THE CIRCUMCISION REFERENCE LIBRARY


BRITISH MEDICAL JOURNAL, Volume 297: Pages 590-591,
3 September 1988.



Save the Prepuce. Painless separation of preputial adhesions in the outpatient clinic

G A MacKinlay

ABSTRACT
In most boys referred for circumcision preputial adhesions are the only problem, but these can predispose to recurrent balanitis. A simple technique using EMLA cream (eutectic mixture of lignocaine and prilocaine) has been devised which allows the adhesions to be separated painlessly in the outpatient clinic. The technique was used on 39 boys aged 2 to 12 years referred for circumcision, none of which had a retractable foreskin. The cream was applied under an occlusive dressing and left for 60 minutes before the adhesions were separated with a probe and a gauze swab. The procedure was completely pain free in 32 boys. One boy had to undergo a repeated procedure because he failed to retract his foreskin in the three weeks after the procedure. Only one boy had to undergo circumcision later because of fibrous phimosis.

In many boys referred for circumcision separation of preputial adhesions is all that is needed, and the use of this local anesthetic technique avoids the need for general anaesthesia.

Introduction

Non-retractability of the foreskin has has been a common pretext for circumcision. A non-retractable prepuce is not, however synonymous with phimosis and it should not be used as an excuse for "lopping off an innocent and useful appendage."1 It has been claimed that the difference between intercourse with a circumcised penis and an uncircumcised penis is "the difference between slipping a foot into a sock that has been rolled up and one that is held open a the top."2 Bokai in 1860, was the first to draw attention to the physiological adherence of the foreskin.3

In 1927 Hamilton and Middleton reported from this hospital an investigation into phimosis and dysuria in infancy and concluded that circumcision was carried out too frequently.4 In many cases separation of the adhesions is all that is required. Deibert showed in 1933 that separation of the prepuce is due to keratinisation of the subpreputial epithelium,5 a process not complete at birth but accomplished during early childhood.6 Apart from religious or tribal reasons there are few indications for circumcision, and its incidence is declining.7 A fibrous phimosis with scarring undoubtedly necessitates surgery, even in other species.8 Balanitis, however, is often quoted as an indication for surgery, in my opinion wrongly.

[CIRP Note: The author, citing Gairdner, reports that the separation of the prepuce is accomplished in early childhood. We now know that Gairdner was in error. In many instances, separation of the prepuce is accomplished in later childhood or adolesnces.]

In cases of recurrent balanitis with a non-retractable foreskin separation of adhesions and subsequent preputial hygiene will prevent further attacks without the necessity of circumcision, which may itself predispose to meatitis and possible meatal stenosis.11 Preputial adhesions have commonly been separated under general anaesthesia,12 since separation in the outpatient department is traumatic to the child, even with the use of 5% lignocaine cream.13 The introduction of Emla cream (eutectic mixture of local anaesthetics; Astra Pharmaceuticals), however, led me to investigate its value in allowing painless separation of preputial adhesions.

Patients and methods.

Emla is a formula of lignocaine and prilocaine designed to alleviate the pain of venepuncture.14 Unlike previous available topical preparations, it penetrates intact skin to produce intradermal anesthesia. It not only reduces the pain of venepuncture in children but also makes the procedure easier.15 It has been evaluated in a variety of other indications, in particular split skin grafting and minor skin operations.16 It must be applied under an occlusive dressing at least 60 minutes before the procedure.

The procedure is as follows. The child first empties his bladder. He then lies on a couch with his parent at the head end for reassurance. The boy is told that some "magic cream" is going to be applied to his penis and warned that it may feel cold. The foreskin is drawn forward over the small open end of the tube of cream and held firmly between thumb and forefinger to prevent any cream from escaping. Any excess is carefully removed with a gauze swab, and a 3 M Tegaderm dressing (supplied with the cream) is applied, the printed paper having been removed to expose the adhesive surface. The dressing is applied with the backing paper in situ. This enables it to be folded in half over the penis, the sides of the dressing being squeezed together to ensure that a large quantity of the cream is retained in and around the prepuce. The child is then allowed to play for an hour.

The dressing is easily removed an hour later and excess cream mopped away. The adhesions can then be separated with a probe or using a gauze swab. It is preferable to use the latter, at least to clear the coronal sulcus. Complete anaesthesia of the glans and prepuce enables the procedure to be completely pain free. In the vast majority of patients the anaesthesia includes the coronal sulcus. A few might feel discomfort at this site. The boy and his parents are then advised to retract the foreskin fully and apply petroleum jelly at bathtime daily for seven days, followed by a week of simple retraction in the bath. The patient is reviewed at two weeks and if the treatment has been successful. then advice about normal preputial hygiene is given and he is discharged.

So far 39 boys with preputial adhesions have been treated. The reasons for their referral is shown in table I. In each case the method was explained to the parents and had their consent obtained.

Table 1 - Reasons for referral for circumcision in 39 boys
treated by separation of adhesions.
----------------------------------------------------------
Reason for referral                              No.

Recurrent balanitis                              13
Phimosis                                         10
"For circumcision"                                6
Ballooning on micturition                         4
Adhesions                                         4
Lump on penis                                     1
Long redundant foreskin                           1

[CIRP Note: Balloon on micturition is no longer regarded as an indication for circumcision. Ballooning on micturition is now understood to be part of the normal developmental process. Ballooning cannot occur unless the prepuce has started the normal physiological developmental process of separating from the glans penis. Ballooning on micturition is a transient condition that goes away as the child matures.]

Results

None of the 39 boys had a retractable foreskin. Their ages ranged from 2-12 years (table II). The procedure was completely pain free in 32 cases. Seven had mild discomfort, particularly on separation of the coronal component of the adhesions. Only one boy shed any tears. In most the complete anaesthesia achieved instilled great confidence.

One 3 1/2 year old child returned to the accident and emergency department with paraphimosis. This was reduced, and surprisingly, at review at two weeks his foreskin was lax and easily retractable. The parents of another child, the 4 year old who had cried at the initial procedure reported great difficulty in retracting the foreskin. At the two week review the boy remained very frightened and at three months he had scarring and a fibrous phimosis necessitated circumcision. Nevertheless, three other patients who had slight splitting and bleeding from a tight constrictive band at the initial procedure had a freely retractable unconstricted foreskin at two weeks. Recurrent dense adhesions in one boy, due to failure of retraction at home, were successfully separated by repeating the procedure. One mother found the method so successful on her 7 year old son that she brought his 5 and 9 year old brothers to the follow up clinic requesting the same technique.

No patient showed any sign of toxicity, although plasma concentrations of lignocaine and prilocaine were not measured. Studies have shown that even in children aged under 1 year (in whom use of the lignocaine-prilocaine cream is not recommended) the application of a full 2 g of cream over a wide area of skin for four hours leads to a maximum plasma concentration of 149 ug/l, far below the toxic concentration (5000-6000 ug/l (Rodgers B, Astra Pharmaceuticals, personal communication).

Discussion

General anaesthesia is not without risk (however small) and if it can be avoided for a simple procedure such as separation of preputial adhesions then that is an advantage. If circumcision can be prevented that is a further bonus. Many doctors, of course advocate neonatal circumcision without the need for anaesthesia and believe that this prevents later foreskin problems. There are, none the less, still risks in neonatal circumcision.17 The technique described here has proved to be effective, simple and cheap - the cost of one tube of lignocaine-prilocaine cream (around pounds sterling 2) compared with the cost of day case surgery.

The infrequent true fibrous phimosis is one of the few medical indications for circumcision. Separation of adhesions is not, however, to be advocated for all other cases referred for possible circumcision on medical grounds. Separation should rarely be required under the age of 3 years. The 2 year old included in this series had had ballooning on micturition and recurrent balanitis. Careful hygiene was advocated but he returned three months later having had two further episodes of balanitis. Separation of adhesions should also prove unnecessary in many cases of a non-retractable foreskin where the simple technique advocated in 1950 by Sir James Spence to assess the foreskin will suffice18: "Retract the prepuce and you will see a pinpoint opening but draw it forward and you will see a channel wide enough for all the purposes for which the infant needs the organ at that early age. What looks like a pinpoint opening at 7 months will became a wide channel of communication at 17 years."

In symptomatic cases this method of freeing the adhesions can prove worthwhile. It enables one to discuss preputial hygiene with the child, apparently a procedure that is often not performed.19 It should be something that is discussed at school medical examinations.20 Circumcision is all too frequently performed without good reason: it is rarely required.

References

  1. Morgan WKC. The rape of the phallus. JAMA 1965; 193: 223-4.
  2. Anonymous. Should baby be circumcised? The Widdicombe File. Lancet 1953; ii: 337-8.
  3. Bokai J. A fityma (preputium) seites adatapadasa a makkoz gyermakelnel. Orv Hetil 1860; 4:583-7.
  4. Hamilton AJC. Middleton DS. Phimosis and dysuria in infancy. A clinical investigation. Lancet 1927; ii: 639-46.
  5. Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933; 54: 387-93.
  6. Gairdner D. The fate of the foreskin. Br Med J 1949; ii 1433-7.
  7. Wiswell TE, Enzenauer RW, Cornish JD, et al. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics 1987; 79: 338-42.
  8. Walker DF. Causes of copulatory failure in beef bulls. Mod Vet Part 1984; 65: 352-6.
  9. Robarts FH. Penis and prepuce. In: Mason Brown JJ. ed. Surgery of childhood. London: Edward Arnold. 1962: 1159-81.
  10. Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow up study. Scand J Urol Nephrol 1986; 20: 84-92.
  11. Anderson GF, Smey P. Current concepts in the management of common urologic problems in infants and children. Pediatr Clin North Am 1985; 32:1133-47.
  12. Cooper GB, Thomson GJL, Raine PAM. Therapeutic retraction of the foreskin in childhood. Br Med J 1983; 286: 186-7.
  13. Griffiths DM, Freeman NV. Non-surgical separation of preputial adhesions. Lancet 1984; 2: 344-5.
  14. Eversh, Von Dardel O, Julian I, et al. Dermal effects of composition based on the eutectic mixture of lignocaine and prilocaine. Br J Anaesth 1985; 57: 997-1005.
  15. Hallen B, Uppfeldt A. Does lignocaine-prilocaine cream permit painfree insertion of IV catheters in children? Anesthesiology 1982; 57: 340-2.
  16. Juhlin L, Evers H. Broberg F. A lidocaine-prilocaine cream for superficial skin surgery and painful lesions. Acta Derm Venereol (Stockh) 1980; 60: 544-6.
  17. Editorial. The case against neonatal circumcision. Br Med J. 1979; i: 1163-4.
  18. Spence on circumcision. Lancet 1964; ii: 902.
  19. Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981: 67: 365-7.
  20. Kalcev B. Circumcision and personal hygiene in school boys. The Med Officer 1964; 122: 171-3.
(Accepted 25 May 1987)

Royal Hospital for Sick Children,
Edinburgh EH9 1LF

G A MacKinlay, FRCSED,
senior lecturer in surgical paediatrics


Citation:
(File revised 25 November 2005)

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