Do penile Fillers for girth enhancement cause tight foreskin in uncircumcised men?

Penile girth enhancement procedures have gained popularity in recent years, which may cause tight foreskin in uncircumcised men after putting in fillers. Penile girth enhancement procedures, however, come with various risks and complications, some of which are not widely discussed in medical literature. One such complication is phimosis, a condition where the foreskin becomes tight and cannot be easily retracted over the glans penis after filler insertions to increase the girth of the penis and fillers migrate to foreskin. The risk of phimosis after filler insertion is higher in adults who already have mild tightness of the foreskin.

Overview of Penile Girth Enhancement Procedures

Penile girth enhancement procedures can involve a range of techniques, including dermal injections and fillers. These methods aim to increase the circumference of the penis by injecting substances such as autologous fat, silicone, hyaluronic acid (HA), and collagen into the penile shaft. Despite their growing popularity, it is crucial to understand that these procedures have not been approved by the Food and Drug Administration (FDA) in the United States, primarily due to the lack of extensive research and documented safety profiles.

Common Fillers Used in Penile Augmentation

1. Autologous Fat: This involves harvesting fat from another part of the patient's body and injecting it into the penis.

2. Silicone: A more permanent option but associated with significant complications.

3. Hyaluronic Acid (HA): HA is commonly used in cosmetic procedures and is favoured for its temporary effects and biocompatibility.

4. Collagen: Used to provide volume and structure, though it also carries risks of allergic reactions and complications.

The Risk of Phimosis with Penile Fillers

Phimosis is a condition where the foreskin becomes too tight to be pulled back over the head of the penis after uncircumcision penis filler insertions. Tight foreskin can cause pain, swelling, and difficulty with hygiene, potentially leading to balanitis. In particular, HA fillers have been noted to cause this dermatologic complication in some cases.

The mechanism behind this complication can be multifactorial:

- Excessive Filler Volume: Over-injection can lead to excessive swelling and tightness of the foreskin.

- Inflammatory Reaction: The body's response to the injected material can cause inflammation and scarring, leading to phimosis.

Improper Technique: Inaccurate placement or uneven filler distribution can create localised swelling around the foreskin, which can become tight.

- Phimosis is higher in patients who already have mild to severe phimosis. Uncircumcised men may be more prone to filler migrating to the foreskin, which becomes tight (phimosis)

Case Representation and Management

A recent case highlighted the occurrence of phimosis following HA penile girth enhancement. The patient developed significant foreskin tightness, making retraction difficult and painful. The management of this complication required a comprehensive approach:

- Prevention measures immediately after the procedure: Those who have filler recently should Keep the penis upright in supportive tight underwear for the first 7-15 days following the procedure. This is to prevent gravity and reduce the impact of walking so it does not cause the filler to migrate down towards the foreskin. If you notice excessive product around the foreskin, try to massage this back up the penile shaft towards the base of the penis before the filler settles down after 1-2 weeks.

- Medical Management: Initial treatment involved anti-inflammatory medications and topical corticosteroids to reduce swelling and inflammation. Injections to dissolve the fillers in some cases.

- Surgical Intervention – circumcision: In severe cases, surgical intervention such as a dorsal slit or circumcision may be necessary to relieve the tightness and restore normal function.

 Conclusion

 While penile girth enhancement procedures offer solutions for men seeking to increase their penile circumference, the risks and complications, including phimosis, should not be overlooked. Patients must be fully informed about the potential dangers, and surgeons must exercise caution and follow stringent protocols to minimise these risks.

Without FDA approval and comprehensive studies, the medical community must rely on case reports and ongoing research to understand and mitigate the complications associated with penile fillers. Patients considering these procedures should consult with experienced urologists and weigh the potential benefits against the risks of tight foreskin.

This blog aims to describe the under-discussed complications of penile fillers and emphasise the importance of informed decision-making and professional guidance in girth enlargement surgery.

Some clinics advise that for a patient having girth enlargement surgery, having a circumcision before can improve the aesthetic appearance of girth increase. Some clinics asked for circumcision before the girth enlargement surgery to prevent phimosis.

 We are a specialist London circumcision centre that can deal with phimosis with filler procedures. Please ask for professional advice and treatment at our London centre.

A white, inflammatory scaring condition called BXO can also develop in congenital tight foreskin in adults.

The Association Between Phimosis and Balanitis Xerotica Obliterans (BXO) 

Phimosis, a condition characterised by the tightening of the foreskin, leading to difficulty in retracting it over the head of the penis, can appear at birth (congenital) or later in adult life (acquired). This blog also discussed the correlation between acquired tight foreskin and balanitis xerotica obliterans (BXO), also known as lichen sclerosus et atrophicus, a chronic inflammatory condition primarily affecting the genital area. 

Correlation Analysis of Phimosis and BXO: Notably, the association between acquired phimosis and BXO is more pronounced than congenital phimosis. BXO is identified as the primary causative factor for acquired phimosis in both adults and children. The inflammatory nature of BXO triggers scarring and constriction of the foreskin, consequently resulting in diseased and acquired phimosis. While the relationship between congenital phimosis and BXO is less explicit, BXO can also be present in cases of congenital phimosis. 

Significance and Treatment Modalities: The heightened risk of BXO linked to acquired phimosis underscores the critical importance of timely diagnosis and effective management. Early intervention for BXO is paramount in averting complications such as extensive scarring and urethral stricture. 

Treatment approaches vary based on severity and aetiology. In milder instances of acquired phimosis, topical corticosteroids and non-surgical interventions may be required. Surgical intervention, particularly circumcision, may be warranted in severe cases of phimosis or BXO, particularly when they pose significant discomfort, impede hygiene, or disrupt sexual function. 

Recent Study on BXO and Phimosis: A contemporary study sought to enhance our understanding of the correlation between BXO and phimosis. Histological analysis of tissue samples from 120 subjects who underwent circumcision for phimosis was conducted. Findings revealed a substantial presence of BXO, with 45.1% of subjects with congenital phimosis and 62.3% with acquired phimosis manifesting BXO. This data strongly indicates a robust association between BXO and acquired phimosis. 

Key message: The study distinctly underscores a robust correlation between BXO and acquired phimosis. Notably, the type of phimosis (congenital or acquired) emerged as the pivotal factor linked to BXO development in this investigation. Nevertheless, further research is warranted to validate and fortify these observations. 

Consultation with our Urological Specialist: Individuals faced with challenges retracting the foreskin are advised to seek consultation with our consultant urologists for precise diagnosis and tailored treatment options. 

Note: This blog is intended solely to serve an informative function and should not be taken as medical professional advice. For specific concerns, it is imperative to use the expertise of our consultant urologists.

Which disposable stapler device is better for adult circumcision: CircCurer or ZSR

Stapler Options for Adult Circumcision: CircCurer vs. ZSR Circumcision Stapler Devices

I. Introduction

In the UK, new stapler options for adult circumcision have been introduced.

We look at the performance, postoperative healing, complications, and stapler removal rate of two disposable circumcision stapler devices used in adult male circumcision: CircCurer and ZSR.

II. Comparison of CircCurer and ZSR Circumcision Stapler devices

   A. Operative Efficiency and Safety

      1. Performance in operative time

      2. Complication rates

      3. Infection and bleeding rates

Operative Efficiency and Safety: Both stapler devices demonstrated similar performance in operative time (around 7 minutes) and complication rates. Patients experienced minimal infections and hematomas in both groups, underscoring the safety of these devices. Pain scores were comparable between the CircCurer and ZSR stapler circumcision groups.

   B. Postoperative Considerations

      1. Healing outcomes

      2. Swelling rates

      3. Stapler’s removal rates

Postoperative Considerations: While both devices resulted in successful circumcision, some subtle differences emerged regarding post-surgical experiences. The CircCurer group showed a slightly higher swelling rate (oedema) than ZSR. However, a significant difference arose with staple removal. The ZSR group had a substantially higher incidence of staples spontaneously falling out (62.9%) than the CircCurer group (38%).

III. Patient Satisfaction and Considerations

   A. Patient satisfaction levels

   B. Healing time comparison

   C. Staple removal considerations

Despite the difference in staple retention, patients in both groups reported remarkably high satisfaction levels at the two-month follow-up, instilling confidence in the effectiveness of these devices. However, it's essential to consider some additional factors when choosing a stapler device for adult circumcision:

Healing Time: At two months, patients of both groups reported satisfaction with the outcome. This means that stapler circumcision takes longer to heal compared to traditional methods of circumcision.

Staple Removal: The study highlighted that ZSR exhibited a higher rate of staple fallout, necessitating an additional follow-up procedure for removal in the CircCure method, sometimes requiring local anaesthesia. More patients (40-60%) in the CircCurer group must return for a follow-up procedure to remove the staplers

IV. Making an Informed Decision

   A. Empowering doctors to make informed choices.

   B. Factors for patient consideration

   C. Highlighting distinctions in stapler devices

This information provides valuable insights for doctors and patients considering stapler circumcision for adults. While both CircCurer and ZSR proved effective and safe for the procedure, the higher rate of staple fallout with ZSR is a noteworthy distinction. Understanding these differences empowers doctors and patients to actively participate in decision-making, selecting the most suitable device based on individual needs and preferences.

V. Conclusion

   A. Summary of benefits of both devices

   B. Noteworthy distinctions

   C. Impact of healing time and staple removal on decision-making

In conclusion, both devices offer similar benefits, including short surgery times, low complication rates, and high patient satisfaction. However, the ZSR device showed a significantly higher rate of metal clips falling out spontaneously and less need for a follow-up procedure for staple removal. Healing time is much longer in stapler circumcision compared to traditional methods.

VI. References

• Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicentre study, International Journal of Impotence Research June 2024, Italy, and Spain DOI:10.1038/s41443-024-00933-3

• Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions: a Cochrane review. BJU Int. 2022 Jul; 130(1): 26–34. doi: 10.1111/bju.15604

• Adult male circumcision with a circular stapler versus conventional circumcision: A prospective randomized clinical trial Braz J Med Biol Res. 2015 Jun; 48(6): 577–582. doi: 10.1590/1414-431X20154530

• A Comparative Study on the Clinical Efficacy of Two Different Disposable Circumcision Suture Devices in Adult Males, Urol J 2017 Aug 29;14: 5013-17

Does Diabetes Mellitus increase the risk of circumcision?

Introduction

The intersection of tight foreskin (phimosis), balanitis, and Diabetes presents a complex interplay of factors that can significantly impact men's sexual health. In this blog, we'll discuss Diabetes and circumcision and explore evidence-based strategies for optimal care.

Medical Indications for Circumcision

In diabetic men, we have identified three main conditions where circumcision may be necessary: balanitis xerotica obliterans (BXO), recurrent balanitis and symptomatic phimosis.

Insights from Recent Studies

Recent epidemiological research has investigated the relationship between type 2 diabetes mellitus and certain penile conditions that might require circumcision. Researchers Wang et al., in a nationwide population-based study, found that type 2 diabetes significantly 42% increased the risk of penile inflammatory disorders like BXO and refractory phimosis.

Correlation Between Diabetes and Penile Inflammatory Disorders like Balanitis

Another study by Hirji et al. from the UK General Practice Research Database showed that diabetes patients were nearly three times more likely to develop balanitis compared to those without Diabetes.

Fakjian et al., in an outpatient setting, discovered that uncircumcised men with Diabetes had a 35% prevalence of symptomatic phimosis, indicating a potential association between Diabetes and tight foreskin.

Clinical Indicators and Demographic Patterns of Diabetes

Certain clinical presentations, like balanoposthitis with a distinctive appearance, have been proposed as early indicators of undiagnosed Diabetes, particularly in older age groups. In the fifty- to sixty-year-old age group, a staggering 83.3% of circumcised patients had Diabetes. This indicates that Diabetes might not only increase the risk of penile inflammatory diseases but also drive the need for circumcision in adult males.

Type 2 diabetes mellitus and the likelihood of undergoing circumcision

A notable recently published study conducted in 2024 analysed a large population from 1997 to 2010 to explore the influence of type 2 diabetes mellitus on the likelihood of undergoing circumcision among men aged 30 to 69. The findings revealed that individuals with Diabetes were significantly more likely to opt for circumcision compared to those without Diabetes, further strengthening the association between diabetes and circumcision decisions.

Conclusion: Implications for Circumcision in TYPE 2 Diabetes

The accumulating evidence underscores a substantial link between diabetes mellitus, penile inflammatory diseases, and tight foreskin, potentially increasing the likelihood of circumcision in affected individuals. In conclusion, the research showed a relationship between Diabetes and penile health, leading to more circumcision in Diabetes.

Preparation for circumcision with Diabetes at London Circumcision Centre

1. It is essential to check HbA1C within six months before circumcision.

2. The level of HbA1C should be less than 70 mmol/mol (8.6%) before the operation.

3. Antibiotics may be required after the circumcision.

4. Diabetes must be controlled after circumcision to prevent delayed wound healing

5. A biopsy is needed if signs of an inflammatory condition called BXO are diagnosed during the examination.

6. Follow-up is required 4-6 weeks after circumcision.

This information is only guidance and not a replacement for professional opinion by our urologist.

References

1. https://londoncircumcisioncentre.co.uk/blog-circumcision/Diabetes/tight-foreskin

2. BMC Urol. 2024; 24: 3. Published online 2024 Jan 3. doi: 10.1186/s12894-023-01392-6

3. https://londoncircumcisioncentre.co.uk/blog-circumcision/cracks_foreskin