This document discusses phimosis and circumcision. It provides background information on phimosis including definitions, types, epidemiology, embryology, anatomy, etiology, pathophysiology, prognosis, history and physical examination. It also discusses the medical and surgical treatment of phimosis, including conservative surgical alternatives and conventional male circumcision. The document is authored by multiple professors and assistant professors from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India.

1. Phimosis And Circumcision
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH
and KMC, Chennai.
2

3. PHIMOSIS
• Phimosis is defined as the inability of the
prepuce (foreskin) to be retracted behind the
glans penis in uncircumcised males.
• Depending on the situation, this condition may
be considered either physiologic or pathologic.
• Physiologic, or congenital, phimosis is a normal
condition of the newborn male.
3
Dept of Urology, GRH
and KMC, Chennai.

4. • The entity of pathologic, or true, phimosis is far
less common and can affect children or adults.
• This is associated with cicatricial scarring of the
prepuce that is often white in appearance.
• Phimosis may occur after circumcision if
redundant inner prepuce slides back over the
glans, with subsequent cicatricial scarring and
contraction
4
Dept of Urology, GRH
and KMC, Chennai.

5. Epidemiology
• Nearly all males are born with physiologic phimosis.
• Data have shown that the foreskin is retractable in
90% of boys by age 3 years.
• Only 1% of boys have physiologic phimosis that
persists until age 17 years.
• Thus, most healthy adult men should not have
phimosis; the presence of the disorder in an adult
male should raise the suspicion of balanitis
(infection of the foreskin), balanoposthitis (infection
of glans and foreskin), diabetes, [29] or malignancy.
5
Dept of Urology, GRH
and KMC, Chennai.

6. Embryology
• Developmentally, during the third month of intrauterine
life (65 mm fetus), a fold of skin develops at the base of
the glans penis.
• This fold of skin grows distally from the glans penis and
eventually becomes the prepuce.
• The dorsal aspect of the fold grows more rapidly than the
ventral aspect, initially only the dorsum of the glans
penis is covered by this fold.
• As the glanular urethra fuses in the midline, it carries
the ventral prepuce along with it. This ventral fusion of
the prepuce is marked by the frenulum.
• Preputial formation is usually complete by the fifth
month of intrauterine life (100 mm fetus).
6
Dept of Urology, GRH
and KMC, Chennai.

7. • The inner surface of the prepuce and epithelium of
the glans, are both stratified squamous epithelium
in type, and both fuses together.
• Later, presumably under the influence of androgens,
the squamous cells begin to keratinize and arrange
themselves in whorls. The whorled cells then
disintegrate so that clefts appear between the
prepuce and the glans.
• These clefts eventually propagate and separate the
inner preputial epithelium and the epithelium of the
glans from each other. This process of separation is
usually incomplete at birth and continues through
childhood and sometimes to adult life.
7
Dept of Urology, GRH
and KMC, Chennai.

8. Relevant Anatomy
• The penis is composed of paired corpora
cavernosa, the crura of which are attached to the
pubic arch, and the corpus spongiosum .
• The proximal portion of the corpus spongiosum
is referred to as the bulb of the penis, and the
glans represents the distal expansion.
• The urethra traverses the corpus spongiosum to
exit at the meatus.
• The cavernosal bodies produce the male
erection when they are engorged with blood.
8
Dept of Urology, GRH
and KMC, Chennai.

9. • The fascial layers of the penis are continuous
with the fascial layers of the perineum and lower
abdomen. Dartos fascia represents the
superficial penile fascia.
• Deep to this lies the Buck fascia, which covers
the tunica albuginea of the penile bodies.
Proximally, the Buck fascia is in continuity with
the suspensory ligament of the penis, which
attaches to the symphysis pubis.
9
Dept of Urology, GRH
and KMC, Chennai.

10. • The penis is supplied by a superficial system of arteries
that arise from the external pudendal arteries and
a deep system of arteries that stem from the internal
pudendal arteries .
• The superficial blood supply lies in the superficial penile
fascia and supplies the penile skin and prepuce.
• The internal pudendal artery, which arises from the
hypogastric artery, gives rise to the penile artery.
• The penile artery then gives rise to the bulbourethral
artery, the urethral artery, and the cavernous artery
(deep artery of the penis) before terminating as the
dorsal artery of the penis.
10
Dept of Urology, GRH
and KMC, Chennai.

11. • The arterial blood supply of the penis arises
from the internal pudendal artery. The internal
pudendal artery gives off branches to the bulbar
artery, cavernosal artery, and dorsal penile
artery. The bulbar artery continues on as the
bulbourethral artery to supply the urethra. The
cavernosal artery gives rise to the helicine
arteries that are end arteries. The dorsal artery
of the penis gives branches off to the circumflex
arteries.
11
Dept of Urology, GRH
and KMC, Chennai.

12. 12
Dept of Urology, GRH
and KMC, Chennai.

13. 13
Dept of Urology, GRH
and KMC, Chennai.

14. Dorsal view of the arterial and venous
blood supply of the penis.
14
Dept of Urology, GRH
and KMC, Chennai.

15. • Somatic nerve supply to the penis comes by way of
the pudendal nerves, which eventually produce the
dorsal nerves of the penis on each side.
• Although cutaneous innervation to the penis is
primarily from branches of the pudendal nerve, the
proximal portion is supplied by the ilioinguinal
nerve after it leaves the superficial inguinal ring.
• The prepuce has somatosensory innervation by
the dorsal nerve of the penis and branches of the
perineal nerve.
• The glans is primarily innervated by free nerve
endings and has poor fine-touch discrimination.
15
Dept of Urology, GRH
and KMC, Chennai.

16. Etiology
• Physiologic phimosis is the rule in newborn males.
Formation of the prepuce is complete by 16 weeks'
gestation. The inner prepuce and glans penis share a
common, fused mucosal epithelium at birth. This
epithelium separates via desquamation over time as
the proper hormonal and growth factors are
produced. Thus, neonatal circumcision is a surgical
treatment of normal anatomy.
• Pathologic, or true, phimosis has several different
etiologies. The most common cause is infection,
such as posthitis, balanitis, or a combination of the
two (balanoposthitis). Diabetes mellitus may
predispose to such infections.
16
Dept of Urology, GRH
and KMC, Chennai.

17. Adult circumcision is most commonly performed to correct
phimosis. When circumcision is performed for phimosis,
25%-46% of removed foreskins are histologically normal.
Other indications for adult circumcision include the following:
• Balanitis xerotica obliterans (BXO)
• Infection without phimosis
• Paraphimosis
• Bowen disease
• Carcinoma
• Condylomas (warts)
• Trauma
• Religious or social reasons
• Disease prophylaxis (eg, HIV infection)
• Personal preference
17
Dept of Urology, GRH
and KMC, Chennai.

18. Pathophysiology
• The foreskin of an uncircumcised child should not
be forcefully retracted. This may result in significant
bleeding, as well as glanular excoriation and injury.
Consequently, dense fibrous adhesions may form
during the healing process, leading to true
pathologic phimosis.
• Adult phimosis may be caused by repeated episodes
of balanitis or balanoposthitis. Such infections are
commonly due to poor personal hygiene (failure to
regularly clean under the foreskin).
18
Dept of Urology, GRH
and KMC, Chennai.

19. • Phimosis may be a presenting symptom of early
diabetes mellitus. When the residual urine of a
patient with diabetes mellitus becomes trapped
under the foreskin, the combination of a moist
environment and glucose in the urine may lead
to a proliferation of bacteria, with subsequent
infection, scarring, and eventual phimosis.
19
Dept of Urology, GRH
and KMC, Chennai.

20. Prognosis
• Phimosis does not recur after proper circumcision.
• If too much penile skin is left, a repeat circumcision
may be necessary for medical or cosmetic reasons.
• In adults, some permanent skin-color discrepancy
along the suture line of the circumcision may occur.
• Overall, careful attention to proper surgical
technique will allow for a pleasing cosmetic result.
20
Dept of Urology, GRH
and KMC, Chennai.

21. History
• Congenital or physiologic phimosis is clinically
asymptomatic so is not a cause for concern.
• It is often associated with "ballooning" of the
foreskin during voiding. This is a self-limited
phenomenon that, in the absence of pathologic
phimosis, does not indicate urinary tract
obstruction.
21
Dept of Urology, GRH
and KMC, Chennai.

22. NEWBORN PHIMOSIS
22
Dept of Urology, GRH
and KMC, Chennai.

23. • Pathologic, or true, phimosis is far less common.
Symptoms include skin irritation, dysuria, bleeding,
and occasionally enuresis or urinary retention.
Physical examination usually reveals white
cicatricial scarring at the preputial ring.
• Pathologic phimosis may be due to balanitis xerotica
obliterans (BXO), a genital form of lichen sclerosus
et atrophicus.
• The etiology of BXO is unknown, and it may
represent a premalignant state. Clinically, it
presents as severe phimosis and possibly meatal
stenosis, glanular lesions, or both.
23
Dept of Urology, GRH
and KMC, Chennai.

24. • In older men, when the phimosis is severe, the distal
foreskin often appears swollen and erythematous
with cracked fissures .
• Men who are affected report pain and discomfort
during sexual activity or when they attempt to
retract the foreskin.
• Unlike in the pediatric population, lower urinary
tract voiding symptoms are absent.
• In older men, acquired phimosis is often associated
with poor hygiene but may be a product of diabetes
mellitus.
24
Dept of Urology, GRH
and KMC, Chennai.

25. Physical Examination
• All uncircumcised adult men should have the
foreskin retracted to exclude occult carcinoma as
a part of a complete urologic examination.
• Squamous cell carcinoma of the penis may
manifest as an ulcerated fungating mass of the
glans or the prepuce.
• Alternatively, carcinoma in situ or penile
carcinoma may appear as a velvety macular
lesion of the glans (erythroplasia of Queyrat) or
the penile shaft (Bowen disease).
25
Dept of Urology, GRH
and KMC, Chennai.

26. Phimosis
• Physical examination usually reveals white
cicatricial scarring at the preputial ring.
Meuli et al devised the following scoring system
to rate the severity of phimosis: [32]
• Grade I - Fully retractable prepuce with stenotic ring
in the shaft
• Grade II - Partial retractability with partial exposure
of the glans
• Grade III - Partial retractability with exposure of the
meatus only
• Grade IV - No retractability
26
Dept of Urology, GRH
and KMC, Chennai.

27. The preputial types can be classified according their
retractability
• In Type I the preputial orifice is too narrow and its retraction
cannot expose the urethral meatus.
This type of prepuce causes ballooning during urination. In
• Type II the preputial opening allows only exposure of the
meatus when retracted.
• In Type III the preputium can be retracted to expose only the
distal half of the glans.
• In Type IV most of the glans can be exposed, but because of
adhesions between the inner leaf of the preputium and the
corona the coronal sulcus cannot be exposed.
• Type V is the normal preputium that can be retracted below
the coronal sulcus without any difficulty.
27
Dept of Urology, GRH
and KMC, Chennai.

28. I II III IV V
28
Dept of Urology, GRH
and KMC, Chennai.

29. Medical Care
• Applications of steroid creams
(0.05% betamethasone) have been used to
manage phimosis medically. [33] The usual
regimen is application of the steroid cream once
or twice daily for 4-6 weeks. Studies have shown
a success rate of 87% with this treatment.
• Higher rates of success have been reported with
concomitant preputial stretching exercises.
29
Dept of Urology, GRH
and KMC, Chennai.

30. • If a patient has concomitant balanitis or
balanoposthitis, depending on the etiology, he
may be treated with topical antibiotics or
antifungals.
• Patients with diabetes mellitus should be
advised on proper serum glucose control.
30
Dept of Urology, GRH
and KMC, Chennai.

31. • Conservative Surgical Alternatives :
Preputioplasty is the medical term for
plastic surgery of the phimotic prepuce.
•preservation of foreskin, erogenous, and sexual
physiologic functions
•Disadvantages : recurrence
• Other methods : Frenulotomy and meatoplasty
is also beneficial
Y- and V-plasties (The Ebbehoj procedure)
• Conventional Male Circumcision
31
Dept of Urology, GRH
and KMC, Chennai.

32. Surgical Therapy:CIRCUMCISION
• The word circumcision comes from Latin:
circum=around, and caedere = to cut.
• It is the most performed surgical intervention
all over the world, done mainly for religious and
then for medical reasons, from birth to
adulthood.
• The goal of circumcision is to remove enough
preputial skin to ensure that no part of the glans
remains covered by it when the penis is flaccid.
32
Dept of Urology, GRH
and KMC, Chennai.

33. HISTORY
• some have suggested that this procedure likely
originated in Egypt some 15,000 years ago and that
its practice later spread throughout the world during
prehistoric human migrations.
• Egyptian mummies and wall carvings discovered in
the 19th century offer some of the earliest records of
circumcision dating this procedure to at least 6000
years BC.
• However, other authors believe that circumcision
developed independently in different cultures. For
example, on his arrival to the New World, Columbus
found that many of the natives were already
circumcised.
33
Dept of Urology, GRH
and KMC, Chennai.

34. • Many cultures have historically used circumcision
for hygienic reasons while others performed it as a
rite of passage to manhood, as a mark of cultural
identity (similar to a tattoo), or as a ceremonial
offering to the gods.
• Ritual circumcisions in Middle Eastern cultures
have been practiced for at least 3000 years.
• Late in the 19th century, this ancient ritual evolved
into routine medical practice influenced by reports
that associated it with miraculous cures for hernias,
paralysis, epilepsy, insanity, masturbation,
headache, strabismus, rectal prolapse,
hydrocephalus, clubfoot, asthma, enuresis, and gout.
34
Dept of Urology, GRH
and KMC, Chennai.

35. • Oldest documented evidence thought to date to
sixth dynasty (2345-2181 BCE) tomb artwork in
Egypt.
• Over 90% Religious group include jews and
muslims
35
Dept of Urology, GRH
and KMC, Chennai.

36. Male circumcision
36
Dept of Urology, GRH
and KMC, Chennai.

37. Surgical Care
• Although several techniques are used in neonatal
circumcision, all of the methods involve the following
common elements:
1. Estimation of the amount of foreskin to be removed
2. Dilation of the preputial orifice to determine the
presence of a normal glans and penis without any
evidence of hypospadias, epispadias, chordee, or other
anomalies
3. Blunt separation of the inner preputial epithelium
from the glans
4. Placement of a device designed to ensure hemostasis
5. Removal of the foreskin
37
Dept of Urology, GRH
and KMC, Chennai.

38. Benefits of Circumcision
• Reduce penile cancer incidence
• Reduce UTI occurrence rate
• Reduce STD transmission rates
• Reduce cervical cancer rate in female partner
38
Dept of Urology, GRH
and KMC, Chennai.

39. Adult circumcision
Although phimosis is the most common indication for
adult circumcision, other reported indications include
the following:
• Paraphimosis
• Balanitis without phimosis
• Condyloma
• Redundant foreskin
• Bowen disease
• Carcinoma
• Disease prophylaxis (eg, HIV infection)
• Patient choice
• HIV prevention in hetero sexuals
39
Dept of Urology, GRH
and KMC, Chennai.

40. Contraindications
• Circumcision is generally not performed in children
born prematurely or those with blood dyscrasias.
• It should not be performed in children with
congenital penile anomalies such as the following:
1. Hypospadias
2. Epispadias
3. Chordee
4. Penile webbing
5. Buried penis
6. Ambiguous genitalia,
7. megalourethra
40
Dept of Urology, GRH
and KMC, Chennai.

41. Circumcision methods
can be classified into one of three types or
combinations thereof:
1. dorsal slit,
2. shield and clamp, and
3. excision
• In recent years, various plastic clamps have been
used
such as the Gomco, Plastibell and Shang Ring.
• These make the operation easier and quicker,
result in a neater scar and reduce the need for stitches
41
Dept of Urology, GRH
and KMC, Chennai.

42. Dorsal slit technique /Free-hand circumcision:
• This is the classical surgical circumcision performed by surgeons
and done under anesthesia
• In this procedure, the prepuce is freed from the glans of
adhesions.
• Prepuce is held in artery forceps and gentle stretch
Circumferential incision in the penile skin made at the level of
corona Prepuce slit up dorsally within 1 cm from corona.
• Under surface of prepuce separated from glans .
• Leaving about 0.5cm of the inner layer of prepuce distal to
corona circumferential incision made Cutting the remaining
connective tissue completes the excision.
• Hemostasis secured by bi-Polar diathermy.
• Starting with a U-shaped hemostatic and approximating suture
applied to the frenulum, the entire cut edges are approximated
with fine sutures.
42
Dept of Urology, GRH
and KMC, Chennai.

43. 43
Dept of Urology, GRH
and KMC, Chennai.

44. 44
Dept of Urology, GRH
and KMC, Chennai.

45. 45
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and KMC, Chennai.

46. 46
Dept of Urology, GRH
and KMC, Chennai.

47. 47
Dept of Urology, GRH
and KMC, Chennai.

48. 48
Dept of Urology, GRH
and KMC, Chennai.

49. SLEEVE TECHNIQUE
49
Dept of Urology, GRH
and KMC, Chennai.

50. 50
Dept of Urology, GRH
and KMC, Chennai.

51. 51
Dept of Urology, GRH
and KMC, Chennai.

52. 52
Dept of Urology, GRH
and KMC, Chennai.

53. 53
Dept of Urology, GRH
and KMC, Chennai.

54. 54
Dept of Urology, GRH
and KMC, Chennai.

55. Forceps guided circumcision
• The forceps guided circumcision method is very
similar in principle to the shield
(Mogen/Magen) circumcision.
• It is more secure than the shield circumcision in
older children and adults.
• As with the shield technique, in this technique
also the frenulum is left intact.
55
Dept of Urology, GRH
and KMC, Chennai.

56. • For performing the procedure, the preputium is pulled forward with
two or three hemostatic clamps placed at the transition edge of the
skin to the mucosa of the preputium.
• Then a large forceps is clamped across the foreskin over the tip of
the glans.
• The forceps should be placed at an angle parallel to the base of the
corona, not straight.
• The distal preputium is cut over the crushing forceps
• The forceps has the dual function of shielding the glans and
reducing the bleeding.
• The relative amounts of inner and outer preputium remaining
depend on adjustments made before the crushing forceps is fully
closed.
• Usually, the minimum amount of inner preputial skin remaining
equals the length of the glans
56
Dept of Urology, GRH
and KMC, Chennai.

57. • Then the distal preputium is cut with the scalpel
over the crushing forceps.
• It is advisable to suture the edges after removing
the forceps to prevent dehiscence and secure
hemostasis.
• After removing the forceps, a hemostatic U-
suture is applied at the frenulum, then sutures
are applied at 3, 6, 9, and 12 o’clock.
• In adults, additional sutures are applied
between the quadrant sutures.
57
Dept of Urology, GRH
and KMC, Chennai.

58. Forceps guided circumcision. (A) Application of the clamp just
over the tip of the glans and parallel to the coronal line. (B, C)
Suturing the
edges.
(A)
B,
C.
58
Dept of Urology, GRH
and KMC, Chennai.

59. 59
Dept of Urology, GRH
and KMC, Chennai.

60. The Mogen/Magen/shield
circumcision
• This is the most ancient type of religious circumcision still
used in the Jewish religion. This circumcision is performed
using a shield and scalpel blade.
• In its most classical form, the preputium is pulled out in front
of the glans, and a metal shield with a slot in it (Mogen/
Magen/shield) is slid over the preputium immediately in front
of the glans .
• The glans is protected from being cut by the shield, and the
frenulum is not touched.
• The scalpel is run across the face of the shield to remove the
preputium.
• The minimum amount of inner leaf of the preputium left is
equal to the length of the glans, and this does not necessarily
destroy the frenulum.
60
Dept of Urology, GRH
and KMC, Chennai.

61. • The Mogen clamp is a variation of the classical shield . It
crushes the preputial tissue as a surgical clamp for
hemostasis.
• This is the preferred device of the more modern Jewish
Mohel (circumciser), because it removes less preputial
tissue, leaves more inner leaf of the preputium, and does
not necessarily destroy the frenulum.
• In addition, it causes less discomfort when used during
infant circumcision than does the Gomco® clamp
technique, which takes longer to perform.
• Its shortcoming is the possibility that the tip of the glans
might be caught in the clamp.
61
Dept of Urology, GRH
and KMC, Chennai.

62. • The more modern Mogen clamp circumcision is carried
out as follows:
• The preputial opening is entered with a blunt edged
probe to separate the preputial adhesions to the glans.
• Complete retractability of the prepuce is checked by
retracting the preputium until the corona can be seen all
around.
• The prepuce is lifted forward, the open jaws of the
Mogen clamp are placed around the prepuce (grooved
side toward the glans), and the clamp is closed, taking
care to leave the glans below the clamp.
62
Dept of Urology, GRH
and KMC, Chennai.

63. • The distal prepuce is excised using a scalpel blade.
• The clamp is left closed for 2–5 minutes and then opened
carefully.
• The penile skin is pulled backward to free the inner leaf
of the preputium from the glans. Care should be taken
not to separate the crushed edges at the cut line. If the
edges are separated and bleeding occurs, fine hemostatic
sutures should be applied for approximating the
separated edges (it is optional to add sutures all around).
• After covering the cut line with an antiseptic ointment, a
light dressing is wrapped around the penis.
63
Dept of Urology, GRH
and KMC, Chennai.

64. • Bleeding is one of the most common
complications, and can be controlled by applying
gentle circumferential pressure with gauze or a
sponge, or by using absorbable gelatin sponge
(Gelfoam®), topical thrombin, or epinephrine-
soaked gauze, or by applying sutures.
64
Dept of Urology, GRH
and KMC, Chennai.

65. Mogen clamp for ritual circumcision
65
Dept of Urology, GRH
and KMC, Chennai.

66. Instrumental circumcision
• The Gomco® clamp and the Plastibell™ are the
most widely used circumcision instruments by
physicians worldwide .
• The Plastibell is used in nearly 60% of all routine
infant circumcisions in the United States, although
the larger models are sometimes used in Europe for
performing circumcisions in teenagers and adults.
• In the USA, 40% of infant circumcisions are done
with a Gomco clamp.
• Both instruments remove a larger portion of the
inner leaf of the prepuce than do the shield or
forceps guided circumcision techniques.
66
Dept of Urology, GRH
and KMC, Chennai.

67. Gomco® clamp
circumcision
. (A) The bell should cover the entire glans. (B) Dorsal preputial slit
eases positioning of the bell. (C) The plate is mounted. (D) The nut is
tightened and the prepuce cut around the bell.
(A) (B)
(C) (D)
67
Dept of Urology, GRH
and KMC, Chennai.

68. Gomco® clamp circumcision
• The Gomco® clamp is made up of four parts: a plate, a bell, an arm,
and a nut to tighten the clamp .
• It comes in a wide variety of sizes for use in infants, boys, and men
of all ages and sizes.
68
Dept of Urology, GRH
and KMC, Chennai.

69. 69
Dept of Urology, GRH
and KMC, Chennai.

70. • At the beginning of the procedure, a blunt-tipped
probe is used to separate the adhesions between the
glans and the preputium so that the preputium is
completely retractile.
• The bell is introduced into the preputial cavity (over
the glans and under the foreskin) and the prepuce is
drawn over it .
• It is important to make sure that the preputial
opening is large enough to insert the bell.
• If not, the opening is stretched. If stretching does
not allow the bell to be inserted easily, a dorsal slit is
made in the preputium to enlarge its opening .
70
Dept of Urology, GRH
and KMC, Chennai.

71. • The preputium is retracted until the entire corona becomes
visible.
• A small amount of lubricant is applied to the glans to ease the
appropriate sized bell to slip over the glans.
• The prepuce is pulled over the bell without stretching it too
much .
Too much pulling may cause removal of too much penile shaft
skin. Also, it may even pull the urethra up, bringing it into the
cutting area, and cause a severe injury to the distal urethra.
• The appropriate plate fitting the bell of the clamp is applied at
the level of the corona and the clamp is tightened to crush the
preputial edges at the level of the corona. This tightening
exerts a crushing force on the prepuce at thejunction of the
bell and plate and prevents bleeding.
71
Dept of Urology, GRH
and KMC, Chennai.

72. • A circumferential incision is made using a scalpel blade. Since
Gomco® clamps are made of metal, no electrosurgical
instrument should be used for cutting the preputium.
• The clamp is left in place for at least 5 minutes to secure
hemostasis and initial adhesion of the cut skin edges.
• Then the clamp is carefully dismantled and the plate and bell
are removed, taking care not to separate the cut skin edges.
• If the crushed edges separate and bleeding occurs, fine
hemostatic sutures are applied or the edges of the skin are
sutured all around.
• If the circumcision is performed in a teenager or an adult, it is
mandatory to suture the incision line to prevent its separation
during erections.
• An antiseptic ointment is applied to the cut line and the penis
is lightly dressed.
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Dept of Urology, GRH
and KMC, Chennai.

73. Plastibell circumcision
• The Plastibell is a disposable plastic bell with a
circumferential groove close to its edge.
• For performing a Plastibell circumcision the bell
is inserted over the glans and under the prepuce.
• Making a 12 o’clock incision to the prepuce
eases correct insertion of the bell .
• Then the prepuce is tied all around, over the
groove of the bell, with a tight
suture.
• The prepuce distal to the string is cut off.
73
Dept of Urology, GRH
and KMC, Chennai.

74. • The skin should not be pulled too tight before being
tied off. This tying ceases the blood flow to the
prepuce.
• After 7–10 days, the remaining prepuce crushed
under the suture necrotizes and falls off, providing a
bloodless circumcision.
• Because no stitches are used with a Plastibell,
usually there is no need for dressings, which makes
things very much simpler, especially with young
children who are not so cooperative.
• The difficult part of this technique is keeping the
pulled prepucein place during application of the tie.
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Dept of Urology, GRH
and KMC, Chennai.

75. Plastibell.™
75
Dept of Urology, GRH
and KMC, Chennai.

76. SmartKlamp® circumcision
• The SmartKlamp® is an additional device for
performing an instrumental circumcision .
• The glans is first measured using the Size-O-
Meter to determine which device is required.
• As with other circumcision techniques, any
adhesions between the glans and preputium are
broken down, and the tube part of the device is
inserted between the glans and the foreskin
76
Dept of Urology, GRH
and KMC, Chennai.

77. • The outer portion is passed over the tube and
rotated half a turn to lock the tube to it.
• The locking arms are then half-closed to lightly hold
the foreskin. The foreskin is adjusted over the tube
so that it will be clamped at the desired place.
• The locking arms are clicked completely shut and
the excess foreskin is circumferentially cut and
removed from in front of the locking ring.
• The device is left to fall off by itself in about a week
to 10 days.
77
Dept of Urology, GRH
and KMC, Chennai.

78. .. (C) Circumcision with
SmartKlamp. Note that
the prepuce is resected.
(A) SmartKlamp® device
for circumcision
(B) Size-O-Meter for
measuring glans to
determine device size to
be used
78
Dept of Urology, GRH
and KMC, Chennai.

79. ZHENXI RINGS
79
Dept of Urology, GRH
and KMC, Chennai.

80. TARA CLAMP
80
Dept of Urology, GRH
and KMC, Chennai.

81. SMART CLAMP
81
Dept of Urology, GRH
and KMC, Chennai.

82. SHANG RING
82
Dept of Urology, GRH
and KMC, Chennai.

83. 83
Dept of Urology, GRH
and KMC, Chennai.

84. PREPEX
• adult male circumcision without the need for anesthesia.
• It consists of a placement ring, an inner ring, and an elastic ring.
• The placement ring is a carrier for the elastic ring to facilitate the
application of latter during the procedure.
• The inner ring has a groove on it for the lodgment of the elastic ring.
• When the device is applied, the prepuce is sandwiched between the
inner ring and the elastic ring. The result is ischemic necrosis of the
“trapped” prepuce.
• The PrePex device is disassembled at about a week after placement
and the withered prepuce is bloodlessly severed from the penis.
• It is said to be safe and effective in mass rollout of adult male
circumcision for the prevention of HIV infection.
84
Dept of Urology, GRH
and KMC, Chennai.

85. ZSR TECHNIQUE
85
Dept of Urology, GRH
and KMC, Chennai.

86. 86
Dept of Urology, GRH
and KMC, Chennai.

87. 87
Dept of Urology, GRH
and KMC, Chennai.

88. • Bleeding 0.1% - 35%
• PENILE SKIN COMPLICATION:
Glanular Adhesions and Skin Bridges.
• Uretheral and glanular resection
• Meatal stenosis
• Meatal baffle
• Balanitis Xerotica Obliterans.
complications
88
Dept of Urology, GRH
and KMC, Chennai.

89. Female circumcision(Infibulation)
89
Dept of Urology, GRH
and KMC, Chennai.

90. Introduction
• Various forms of FGC is practiced throughout the world, but it is
most common in sub-Saharan Africa. It also exists in the Middle
East, North and South America, Indonesia and Malaysia.
• Approximately 2% of women are circumcised worldwide
• WHO definition : All procedures involving partial or total removal of
the external female genitalia or other injury to the female genital
organs whether for cultural, religious or other non-
therapeutic reasons.
• Other names are
FGC - Female Genital Cutting
FGM - Female Genital Mutilation
INFIBULATION or PHARANOIC CIRCUMCISION – closing of the
introitus
CLITORIDECTOMY
90
Dept of Urology, GRH
and KMC, Chennai.

91. Toubia (1994) classified the more extensive female genital mutilation
procedures according to the amount of tissue destruction:
• Type I: Complete or partial removal of the clitoris.
• Type II: Excision of the clitoris and a portion of the labia
minora.
• Type III: Excision of the entire clitoris and labia minora
with incision of the labia majora along its medial aspect
to create raw surfaces.The anterior two thirds of the
labia majora are approximated to cover the urethra and
introitus, with the lower third at the level of the posterior
fourchette left for the passage of urine and menstrual
fluid.
• Type IV: Excision of the entire clitoris and labia minora
with nearly complete approximation of the labia majora
and only a pinhole opening left near the posterior
fourchette for the passage of urine and menstrual fluid
91
Dept of Urology, GRH
and KMC, Chennai.

92. Female infibulation
• scarred labia majora with only a pinhole opening
for the passage of menstrual fluid and urine
92
Dept of Urology, GRH
and KMC, Chennai.

93. Complications
Short term Long term
• Severe bleeding
• Infection
• Pain
• Death
• Chronic pain
• Recurrent UTI
• Urethral scarring or closure
• Dyspareunia
• Dysmenorrhoea
93
Dept of Urology, GRH
and KMC, Chennai.

94. •THANK YOU
94
Dept of Urology, GRH
and KMC, Chennai.