With the summer holidays approaching, a large number of circumcisions for pediatric and middle and elementary school students are coming, and dozens of private messages on Twitter every day make it imperative for me to do a serious job of once again popularizing circumcision, pardon me for not being able to Q&A bloggers one by one, see my previous long tweets for specific surgical methods, thanks!
The American Academy of Pediatrics released a policy statement on circumcision in 2013, updating the 1999 Recommendations for Circumcision, which, based on data obtained over five years from 1995-2010, proposed that, the benefits of neonatal circumcision outweigh its risks and that this operation should be offered to families who choose to circumcise and be covered by health insurance.
The third edition of the People’s Health Publishing House’s Urological Surgery advocates, prepuce and foreskin can impede urination, and urine is obstructed through the narrow foreskin opening during urination, and urine forms eddies, leading to recurrent foreskin and penile head inflammation, adhesions and urinary tract infections, which can occasionally cause cancer. Therefore, it is advisable to perform early surgery on circumcision, at the latest before school age, usually at 8 months to 2 years old.
Having performed tens of thousands of circumcisions, I strongly agree with the American Academy of Pediatrics, but have reservations about the more radical indications for the procedure in the Chinese urological community.
The indications for circumcision that I have set for myself
1.Children in the neonatal period and early childhood (from birth to 3 years old) with circumcision and prepuce, do not need to be treated, but wait for observation;
2.Pedunculosis in children over 5 years old must be operated;
3.Children whose foreskin is too long and can be turned out to the coronal sulcus without adhesions or a little adhesions do not need surgery;
4.Children whose foreskin is too long and can be turned out to the coronal sulcus should be operated to separate the adhesions;
5, the foreskin is too long, adhesions are serious, the foreskin can barely flip out to reveal the urethral opening, is the absolute surgical indication of circumcision; 6, adult men, repeated circumcision, glansitis, recommended surgery.
The age of pediatric circumcision, personally I think 5-7 years old is the best, because children basically know how to cooperate with local anesthesia, the biggest benefit, after the vigorous development of adolescence, the development of a mature penis almost can not see the difference in pigmentation of the inner and outer plate and surgical traces.
Every winter and summer, there are a large number of circumcised children brought to the hospital by their parents for consultation or appointment for circumcision in the outpatient clinic. Those younger than 5 years old are discouraged and not given special treatment; those older than 5 years old are given treatment advice according to the specific circumstances of the child, either waiting for observation or manual stripping or arranging surgery.
There are many parents, because of the white bumps under the foreskin of the child to the hospital, white bumps is commonly known as foreskin scale, foreskin is too long and prepuce reason, when the child urinates, urine also seeped into the foreskin and the coronal sulcus adhesion between some small spaces, and the sebaceous glands of the inner plate of the foreskin chemical reaction, turned into the foreskin scale, combined with odor, long-term accumulation of foreskin scale gradually become hard lumps, so that parents mistakenly believe that the long “tumor”.
In newborn and early childhood children (at birth – 3 years old), this condition does not need to be treated and they should come back to the hospital after they are 5 years old for the doctor to decide on the treatment. The day-to-day task of flipping the foreskin and cleaning it is a difficult one, and improper flipping and cleaning methods can aggravate a child’s condition, unless there are recurrent urinary tract infections and glansitis, and circumcision is the most effective treatment.
In children whose foreskin is too long and can be turned out close to the coronal sulcus, good results can be obtained by separating the adhesions by hand.
One day I went to a friend’s house to play, and my friend’s son happened to fall into this category, so I pointed to him and said, “This is a worm, it will eat your penis if you don’t get it out, and you will squat to urinate like a girl.”
He agreed to my method to help him peel, it really hurts, just when he was about to refuse me to continue, I suddenly bawled, “Bugs bit my uncle’s hand, it hurts me.”
He hurriedly patted my back and comforted me with an extremely distorted expression of pain, “Uncle, don’t cry even if I don’t cry!”
Every day after that, my friend insisted on doing the foreskin flap and cleaning for his son, the daily flap is to avoid re-adhesion between the foreskin and the coronal sulcus.
The circumcision of the foreskin is an absolute indication for surgery, which can completely remove the foreskin and expose the glans.
There are three recognized surgical methods in the industry
1.Dorsal incision circumcision;
2.Cuff circumcision;
3.Circumcision. Circumcision is currently the most popular procedure, simple, time-saving, and doctors everywhere perform circumcision in the way they like and are familiar with.
There is one misconception that needs to be corrected.
Will no circumcision affect a child’s development? The answer is, no, except in the case of occult penis.
Fatty Zhang from the hospital’s logistics office approached me to make an appointment for his son’s circumcision, and despite my abhorrence of circumcision, I agreed to do it.
Only at noon overtime, Fatty Zhang brought his son to the outpatient operating room, and to my slight displeasure, Old Zhang brought his brother’s son as well, and I drew a breath of cold air.
Fat pediatricians and fat adults have in common, running abdominal jiggling significantly more than the penis. Fat children are circumcised, often because of the prepubic fat accumulation and increase the difficulty of surgery; fat adults are separated by a layer of rounded belly, never to see the once proud of the penis.
I joked with Zhang Fatty, “You are too poor, fat only meat left, and then do not lose weight, after sitting down are becoming a problem, must be two benches, one to rest on the buttocks, one to rest on the belly.”
Urologists are not like to do circumcision for fat children.
First do Zhang fat son, 9 years old, 56 kg, heavier than me, obese, penis completely buried by the fat in front of the pubic bone.
This bear child, a pile of fat, but also timid as a mouse, I guess often play in the hospital because, know a lot of medical terminology.
“Uncle, why there is no painless circumcision like painless abortion ah?”
I patiently explained, “that has to be general anesthesia, general anesthesia will affect your memory, you will have to become a melon child, not to mention your father to spend an extra 1000 yuan, can not scratch, so, you accept the local anesthesia surgery, the savings of 1000 yuan to you.”
I winked at Fatty Zhang, who understood, “That’s for sure, good son!”
For children who really do not want to accept local anesthesia, the use of propofol intravenous drip for general anesthesia before surgery, the disadvantage is that it increases the cost of surgery, the need for anesthesiologists to give drugs and cardiac monitoring, respiratory monitoring, propofol intravenous drip, rapidly distributed throughout the body, within 40 seconds the child sleep state, I like to call propofol “happy milk I like to call propofol “happy milk”, because it is like milk-like white liquid, the child in a completely painless situation to receive surgery, the surgeon should be swift to complete the operation to prevent too much propofol into the body side effects, but will not affect the memory and intelligence of the child after surgery, circumcision before the doctor generally and parents jointly deceive the child, the most common excuses are, 1, there are worms in the penis The most common excuses are: 1, there are worms in the penis, not to catch worms out will eat your penis; 2, not to cut off the foreskin, the penis is not long, you will not be able to marry a daughter-in-law; 3, after general anesthesia you will become a fool, not to mention that local anesthesia is not painful, like an ant bite you.
The surgery is really tough, you have to use your fingers to pull out the penis while using the palm of your hand under the pressure of fat, sweating to do half, Zhang Xiaofat screwed also do not want me to continue, he said his father is a liar, such as going to Hong Kong Disney, are three years, did not fulfill the promise to him.
Hurry to call the operating room outside the fat Zhang sent 1000 yuan in, Zhang Xiaofat counted the pile of bills, shedding hot tears of happiness and pain.
Excessively obese children, urologists often refuse to circumcise them or simply arrange for them to be admitted to the hospital for surgery. Many urologists like to remove the excess fat in front of the pubic bone and fix the skin at the junction of the penis and scrotum with sutures on the surface of the superficial fascia in order to restore a normal appearance after surgery.
I do not like to do this, still follow my surgery, although the result is very ugly, the perineum is only a navel-like eye, painstakingly pick open, only fat little children’s penis, but rest assured that the development is mature, the penis will be drilled out.
This is one of my longest surgery circumcision, general pediatric, 15 minutes to get it done, Zhang Xiaofat took me 45 minutes.
Then did the second, Fatty Zhang’s 7-year-old nephew, lying on the operating table, I desperately pull out his penis, circumcision, penile skin dorsal short, ventral long, cut open is also certainly more inner plate, less outer plate, diagnosed as occult penis, have to be admitted to perform occult penile correction.
As soon as he heard of the hospitalization, Zhang Fatty’s fat nephew immediately howled, he thought he could repeat the same trick, like his brother to extort 1000 yuan to hand.
Fatty Zhang asked me worriedly, “Can we do it when he grows up?”
I replied, “No, because it affects the development.”
The normal penis has a loose and fat-free fascia under the skin, called the meatus, which separates the two layers of foreskin, and the meatus has a strong elasticity, so the penis body can slide freely under the skin.
It is not uncommon to see occult penis in the clinic, and the pathogenesis is still unclear. It is manifested by shortening and thickening of the sarcolemma, forming an inelastic fibrous band that restricts the penis from extending.
On the day of the surgery, Fatty Zhang’s brother and sister-in-law came, and both of them were very anxious and kept asking me, “Can it be cured?”
I smiled bashfully, “If you operate before puberty, the child has a chance of healing.”
In fact, I would like to say that healing is definitely possible, but the current increasingly tense doctor-patient relationship has caused the unspoken rules of the medical field, when doctors talk with families before surgery, they will intentionally exaggerate the risks of treatment or surgery to better protect themselves, and their friends in general are no exception. When the final result of treatment is not expected, most patients and families change their faces faster than the sky.
For occult penis, many doctors in secondary hospitals also fail to fully recognize the anatomical variation of this disease, and perform circumcision as a general prepuce, which not only fails to restore the normal anatomical position of the penis after surgery, but also is prone to foreskin opening stenosis and skin shortening, adding more difficulties to future treatment.
The surgery for occult penis is not complicated and requires removal of all thickened, inelastic meatus and fibrous cords, cutting of the foreskin, enlarging the foreskin cavity, and ensuring good fixation of the penis body and exposure of the penis head.
There is also a more common developmental malformation of the penis, webbed penis, refers to the skin of the scrotum extends to the ventral side of the penis (tethered side), the penis develops normally, because the skin of the scrotum extends, resulting in part of the penis skin and penis body is not attached, this situation is clear at a glance, parents can check their baby son, most webbed penis surgery to take a transverse cut webbed skin, so that the penis and scrotum Separate, and fix the scrotum at the root of the penis, longitudinal suture incision, simple physics, transverse incision longitudinal suture, the skin of the penis is naturally elongated. Of course, a few severe webbed penises require a complex flap transfer.
What are the precautions to take after circumcision?
It is best to rest 1-2 days, less activity, avoid bleeding, use antibiotics and painkillers as appropriate. In China, circumcision is classified as a Class I surgery (sterile surgery), and according to the strictest principles of rational use of antibiotics ever introduced by the Health Planning Commission, it is against the rules for doctors to prescribe antibiotics after surgery, which is really overkill, and many doctors have no choice but to add a false combination to the diagnosis of circumcision Circumcision.
Diet, no manic spicy food, no alcohol.