Congenital anomalies of the penis are rare and should only be managed by experienced pediatric urologists. Although penile tissue is forgiving, meticulous planning and precise technique are required to achieve normal urologic and future sexual function and an acceptable appearance. Hypospadias must be recognized when performing a circumcision as any abnormality of the meatus is a contraindication – the foreskin might be needed for the reconstruction. Likewise, webbed penis, in which the scrotal skin encroaches onto the ventral shaft, is a contraindication to circumcision. Except during a circumcision, filmy foreskin adhesions should be left alone as they always recur and tend to become more painful. Repeated lysis can lead to skin bridges, which require incision under anesthesia.
There are very few medical indications for circumcision. The purported benefits are minimal, it is painful even in newborns, and the procedure is associated with a small but significant risk of major complications. Parents are nearly always motivated by misplaced cosmetic or cultural concerns. Some feel that the procedure should be more broadly condemned by society as a form of genital mutilation and only be performed when there is a clear medical indication. Nevertheless, if we can ethically justify performing the procedure at all, it is our obligation as surgeons to at least do it well and with an absolute minimum of complications. Anesthesia and antiseptic should always be used. The free-hand technique provides a nice result but it is important to avoid taking too much skin. It is far better to take too little than to take too much. It is best to place the penis on maximal stretch before deciding how much should be removed and then err on the side of leaving a little bit extra. Parents should be gently reassured that the boy is likely to need the extra skin in the future. A common complication is bleeding, which can be profuse and usually requires a trip back to the OR.
The clamp techniques all involve crushing the skin rather than incising it. Many use the Mogen clamp, variations of which have been around for centuries. The foreskin is stretched beyond the glans and then pinched transversely in the hinged metal clamp. There is a small risk of amputation of the glans. The Gomco clamp uses a metal bell placed within the foreskin. The skin is pinched against the heavy outer part of clamp by tightening a screw. Although safe in experienced hands, some find the heavy metal clamp unwieldy and the fact that the glans seems to disappear into the machinery disconcerting. The Plastibell technique is increasingly popular and comes in six sizes between 1.1 and 1.7 cm. After performing a dorsal slit and, if necessary, dividing the frenulum, the bell is placed within the foreskin and a linen cord is tied very tightly around, crushing the skin against the bell. The excess skin is trimmed and the bell is allowed to fall off in 7–10 days. The bell sometimes falls off prematurely, but this is rarely an issue, even if there is a short distance between the skin edges. After the bell detaches, the foreskin should be pulled back behind the corona at frequent intervals to prevent “recurrent” phimosis. If the bell is too large, the glans can become trapped and strangulated in the opening. When performing a dorsal slit, it is important to avoid inadvertently placing a jaw of the clamp inside the urethra. Dividing the frenular artery can result in meatal stenosis, which usually presents in toddlers as a narrow urine stream that is directed at an upward angle.
As circumcisions become less common, we should expect to see an increase in foreskin complications. Phimosis is the inability to retract the foreskin and is one of the rare indications for at least a partial circumcision. Paraphimosis is when the foreskin retracts but gets stuck, strangulating the glans. This can usually be relieved with firm manual compression of the glans to make it smaller, allowing the prepuce to be reduced. Ice does not help and risks frostbite. Usually the result of rigorous sexual activity, frenular artery tears can bleed profusely. It can sometimes be treated at the bedside with direct pressure but sometimes requires ligation under anesthesia. Balanitis is a painful skin infection that is slightly more common in the uncircumcised. It is usually treated with frequent retraction of the foreskin, gentle cleansing, and topical antibiotics. Systemic antibiotics are indicated for invasive infection.