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Indications for Circumcision
Medical Indications for Circumcision
Religious and Non-Religious Traditions
Religious or non-religious traditions are the most common reason for circumcision in the postnatal period and childhood. The circumcision of the child due to the request of the parents is legally problematic. The child's right to physical integrity collides with the religious or traditional wishes of the parents.
Contraindications for circumcision
Contraindications to circumcision are coagulation disorders, acute and untreated balanitis, paraphimosis with necrosis or prominent edema, untreated hypospadia with the need for a surgical therapy.
Surgical Technique of Circumcision
Remove bothersome genital hair. Perform local anesthesia by a penile nerve block (see section above), alternatively spinal anesthesia or general anesthesia (in children). In patients with general anesthesia, an intraoperative penile nerve block reduces intra- and postoperative pain medication. Retract the prepuce if possible before skin disinfection.
Incision on the outer layer of the prepuce
Clamp and stretch of the outer prepuce. The skin incision is made along the coronal sulcus. Depending on the surgical technique, the incision is performed proximally (complete circumcision) or distally (incomplete or plastic circumcision) of the coronal sulcus. Careful hemostasis.Incision of the inner prepuce:
The prepuce is retracted. If this is impossible due to phimosis, the phimotic ring is incised at the 12 o'clock position. The inner prepuce skin is incised in a circular manner along the coronal sulcus. The distance to the coronal sulcus is variable: if the space is ample, much of the inner leaf of the foreskin remains, and the frenulum can be left in place. The frenulum is removed if the distance is small (5 mm).
Resection of the prepuce
Resect the skin between both incisions. Careful hemostasis.
Wound closure:Use 4-0 or 5-0 quickly absorbable suture material. Frenular sutures in the direction of the raphe should control the bleeding from the frenular artery. Subsequently, adapt the skin between the two incision lines, use stay sutures at the 12 and 6 o'clock position for orientation. Cover the wound with ointment dressing or gauze dressing with some compression.
Remove the gauze dressing the next day. Ointment dressing or loose protective wound dressings may be used for the following days. Advise regular showering and rinsing of wound secretions. After plastic (incomplete) circumcision, regular retraction of the penile shaft skin and cleaning the coronal sulcus from wound secretions is necessary.
Complications of Circumcision
- Bleeding, hematoma
- Wound infection, wound dehiscence
- Disturbing scars and adhesions
- Urethral stenosis, urethral fistula
- Hyperesthesia or hypoesthesia of the glans, ischemia of the glans.
- Erectile dysfunction after severe complications
Alternative Techniques of Circumcision
Gomco clamp, Mogen clamp, or Plastibell clamp are standard techniques for neonatal circumcision. The devices simplify the procedure, which is possible with minimal anesthesia: application of topical EMLA, oral acetaminophen, and penile nerve block. The complication rate for newborn circumcision is 0.2–3%. Most complications are minor, but devastating complications like partial glans removal or ablative penile injury have occurred.
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Deutsche Version: Technik der Zirkumzision