Circumcision refers to a condition in which the foreskin cannot be turned up above the coronal sulcus, preventing the head of the penis from being fully exposed. The inability of the foreskin to be completely turned up can be due to the narrow opening of the foreskin or due to the formation of adhesions between the foreskin and the head of the penis.
In a survey analysis involving 10,421 male children and adolescents between the ages of 0 and 18 in China, it was found that the incidence of prepuce can drop from 99.7% at birth to 6.81% during adolescence.
There are two types of prepuce: congenital (physiological) and secondary (pathological). Congenital prepuce can be seen in every normal male newborn and is a natural phenomenon in the development of the individual male. Early in embryonic development, the inner plate of the foreskin and the head of the penis fuse with each other. Under the action of androgens, the epithelial layer between the inner plate of the foreskin and the head of the penis becomes keratinized and desquamated before gradually forming a gap between them. At birth, about 96% of newborns have physiological prepuce due to the natural adhesion between the foreskin and the head of the penis. By the age of 3 to 4, with the growth and development of the penis and the accumulation of prepuce, as well as intermittent penile erection and instinctive squeezing, the foreskin and the head of the penis gradually separate and the foreskin recedes upward to reveal the head of the penis.
Secondary prepuce is mostly caused by injury or infection of the foreskin and the head of the penis, the foreskin mouth forms a circular scar narrowing, the skin hardens and loses elasticity, resulting in the foreskin cannot be turned up to reveal the head of the penis. If the foreskin is serious, it can cause difficulty in urination, and long-term inflammatory stimulation can induce carcinoma.
Diagnosis and differential diagnosis
The diagnosis of prepuce mainly relies on physical examination. If the foreskin mouth is narrow or the foreskin and the head of the penis cannot be turned over to completely reveal the head of the penis, it can be diagnosed as prepuce. There is a big difference in treatment between physiological and pathological prepuce, so careful identification of the two types of prepuce is needed. Usually, physiological prepuce only has the obstacle of flipping the foreskin since childhood, without pain, difficulty in urination and local or urinary tract infection; when the foreskin opening is gently flipped, the foreskin opening is wrinkled and healthy and red. In contrast, pathological prepuce is usually accompanied by local pain, inflammation, bleeding or difficulty in urination, urinary tract infection, etc. The opening of the foreskin is narrow and the foreskin at the opening is white and fibrotic change.
In cases of hypospadias, the head of the penis is completely covered by the foreskin in the erect state and cannot be revealed, but the foreskin can be turned up to the coronal sulcus to reveal the head of the penis. Patients with occult penis often due to obesity, local fat pad accumulation, Yinba is hidden in the fat pad, push back the fat pad, flip the foreskin to reveal the head of the penis.
【Treatment】
Specific treatment is selected according to the patient’s age, type of prepuce, severity, etiology and the presence of urethral deformity and complications.
I. Wait and see
For children with physiological prepuce who are << span="">2 years old and have no symptoms, they can be observed and wait. This is because physiological prepuce has the potential to heal itself as it grows older.
Second, medication
Steroid creams/creams can relieve the narrowing of the foreskin opening, make the narrowed foreskin soft and elastic, reduce the degree of prepuce, and even achieve a complete or partial foreskin flip. For simple physiological prepuce, or complication of foreskin glansitis, when 0.05%~0.1% steroid cream is applied locally twice a day for 20~30 days, the success rate of treatment is over 90%, and the recurrence rate is 17%. Topical application of steroids does not increase blood cortisol concentration, does not affect the hypothalamic-pituitary-adrenal axis, and has no local and systemic side effects.
Third, the foreskin mouth expansion
Frequent pulling of the foreskin mouth can make the foreskin mouth gradually expand. In recent years, there are reports of good results of foreskin mouth expansion using expansion apparatus. The method is effective for children without foreskin infection and fibrosis, and can be combined with local steroid application { treatment.
Fourth, manipulation flip or reset
For children with symptomatic physiological prepuce, it may be considered to try to flip the foreskin up to reveal the head of the penis and clean the prepuce. Forcing the foreskin to flip may cause foreskin tearing and scar formation, which may cause pathological or embedded prepuce.
V. Surgical treatment
Circumcision There are many types of circumcision, including full-layer excision of the inner and outer plates of the foreskin, cuff-like circumcision of the foreskin, circumcision of the foreskin ring ligature, etc.
Recommended surgical indications: pathological prepuce, physiological prepuce combined with recurrent glans vulgaris and recurrent urinary tract infections. Physiological prepuce combined with enlargement of the foreskin cavity during urination is not an absolute indication for circumcision.
Contraindications to surgery: blood clotting disorders, acute local infections, congenital anomalies of the penis (e.g. congenital hypospadias, congenital hypospadias, occult penis)
The complication rate of the operation is low, mainly: bleeding, infection, incision dehiscence, foreskin adhesion, too much or too little foreskin removal and foreskin stricture, urinary fistula, etc.
VI. Prognosis and follow-up
Most of the physiological prepuce can heal on their own. Patients with prepuce should be followed up after surgery. The follow-up mainly relies on the patient’s subjective symptoms and physical examination to understand whether there are complications so as to detect and deal with them in time.