 1, 12 and 24 months. Cosmesis was considered excellent by parents in 95.2% of patients. In these patients, the glans was almost completely covered by soft foreskin, normally running upon the glands. No surgical scar was seen (Fig. 8). Histopathological examination of the removed foreskin documented the characteristic findings of BXO in 162 (45%). In the remaining 198 (55%) cases, light microscopy showed nonspecific fibrosis. Twelve (3.3%) patients of which nine with histological diagnosis of BXO, complained of recurrence and a radical circumcision was performed. In five (1.4%) cases, a smegmatic cyst was noted for the presence of mucosa lamina propria along the suture line. In these cases, surgical resection of the smegmatic cyst was performed.
Without knowledge of the normal development of the penis, some physicians advocate childhood circumcision as a surgical treatment of normal anatomy 2. For this reason, it has been estimated that the number of circumcision performed for medical reasons is less than 10% of all performed circumcision 21. The foreskin is considered a main, erogenous tissue necessary for normal sexual function 2 and it is unclear if amputation of the foreskin might cause changes in sexual behaviour in men 9,22–24. It has been suspected that the increased frequency of masturbation, anal intercourse, and fellatio reported by circumcised men in the USA might be due to the sensory imbalance caused by circumcision 25. Furthermore, it has also been reported that woman preferred vaginal intercourse with an anatomically complete penis over a circumcised penis, which causes abrasion, pain, or bleeding during intercourse 25.
Many circumcised men complained of an annoying dryness and it has been reported that restoration of the foreskin resolves the unnatural dryness of the circumcised penis 12. Uncircumcision, the procedure restoring the foreskin, has been performed from antiquity 13 and one of the first detailed descriptions of the operative technique was performed by Celsus 26.
In the last few years, many surgical techniques of preputioplasty have aimed to preserve the foreskin in the case of phimosis 16–19. Unfortunately, these techniques have not been proven reliable for patients affected by phimosis linked to BXO and in patients with scarred foreskin as these preputioplasties leave the pathological foreskin in situ. Furthermore, traditional partial circumcision, leaving the residual pathological foreskin behind, is often followed by recurrent cases, 50% in Becker’s experience 27.
To resolve these issues, we tried this original surgical technique of resection of pathological foreskin, removing the mucosal internal layer followed by the reconstruction of the foreskin using the remaining unaffected cutaneous external layer, thus allowing an almost complete coverage of the glans.
Moreover, this technique, almost completely preserving the foreskin, appears well accepted by patients and parents, also because circumcision is considered as a mutilation in Europe. Moreover, using this technique, the suture line lies on the internal part of the balanopreputial sulcus with a very good cosmetic appearance of the penis. To reduce the incidence of recurrences of BXO in the remaining foreskin, meatus and urethra, we suggest pharmacological treatment with 0.05% clobetasol propionate 20,28,29. In this manner, phimosis recurrence is 3.3% using this technique even if BXO could be considered as a risk factor 30. In our experience, a recurrence occurred in 5.5 and 1.5% of patients with or without BXO, respectively. We believe that a complete resection of the lamina propria of preputial mucosa is mandatory to avoid the formation of smegmatic cysts: Tyson’s glands, the source of smegma, are allocated in the mucosal lamina propria 2.
The surgical technique of modified partial circumcision that we have described above for the correction of pathological phimosis is safe and simple. Cosmetically, it is well accepted by patients and parents, with low rate of late postoperative complications and with an acceptable rate of recurrence. We believe that a prospective study evaluating the satisfaction of sexually active patients who underwent modified partial circumcision could be useful.
Conflicts of interest
There are no conflicts of interest.
1. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291–295.
2. Cold CJ, Taylor JR. The prepuce. BJU Int 1999; 83 (Suppl)1:34–44.
3. Rickwood AM. Medical indications for circumcision. BJU Int 1999; 83 (Suppl)1:45–51.
4. Rickwood AM, Hemalatha V, Batcup G, Spitz L. Phimosis in boys. Br J Urol 1980; 52:147–150.
5. Escala JM, Rickwood AM. Balanitis. Br J Urol 1989; 63:196–7.
6. Jayakumar S, Antao B, Bevington O, Furness P, Ninan GK. Balanitis xerotica obliterans in children and its incidence under the age of 5 years. J Pediatr Urol 2012; 8:272–275.
7. Elder JS. Circumcision. BJU Int 2007; 99:1553–1564.
8. Winkelmann RK. The erogenous zones: their nerve supply and its significance. Proc Staff Meet Mayo Clin 1959; 34:39–47.
9. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014; 11:2847–2864.
10. Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res 1986; 371:205–230.
11. Halata Z, Spaethe A. Sensory innervation of the human penis. Adv Exp Med Biol 1997; 424:265–6.
12. Hammond T. A preliminary poll of men circumcised in infancy or childhood. BJU Int 1999; 83:85–92.
13. Brandes SB, McAninch JW. Surgical methods of restoring the prepuce: a critical review. BJU Int 1999; 83:109–113.
14. Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006; 45:49–54.
15. Yegane RA, Kheirollahi AR, Salehi NA, Bashashati M, Khoshdel JA, Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int 2006; 22:442–445.
16. Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994; 29:561–563.
17. De Castella H. Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl 1994; 76:257–258.
18. Nieuwenhuijs JL, Dik P, Klijn AJ, de Jong TP. Y-V plasty of the foreskin as an alternative to circumcision for surgical treatment of phimosis during childhood. J Pediatr Urol 2007; 3:45–47.
19. Impellizzeri P, Turiaco N, Antonuccio P, Manganaro A, Romeo C. [Preputioplasty in the treatment of phimosis in pediatric age. Indications and results]. Minerva Pediatr 2006; 58:15–19.
20. Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review of the literature and current recommendations for management. J Urol 2007; 178:2268–2276.
21. Ceylan K, Burhan K, Yilmaz Y, Can S, Kuş A, Mustafa G. Severe complications of circumcision: an analysis of 48 cases. J Pediatr Urol 2007; 3:32–35.
22. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 1997; 277:1052–1057.
23. Hosseini SR, Mohseni MG. Effect of timing of circumcision on sexual satisfaction and function. Open J Urol 2011; 1:8–10.
24. Kim D, Pang MG. The effect of male circumcision on sexuality. BJU Int 2007; 99:619–622.
25. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999; 83:79–84.
26. Rubin JP. Celsus’ decircumcision operation: medical and historical implications. Urology 1980; 16:121–124.
27. Becker K. Lichen sclerosus in boys. Dtsch Arztebl Int 2011; 108:53–58.
28. Folaranmi SE, Corbett HJ, Losty PD. Does application of topical steroids for lichen sclerosus (balanitis xerotica obliterans) affect the rate of circumcision? a systematic review. J Pediatr Surg 2018. [Epub ahead of print].
29. Celis S, Reed F, Murphy F, Adams S, Gillick J, Abdelhafeez AH, et al. Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. J Pediatr Urol 2014; 10:34–39.
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30. Schellhammer PF, Jordan GH, Robey EL, Spaulding JT. Premalignant lesions and nonsquamous malignancy of the penis and carcinoma of the scrotum. Urol Clin North Am 1992; 19:131–142.