1. Circumcision

2. Ethical considerations
Children under 12 or over 12 but lacking the maturity to make an informed decision
A parent or guardian may also consent to surgical treatment on the child’s behalf.

3. Ethical considerations
Male circumcision is prohibited under the age of 16, unless it is carried out for religious or cultural reasons or is deemed necessary on medical grounds.
The Children’s Act 2005 states: “Taking into account the child’s age, maturity and stage of development, every male child has the right to refuse circumcision.”
The circumcision of males over the age of 16 may only be performed with their informed consent, in an approved setting and after the appropriate counselling.
Children aged 12 or more
If the proposed treatment involves a surgical procedure, a sufficiently mature child may still consent, if he or she is “duly assisted by his or her parent or guardian”.

4. Ethical considerations
Circumcision on a child less than 16 years is prohibited unless it is for cultural, religious or medical reasons
True
False

5. Medical indications Pathological phymosis Paraphymosis
Phymosis = Inability to retract the foreskin
Paraphymosis
Paraphymosis = Phymotic foreskin retracted behind glans becomes oedematous and not reducible
Recurrent balanoposthitis
Infection of the glans and foreskin
Candida in Diabetics
Carcinoma of penis
Small foreskin lesion
Condylomata accuminata
Warts on foreskin
Foreskin trauma
Zipper
Inadequate previous circumcision
Iatrogenic phymosis

6. Contra-indications Neonatal factors Congenital penile abnormalities
Prematurity
Illness
Blood dyscrasia
Familial history of bleeding disorder
Congenital penile abnormalities
Hypospadias
Chordee
Buried penis
Webbed penis

7. preparation Counsel the patient and obtain consent Penile block
Use to 2 ml of local anaesthetic WITHOUT ADRENALINE!!!!
1% lignocaine or 0.5% bupivacaine
Ringblock at the base of the penis
Or dorsal midline at the base of the penis

8. procedure
Mark site of coronal sulcus on outer prepuce in unretracted foreskin
Allow an inverted “v” at the frenulum (12 o’ clock postion)

9. procedure Retract the foreskin
Mark a second incision 0.5cm from the coronal sulcus
NOTE: Do not leave too much skin as lymph-oedema of the residual skin may result

10. procedure Make the inner preputial incision Then reduce foreskin
Reduces bleeding

11. procedure
Incise proximal marked line

12. procedure
The two incision are connected by cutting the skin in the midline
The foreskin is excised circumferentially
Haemostasis is achieved with bipolar cautery

13. procedure
Approximate the skin edges with or 4-0 polyglycolic acid sutures
Be careful not to invert the edges
Gently approximate the skin edges
Too tightly approximating the edges will cause wrinkling

14. COmplications Haemorrhage Infection Glanular injury Necrosis
Urethrocutaneous fistula
Meatal complications
Ulcer/stricture
Skin complications
Phymosis, concealed penis, skin bridge, chordee
Miscellaneous
Inclusion cysts
Urinary retention

15. REferences
Heyns CF, Barnes RD. Introduction to Urology. Urologocal association of South Africa.
Elder JS. Surgery illustrated-Circumcision. BJUI 2007; 99(6):
Hinman, Frank Jr. Atlas of urologic surgery.2nd ed. Philadelphia: WB Saunders Company,1998.

16. Watch the video https://www.youtube.com/watch?v=gQ4wzj-Kk3I
Please note that here mono-polar electro-cautery is used for haemostasis. Bipolar is the recommended and preferred method as it does not have the risk of damage to penile blood supply as may been encountered with mono-polar electrocautery. The lumps on the penile shaft are subcutaneous beads.