The penis Phimosis Phimosis is sometimes congenital but is much over-diagnosed.

The physiological adhesions between the foreskin and the glans penis may persist until the boy is 6 years of age or more, giving the false impression that the prepuce will not retract. Rolling back the prepuce causes its inner lining to pout and the meatus comes into view. This condition should not be confused with true phimosis in small boys where there is scarring of the prepuce which will not retract without fissuring. In these cases, the aperture in the prepuce may be so tight as to cause urinary obstruction. Urinary difficulty with residual urine and back-pressure effects on the ureters and kidney is more commonly due to meatal atresia which may be masked by the prepuce. Phimosis also occurs later in life as a result of balanitis xerotica obliterans, a curious condition in which the normally pliant foreskin becomes thickened and will not retract. It is difficult to keep the penis clean, and there is both a problem with hygiene and an increased susceptibility to carcinoma. Treatment is by circumcision. Circumcision Apparently, circumcision did not originate among the Jews: they took the practice from either the Babylonians or the Negroes, probably the latter. It had been practised in West Africa for over 5000 years. Indications. In infants and young boys, circumcision is most usually performed at the request of the parents for social or religious reasons. Occasionally, there is true phimosis with recurrent attacks of balanitis. As stated above, it is normal for the prepuce to be long and adherent to the glands during the first few years of life. Recurrent balanoprosthitis and phimosis may result from misguided attempts by parents to expose the glans forcibly. In adults, circumcision is indicated because of inability to retract for intercourse, for splitting of an abnormally tight frenulum, balanitis and sometimes prior to radiotherapy for carcinoma of the penis. Technique in an infant. The much advocated method of applying a clamp or bone forceps across the prepuce distal to the glans with blind division of the foreskin can no longer be condoned. To see one little boy with partial or total amputation of the

glans is enough to realise the folly of this technique. It is far better to perform a proper circumcision under direct vision as in an adult. The Plastibel (Hollister) is used as shown in Fig. 67.18: the ring separates between 5 and 8 days postoperatively. Technique in adolescents and adults. In adolescents and adults the following method is preferable. The prepuce is held in haemostats 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 up the midline dorsally to within 1 cm of the corona. This converts the foreskin into two flaps connected at the midline anteriorly. When the undersurface of the prepuce has been separated from the glans, the inner layer of each flap is incised with a second circumferential incision leaving about 5 mm of the inner layer of the prepuce distal to the corona. Cutting the remaining connective tissue completes the excision (Fig. 67.19). Monopolar diathermy should be avoided in operations on the penis in small boys because there is a danger that the small current path will cause coagulation at the base of the penis. Haemostasis is important in circumcision, however, and should be secured by bipolar diathermy or ligated with catgut. The cut edges are approximated using catgut sutures and the layers in the immediate region of the frenulum are brought neatly together using a mattress suture (Fig. 67.20). Preputial calculi Late in life, chronic posthitis may lead to adhesions between the prepuce and the glans and closure of the orifice of the preputial sac. Preputial calculi result from inspissated smegma, urinary salts or both. Injuries Avulsion of the skin of the penis Entanglement of clothing in rotating machinery is the usual cause. Repair is effected by burying the shaft of the penis in the scrotum (Fig. 67.21) with subsequent release at the time of a definitive plastic surgical repair. The prepuce is also at risk in the zip fastening of the trouser fly. Fracture of the penis Fracture of the penis is an uncommon accident usually occurring when the erect penis is bent violently downwards during over-enthusiastic intercourse. The

extravasation of blood causes great pain and swelling. In early cases, incision and drainage of the clot with suture of the defect in the tunica of the ruptured corpus cavernosum give acceptable results. Strangulation of the penis Strangulation of the penis by rings placed on the penis, usually for sexual reasons, can cause venous engorgement which prevents their removal. It may help to aspirate the corpora cavernosa but often the ring must be cut off with a ring cutter or hacksaw.