Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
Appendix 5.1
VARIATIONS IN TECHNIQUE FOR MINOR ABNORMALITIES OF THE FORESKIN
The techniques described in this manual assume that the foreskin and frenulum are normal.
However, clinic-based circumcision can be undertaken in the presence of minor
abnormalities, if the circumcision team has sufficient experience. Any abnormalities should
be detected in the preoperative examination of the penis, which should include full retraction
of the foreskin. Two abnormalities – both of which are common indications for circumcision –
require a slight variation in technique.
Phimosis
Phimosis is scarring of the aperture of the foreskin to the extent that the foreskin cannot be
retracted. Often the tip of the foreskin will appear white because of scar tissue. If the scar
tissue is extensive, then the man is not suitable for clinic-based circumcision and should be
referred to a higher level of care.
The first step in all circumcision operations is to mark the foreskin with the line of the incision.
If the sleeve resection method is used, the phimosis will prevent retraction of the foreskin and
the line of incision near the corona cannot be marked. In this case, a small dorsal slit should
be made, which is just long enough to allow the foreskin to be retracted. Once retracted, any
adhesions can be divided and any debris under the foreskin cleaned with a swab soaked in
povidone iodine or cetrimide. Once all adhesions have been divided, the second line of
incision on the foreskin near the corona can be marked and the circumcision operation can
proceed as usual.
In the forceps-guided or dorsal slit methods, the line of incision is marked on the outer aspect
of the foreskin in the normal manner. However, with minor degrees of phimosis, it may be
necessary to make a small dorsal slit to allow full retraction and cleaning under the foreskin
before proceeding with the operation. The forceps-guided method should not be used if there
is evidence of extensive scarring.
Tight or scarred frenulum
All males have a band of tissue (the frenulum) on the ventral side of the penis, just below the
glans. Usually the frenulum does not interfere with retraction of the foreskin. During early
sexual experiences, the frenulum may be stretched as the foreskin is retracted, and minor
tears are a frequent problem. Such tears can heal, leaving inelastic scar tissue, which
tightens and makes further tearing and scarring more likely. The problem can be seen when
the foreskin is retracted during physical examination. Instead of the normal pink frenulum, a
tight band of white tissue is seen (Fig. 5.43A). This restrictive frenular band can be easily
corrected during circumcision.
Spread open the foreskin and retract it ventrally to put the frenular band under tension. Using
dissection scissors, snip the band at its centre, taking care not to injure the urethra, which is
just under the frenulum. Any bleeding from the frenular artery should be controlled by careful
tying or under-running. After the frenulum has been cut, there will be an inverted V-shaped
defect (Fig. 5.43B).
The circumcision can then be performed as usual. In this case, however, do not suture the
penile skin up to the edge of the foreskin defect, since this will cause increased tension on
the ventral side. This tension may cause curvature of the penis or possibly make erection or
Surgical procedures for adults and adolescents Chapter 5-33