When will circumcision be needed for tight foreskin (phimosis) in adults or older men?

Male circumcision is rarely discussed, leading to insufficient information about foreskin conditions. This causes many conditions to go unnoticed, worsening one's health. One such condition is phimosis, where the foreskin is too tight to retract. Sometimes, it can fold back when the penis is relaxed but not when erect. This tightness causes minor damage during erections and sexual activity, leading to scarring. In adults, phimosis can be associated with infections like balanitis or sexually transmitted diseases.

Facts:

- Physiological phimosis in children often improves with age. The foreskin attachment breaks down, releasing a white material called smegma pearls. Most boys have a fully retractable foreskin by ages 10-12.

- Pathological phimosis is a medical condition caused by disease or scarring (BXO). It's important to distinguish it from a natural tight foreskin (physiological phimosis) as treatments differ.

Paraphimosis occurs when the foreskin gets stuck behind the penis head due to a tight ring. It requires immediate treatment, such as pulling the foreskin forward or preputioplasty to preserve it.

Causes:

- Skin conditions like BXO, Lichen planus, or Eczema.

- Infections: Circumcised men have lower rates of sexually transmitted infections, including syphilis, chancroid, and genital herpes (HSV-2).

- Scarring: BXO can cause severe scarring and phimosis.

- Potential cancer: There's a long-known link between un-circumcised men and penile cancer, especially in cases of phimosis history.

Non-surgical treatment:

Treatment for phimosis depends on age and severity. Options include:

- Steroid creams or ointments.

- Stretching exercises in early stages.

- Antifungal or antibiotic medications.

However, stretching scarred foreskin may cause more tearing and scarring. Scientific evidence is lacking for its effectiveness. Phimosis creams have had limited success in recent reports. Mild phimosis symptoms in adults can be managed by using condoms and lubricants during sexual activity.

Mild tight foreskin caused by fungal infection can be treated with antifungal medications and steroid cream. Adults with high blood glucose levels (diabetes mellitus) and phimosis may require circumcision due to recurring fungal infection or possible BXO. Tight foreskin (phimosis) in diabetic patients often requires circumcision and biopsy of the foreskin.

Surgical treatments:

- Frenuloplasty: A procedure that releases the frenulum, a small fold of tissue. It allows the foreskin to detach from the penis head.

- Preputioplasty: A procedure that expands the foreskin by an incision in front, enabling full retraction.

- Partial circumcision: Leaving part of the foreskin covering the penis head. It has long-term complications.

- Full circumcision: The standard surgical option with glue or stitches for tight foreskin, particularly for BXO phimosis, traumatic injury, or penile cancer.

If sexual activity is painful or uncomfortable due to phimosis, urgent treatment is needed. Home treatment includes daily cleansing, controlled stretching exercises, and clearing smegma. Infections with tight foreskin (balanitis) require antibiotic or antifungal treatment. It's essential to get examined for sexually transmitted diseases by a GUM clinic or a doctor.

In summary, there are various alternatives to full circumcision, such as medications, creams, frenuloplasty, preputioplasty, or a combination. These options should be discussed with a specialist or urologist. Full circumcision without any medical problems should be seriously considered as it is irreversible surgery.

PS: This information is for guidance only. This is not a replacement for professional medical advice. Please call Dr Khan for video consultation £150 advice at +447527314081 without any obligation.

Balanoposthitis Or Balanitis

Balanoposthitis and Balanitis for adults and Children

Balanoposthitis is an inflammatory condition that affects both the glans penis (balanitis) and prepuce (foreskin). The condition is most common in uncircumcised males and is characterized by symptoms such as penile pain, pruritus (itching), discharge, erythema (redness), rash, or inconsolable crying in children.

There are several possible causes of balanoposthitis, including poor hygiene, infections (such as candidal, bacterial, or viral infections), inflammatory skin diseases, irritants, trauma, and cancer. Poor hygiene is the most common cause of nonspecific balanoposthitis. Infections such as candidal infections are common in children. They can be associated with diaper rash, while other infectious causes include aerobic bacteria such as Staphylococcus aureus and Group A Streptococcus, anaerobic bacteria, and viruses such as human papillomavirus.

The prevalence of balanoposthitis is between 12% to 20% in males of all ages. Paediatric patients commonly present around ages 2 to 5 years, likely due to physiologic phimosis and hygiene habits. In adults, uncircumcised males with diabetes mellitus are at the highest risk, with a prevalence of around 35%. Circumcision has been shown to decrease the prevalence of inflammatory conditions of the glans penis by 68%.

According to the American Urological Association, balanitis affects up to 11% of men and can occur at any age, but it is more common in older men and those who are uncircumcised.

Pathophysiologic processes can vary widely depending on the aetiology of balanoposthitis. Most cases commence with moisture such as urine, sweat, or smegma (physiologic secretion from genital sebaceous glands) becoming trapped within the preputial space, creating a nidus for bacteria and fungi. Balanoposthitis can also be commonly provoked by irritants and allergens, causing non-specific inflammation leading to erythema and pruritis.

A thorough history and physical exam are sufficient in most cases of balanoposthitis for diagnosis and establishing a course of treatment. Your doctor may also recommend testing for sexually transmitted infections (STIs) if there is a suspicion of infection.

if you experience persistent or severe symptoms of balanitis or balanoposthitis, or as untreated cases can lead to complications such as scarring or phimosis. The diagnosis of BXO is typically made based on the appearance of the affected skin. Still, a circumcision and biopsy may be necessary to confirm the diagnosis and treatment of the phimosis.

Treatment may include hygiene improvements, topical or systemic antimicrobial agents, anti-inflammatory agents, topical steroids and circumcision in severe cases. Establishing the underlying cause of balanoposthitis is vital to guide appropriate treatment. Additionally, practising good hygiene habits and using protection during sexual activity can help prevent the development of balanitis.

Circumcision is recommended in phimosis and scaring due to BXO

Treatment options for BXO include topical and intralesional steroids, circumcision with frenuloplasty, and various surgical techniques for more severe cases.

Regular follow-up care is important to monitor changes in the affected areas that may indicate malignancy.

Sources:

1. American Urological Association. Balanitis. https://www.auanet.org/education/auauniversity/medical-student-education/conditions-education/balanitis

2. Mayo Clinic. Balanitis. https://www.mayoclinic.org/diseases-conditions/balanitis/symptoms-causes/syc-20354817

3. NHS. Balanitis. https://www.nhs.uk/conditions/balanitis/

4. Harvard Health Publishing. Balanitis. https://www.health.harvard.edu/a_to_z/balanitis-a-to-z

Can I be circumcised as an adult

incidence of circumcision 

In the USA, 75% of men are circumcised; however, 6% of men are circumcised in the UK. Jews and Muslims are circumcised as a part of their religious obligation. Historically, Christianity has had periods of both pros and cons. In most societies, males are circumcised at birth. Adults are circumcised if they have medical problems or cultural or personal reasons in our London clinics. 

Indications of adult circumcision 

General Indications

Several medical indications for adult circumcision are phimosis, paraphimosis, and Balanitis, and non-infectious causes include lichen sclerosis (also called BXO - balanitis Xerotica Obliterans), allergic dermatitis, trauma, and Zoon’s balanitis.

 
Phimosis is a condition in which the foreskin (also called prepuce) is unable to be reduced over the head of the penis (glans penis). This can result in pain with erection and intercourse. 

Diabetes is a risk factor for phimosis, recurring balanitis and BXO. 

Paraphimosis is a condition in which the foreskin can be retracted over the glans but stuck or tight behind the head of the penis. When there is a partially tight band at the inner skin of the foreskin, and the foreskin does not reduce naturally over the glans, the tight band acts like a constricted ring over the shaft of the penis. A history of recurring paraphimosis may result in a more tight foreskin, leading to swelling of the glans and significant pain. This may require urgent medical treatment. 

Balanitis is also a medical indication for circumcision. Balanitis is the infection of the glans penis. Balanitis may occur along with infection of the foreskin. This combination of infections is called balanoposthitis. 

The combination of phimosis and diabetes is a recognised risk factor for balanitis. Balanitis can be caused by both infectious and noninfectious causes. In the case of phimosis, fungal infection is also expected along with bacterial infection. Non-infectious causes include allergic dermatitis, trauma, and Zoon’s balanitis.

Sexually transmitted disease (STD) Prevention

Circumcision is a preventative measure against the spread of HIV and AIDS, as shown in many African studies. The inner preputial skin has special cells called Langerhans cells, which contain receptors for HIV. Removing most of the inner preputial foreskin by circumcision may prevent to prevent HIV viruses. Additionally, the inner preputial skin contains a little protective keratin layer relative to the outer foreskin, making it less mechanically resistant to injury, which may be a source of HIV. 

Lichen Sclerosis or Balanitis Xerotica Obliterans (BXO) 

Lichen sclerosis (LS) can affect both children and adult populations. LS has been known as lichen sclerosis or balanitis xerotica obliterans (BXO). The typical peak ages of presentation of BXO are 8–10 years of age and 30–50 years of age. The clinical presentation can be variable; however, the advanced classic appearance is atrophic white scarring. Purplish scaly scars, red abnormal blood vessels, tears, splits, and ulcerations have also been documented. The foreskin is the largely common site of involvement; however, it can affect the glans, wee hole (meatal opening), and wee tube (urethra).  Symptoms can vary according to the different areas of involvement. Please see further information for BXO. Circumcision in men is a medical indication for BXO symptoms. 

Circumcision for medical reasons is available in the NHS.  However, there is a long waiting list for urological consultation and circumcision in the NHS hospitals. 

Surgical Techniques

Although circumcision is done in our London clinic, the best method of circumcision is with the glue with different circumcision styles. We do circumcision with stitches and surgical staplers (ZSR or CircCurer (LangHe) staples suture device). Adult circumcision costs £680 with glue at our London Circumcision Centre. Circumcision cost in the UK depends upon the technique and methods of circumcision. Circumcision is a low-risk surgical procedure, at least in our hands. History of bleeding disorders needs to be excluded, and all medications affecting platelet function (aspirin, clopidogrel, warfarin ) should be stopped 5 days before adult circumcision after a discussion with your doctor. 

Anaesthesia

Circumcision can be performed under local or general anaesthesia. Most patients are suitable for local anaesthesia, which involves injections into the skin. 

Informed Consent

We provide the patient with all the information about the circumcision, and consent is taken before the procedure in our centre. Circumcision is an irreversible procedure and exposes the glans permanently. 

Forceps-guided method, sleeve technique and Glue circumcision are standard techniques used. 

The most common method is the glue circumcision technique. It has been reported that the stretched length of the penis is the equivalent length of the erect penis. By having the penis on stretch, we make sure that no excessive shaft skin is excised, which would produce penoscrotal webbing due to underneath skin deficiency and hairy skin from the pubic area pulled to the shaft of the penis due to less shaft skin, especially during erection. 

Complications

Risks are bleeding, bruises, haematoma formation, infection, removal of too much or too little skin, lymphoedema,  displeasing results that require revision circumcision and a change of sensation during sexual activity.

Sexual Dysfunction

Change in sexual function after circumcision is very controversial. Studies investigating sexual dysfunction have shortcomings of self-reported variables, non-validated questionnaires, small population studies, and the investigation of patients with prior foreskin disease. 

Summary 

Adult circumcision is a safe surgical procedure with uncommon complications. Adults have circumcision due to tight foreskin (phimosis, paraphimosis), infection (balanitis), and scaring due to lichen sclerosis (BXO). A lot of African studies also reported that circumcision can be preventative in HIV and AIDS transmission and some sexually transmitted infections. Several methods of performing an adult circumcision exist at the London circumcision clinic, but glue circumcision remains our method of choice. Although sensation appears to be different in circumcised adults in the first 6-12 months, studies have not proved if there is any difference in sexual function as compared to uncircumcised men. The benefits of circumcision are well-reported in the literature. Men can be circumcised in our London circumcision Centre.

This is for information about purposes that can not replace professional advice. Please contact Dr Khan or a consultant Urologist for further details.