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When is surgery necessary?


What is Phimosis? When is circumcision required?

THE term "Phimosis", derived from Greek word for "muzzling", has been widely applied to narrow foreskin. Normally, the skin over the tip of penis folds on itself. This extra skin is called foreskin. In newborns, the under surface of the foreskin is fused to the head of penis. So, the foreskin cannot be pulled back. This is normal feature referred to as "non retractile foreskin". As the children grow the foreskin separates slowly and by 15 years almost 90 per cent have normal adult pattern.

Variable adherence

Up to five years of age the adherence to the penis is variable. Sometimes there can be accumulation of white discharge called "smegma". Some times the foreskin balloons as the boy passes urine. These are entirely normal and should not cause concern. Some parents get the child to practice retraction exercises to see if they can overcome the problem. But this can cause soreness and bleeding.

Excessive retraction can also damage the skin leading to scarring and real phimosis. However boys older than seven years of age can attempt self-retraction at bath, as they will know when it will hurt and when to stop. It is essential to put back the foreskin after retraction, as skin left retracted can get stuck in that position.

Circumcision is one of the oldest operations known to mankind. There are several reasons for circumcision: as a treatment for true Phimosis; as a preventive step in children with recurrent urine infections or kidney problems like hydronephrosis and reflux; for religious reasons; and as a preventive step against many diseases. There is medical evidence that circumcision does protect against infections and cancer of the penis.

In a boy with phimosis, surgery is required if the following problems are encountered: Scarring of the skin at the tip; recurrent infections; straining and only dribbling when passing urine; para phimosis (swelling and inability to put back the pulled foreskin). Some times children have kidney problems like hydronephrosis, where the kidney is swollen with urine but there is no real blockage. In some children the urine goes upstream towards the kidneys while passing. This is known as reflux and these children are at higher risk of infection. Some boys get recurrent urinary infections without any kidney abnormalities. In such cases circumcision is said to reduce the chance of infection by half.

When to avoid

Circumcision in children is usually done under general anaesthesia. It involves removing the excess skin at the tip of the penis. The operation lasts for 30 minutes. The stitches are dissolvable. There can be a variable degree of swelling and it may take about two weeks for healing.

There are certain situations when a circumcision should be avoided. In children with hypospadias, urine exits from the hole on the under surface of penis. In these children the foreskin is used to make a new skin tube and bring the hole to the tip. If these boys have had circumcision it makes future hypospadias surgery extremely difficult.

The writer is a paediatric urologist based in Chennai. E-mail

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