The normal physiological process involving the foreskin is that by age 5-7, with some variability, as penile length and growth increases in childhood, and with the advent of normal erections, the adhesions between the foreskin and the glans penis break down and the foreskin should become normally retractile, all the way to behind the coronal sulcus.
In certain patients this process takes longer than others, and short courses of topical ointments may assist. One should never forcefully try and retract the foreskin, as this will cause bleeding and subsequent inflammation and scarring. As boys get older, some whose foreskin was initially retractile may scar, and become non-retractile and this patient may require a formal circumcision.
Other patients in early adolescence or even early adulthood, find that they have a scarred non-retractile foreskin that requires circumcision. In these later stages, the problems are more that the urine pools within a non-retractile foreskin, causing recurrent infection and inflammation, or that during erection, the foreskin does not pull all the way back, making erection and ejaculation uncomfortable.
Certain patients end up with a chronic inflammatory condition, known as Balanitis Xerotica Obliterans (BXO), which is a risk factor for further dysplastic and even cancerous change of the head of the penis, (squamous cell carcinoma). This is the strongest indication for circumcision, however all aforementioned states are also as equally acceptable for circumcision. The foreskin is always sent off to be analysed at the time of the operation.
The operation is performed under a general anaesthetic, taking approximately 30-45 minutes, where there is careful marking and excision of the foreskin and meticulous reconstruction after the bleeding is stopped. Topical creams and tight underpants are required for a short period of time, with a short oral course of antibiotics and the wound is reviewed several times in rooms.
We perform circumcision in all age groups (except in infants) on a weekly basis.
Urethral hypospadias is a relative contra-indication, depending on the severity to circumcision, as at times the foreskin is used a part of the reconstructive flap, in order to re-site the urethral meatus, into its normal position.
Circumcision should not be performed as a general rule under local anaesthesia. Dorsal slit without circumcision is reserved for elderly co-morbid patients, with phimosis or paraphimosis, who are not fit enough to undergo general anaesthesia, and leaves the patient with an unsatisfactory cosmetic outcome.
The frenulum is the tight band on the undersurface of the penis, that connects the distal shaft to the glans and there is a vessel running through it, and this is always divided as part of routine circumcision and the vessel is ligated. Without frenular division, the glans bends downwards, (concord nose tip deformity). Certain patients with a normally retractile foreskin, but are only bothered by a tight frenulum, can simply undergo a frenular release (frenuloplasty).