I. Overview: Prepuce and foreskin is a common disease of male external genitalia, although after birth, with the development of the penis and foreskin, 90% of physiological prepuce gradually heal themselves after the age of 3, to 17 years old still have prepuce less than 1%, prepuce can prevent urination, easy to lead to the deposition of foreskin scale, recurrent episodes of penile head circumcision and episodic urinary tract infection, and can induce penile cancer; will also affect the penile development of minors For married adults, it will affect their sexual life and family harmony to varying degrees.
(A) Definition Phimosis is a narrowing of the opening of the foreskin of the penis or adhesion of the foreskin to the head of the penis, so that the foreskin cannot be turned up to reveal the head of the penis. There are congenital phimosis and acquired phimosis. Congenital prepuce, also known as physiological prepuce, is a physiological adhesion between the inner plate of the foreskin and the epithelial surface of the penis head when the boy is born. With the growth and development of the penis most congenital prepuce can disappear on its own; acquired prepuce is secondary to inflammation of the foreskin and penis head, scar contracture of the foreskin after trauma and loss of elasticity and expansion ability of the foreskin resulting in the foreskin not being able to retract upward. This type of prepuce will not heal on its own.
Redundant prepuce refers to a condition in which the foreskin of the penis covers the entire head of the penis and the urethra, but can be turned up to reveal the head of the penis and the urethra. There is a difference between true and pseudo-circumcision. True prepuce is that the head of the penis cannot be fully exposed even after erection; pseudo prepuce is that the head of the penis cannot be fully exposed when the penis is weak, but can be fully exposed in the erect state.
(B) Pathophysiology The normal glandular secretions of the inner plate of the foreskin and the degenerated epithelium shed by the head of the penis accumulate in the foreskin cavity in patients with prepuce and circumcision. Circumcision can affect the development of the head of the penis or even the whole penis of the patient, and can also cause difficulty in urination, increased pressure in the bladder, urinary ureteral reflux, expansion of the renal pelvis and ureter, causing upper urinary tract infection, scar formation, and in severe cases, reflux nephropathy and even renal function damage.
A small domestic clinical study found that circumcised and circumcised patients had varying degrees of inflammatory changes in the inner plate of the foreskin as they grew older. In patients with prepuce, chronic inflammatory cells infiltrate the superficial dermis when they are 3 to l5 years old, and such changes are limited to the superficial dermis; chronic inflammatory cells infiltrate the whole dermis when they are 15 to 20 years old; after 20 years old, chronic inflammatory cells infiltrate more obviously and squamous epithelial cell hyperplasia and papillomatous hyperplasia appear, and squamous epithelial hyperplasia is active after 60 years old.
The clinical manifestations of circumcision and prepuce vary in each age group. In infants and young children, because of the thin foreskin, when secretions accumulate in the inner plate of the foreskin to form foreskin scale, small white lumps can be seen through the foreskin. When foreskin scale induces foreskin penile head infection, it is manifested as redness and swelling of foreskin and penile head and painful discomfort. The narrowing of the foreskin opening can lead to difficulty in urination, manifested by thinning of the urine line, difficulty in urination, and a sac-like bulging of the foreskin during urination. Painful intercourse can occur in adults with circumcision. Foreskin impaction is a common complication of prepuce, manifested as foreskin edema and penile head pain, which can cause dry gangrene of penile head in serious cases.
Diagnosis According to the above definition, the diagnosis of prepuce and circumcision is easy, but it is necessary to distinguish between congenital physiological prepuce or acquired pathological prepuce, and whether it is true or pseudo-circumcision in order to choose the treatment plan.
Treatment (a) Non-surgical treatment The purpose is to expand the foreskin opening as early as possible to reveal the head of the penis, which is conducive to penile hygiene and prevention of complications. This treatment method is suitable for 3~6 years old with adhesion of foreskin and penis head, prepuce and no inflammation of penis head and foreskin, prepuce with foreskin scale formation.
2.Vascular clamp expansion foreskin mouth method Use vascular clamp to expand the foreskin mouth and separate the foreskin penile head adhesion, remove the foreskin scale, completely reveal the penile head, apply antibiotic ointment, one week after the follow-up. A small amount of bleeding may occur after the foreskin opening is propped open, which will usually self-clot and no special treatment is needed.
3.Topical steroid ointment application method is the preferred non-surgical treatment method in Europe and America. Use 0.05% betamethasone cream applied to the distal end of the foreskin 3 to 4 times a day for 4 to 6 weeks. Parents are instructed to turn up the foreskin after each application of the cream. This treatment has the advantages of non-invasive, painless and easy to operate.
4.Balloon dilation method is to use the balloon of the balloon catheter to inflate the narrow opening of the foreskin to achieve a loose foreskin opening and foreskin upturning.
（The timing of surgery: The timing of circumcision varies significantly according to local customs and hygiene practices. The majority of American boys are circumcised before the age of 3, and 78% of these boys are circumcised before the age of 1. The timing of circumcision treatment for infants and children is still controversial, but scholars who support early circumcision believe that early circumcision can prevent penile cancer, reduce the incidence of urinary tract infections, foreskin priapism, and prevent sexually transmitted diseases such as HIV. A comparative analysis of postoperative complication rates, incidence of urinary tract infections, foreskin penile head infection, penile cancer, adult prevention of post-HIV sexually transmitted diseases, and cost-effectiveness found that infancy is the best time for circumcision. In addition, there are inevitable complications after circumcision in children, which may affect sexual function in the future, and there are many inconveniences in anesthesia and care.
Surgical methods Circumcision can be divided into traditional circumcision, modified circumcision and circumcision with a circumcision device. Each procedure has its own advantages.
The traditional procedures of dorsal cut circumcision, vascular clamp guided circumcision and cuffed circumcision have been recommended as classical circumcision in the World Health Organization’s 2010 guidelines for male circumcision.
Modified circumcision uses minimally invasive and painless technology, which has the advantages of less intraoperative bleeding, short operation time, no medication change or injection after surgery, no pain, quick recovery of the surgical incision and beautiful incision.
Circumcision by circumciser Circumcision is a technological innovation of circumcision with certain advantages, but it is still under continuous trial and improvement, and the outer plate of foreskin is not spread flat when circumcised by circumciser circumcision, and the double outer plate is easy to cause double cutting of the outer plate of foreskin between the inner and outer ring of circumciser.