Gaze and Seduction

xlii Inclusion Cyst

Cyst may be caused by implantation of smegma in the circumcision wound or by surgical rolling in of epidermis at the time of circumcision. ²⁰ The cyst can grow to a large size or become infected. These cysts are distinguished from penile epidermoid cyst only by their location. The treatment is surgical excision. It tends to be commoner in female circumcision as reported by Badejo⁵³ Four girls and a boy presented with post-circumcision inclusion cyst in his series. All of them had surgical excision.

Granuloma

The use of silica talc on surgical gloves has been associated with the formation of granuloma. Such a lesion was described in a circumcision wound 15 years after the original surgical procedure.²⁰

NON-OPERATIVE COMPLICATIONS

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Psychosexual Problems: Impotence may follow amputation of the glans even after successful reattachment²⁰

Dysmorphobia: Some patient may feel displeased with the appearance of their penis ⁸⁰ or some who may want to change their identity may make attempt at reconstructing the foreskin ²⁰ (e.g. the Jews during Nazi wars)¹³.

Castration anxiety: A male child at age 4 to 5years is at the phallic stage, when he cherishes his genital organ and jealously guards it. Circumcision done around this age may impose some fear in the child that something sinister may happen to his prized organ²⁰.

POST CIRCUMCISION SATISFACTION AND COSMESIS

A lot of personal taste has been injected into the scientific debate of cosmesis in circumcision. Leitch in Australia ⁸¹ once commented "The exposed glans is the fashion.

The undressed penis is still a schoolboy’s curiosity viewed secretly and with wonder and awe.”

Brown and his associate in Denver, USA,⁸² prospectively carried out the opinion survey of parents of 124 male newborns soon after they made the circumcision decision.

The medical, social and cultural reasons for their decision were explored. They found that the strongest factor associated with circumcision decision was whether or not the father was circumcised (P < 0.0001). Parents wanted the child's penis to look like his father’s, siblings’ and friends’. While medical concerns accounted for a third of the responses, the appearance of the penis and the perceived future ridicule by sibling(s) or schoolmates are important social concerns for circumcision decision of most parents.

The aim of circumcision is to excise sufficient foreskin of both penile shaft and inner preputial epithelium and leave the glans exposed to provide the best cosmetic result together with the lowest possible morbidity rate. ²⁰

While procedures are standardized, specifics regarding the exact amount of foreskin to remove are not well documented,⁸³ there had been confusing interpretations of normalcy in appearance of circumcision penis⁸⁴. Maurice King⁸⁵ recommended that 2 or 3 millimetres fringe of the inner preputial layer of the newborn penis should be left so as to provide enough skin to allow for free erection without drawing up the pubic hair to the erected penis. Care should also be taken not to leave too excess foreskin to avoid the risk

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of recurrent phimosis. However, the achievement of this objective with a circumcision device may not be easy. When operatimg on an infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages such that a small difference at the time of surgery may translate into a large one in the adult circumcised penis. To date, there had been no published studies showing the ability of a circumciser to predict the later appearance of the penis⁸⁶. Nevertheless, a penis without a foreskin, which may be seen as nicer looking by some persons, is in no way more natural than an intact one⁸⁴. It is therefore not possible for the cosmetic outcome of the circumcision to satisfy all parents. It is difficult to measure the prevalence of parental dissatisfaction.⁸⁶

Past studies revealed that between 1% ^87,88 and 9.5%⁸¹ of boys circumcised at birth will have the procedure revised or redone and 2.8% ⁸⁹ of parents will complain of cosmetic appearance. One of the weaknesses of previous studies was their reliance on parental comments as the sole inclusion criterion. The scarcity of comments may reflect the lack of a clear notion of how a circumcised penis should appear.

The appearance of circumcised penis is not cosmetically acceptable if it presents in any of the following ways:

(1) Penis with redundant skin or inadequate circumcision.^{1, 58,81} (2) Penis grossly denuded of shaft skin. 1, 20,53,60,90

(3) Penis with scarring or keloids or gangrenous penis. ^20,69 (4) Concealed or buried penis .^20,74 (5) Pigmentation variations of the circumcised penis ⁷² (6) Penis with amputated glans. ^58,75,91

(7) Penis with bi- valved urethra. ⁷²

(8) Penis with excavated frenulum. ^{71 may} appear normal to a mother if it is mild, but may present as iatrogenic hypospadias or urethra-cutaneus if it is severe.

(9) Skin tags, which are portions of foreskin, which remain after circumcision.

(10) Iatrogenic chordae, which is the abnormal bending of the penile shaft resulting form uneven circumcision scar⁷².

These are possible circumcision disasters the occurrence of many one of which should be viewed with dismay. However, prevention is far better than cure.

xlv Inadequate circumcision or redundant skin

Lack of specific documentation as to the amount of foreskin to be removed during circumcision dictates that errors of either; omission (too little) or commission (too much) in intra operative assessment may happen. Therefore one of the commonest complaints is of an unsatisfactory cosmetic result²⁰. If insufficient foreskin is removed the cosmetic appearance is such that the penis does not appear to have been circumcised. The redundant remnant of prepuce commonly becomes stretched or elongated, causing a mush room-like widening of the distal shaft and preputial skin.⁸¹

In a study of post circumcision complications in Lagos, Bode and Kene-Ewulu,¹ prospectively reviewed 90 consecutive complications of male circumcision seen in Lagos University Teaching Hospital. They noted in each case, the type of complication, medical personnel that performed the procedure and the method employed.

Redundant foreskin occurred in 19 boys (21%). This was said to have been caused by plastibell method in 10 (53%) patients while the open method accounted for 9 cases (47%). All of them reported to the clinic within a month of circumcision 11 cases resulted from procedure performed by doctor, 8 were by nurses.

Insufficient excision of the foreskin and inner preputial epithelium may result in wound contraction and cicatrization of the distal foreskin.²⁰ The fibrotic ring so produced may result in true phimosis, an event observed in 7 (37%) of the 19 cases seen in Lagos University Teaching Hospital. All of them had circumcision revision done. In the remaining 12 (63%) of the boys the redundant skin was acceptable because the prepuce was easily retractable for cleansing and parents were reassured. In untreated severe cases urinary obstruction may ensue.

Shaft Denudation

When at least 2/3 of the penile skin denuded, the circumcision scar appears high.^72.

On erection the hairy scrotal skin is drawn up the shaft, with the scar pulling on the shaft and the glans is tilted downward. There will be loss of coronal differentiation between the glans and shaft due to total excision of all the mucosal skin beyond the preputial fornix up to the corona. ^20,72 Removal of too much skin from the penile shaft may result from:

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(1) Pulling the foreskin over the glans during circumcision. After excision of the foreskin the remaining skin slides back leaving a denuded shaft.⁹²

(2) Failure to break down the ventral foreskin adhesions to the glans completely.^54,56 (3) Sepsis.^20,56

(4) Diathermy injury. ⁹⁰

(5) Injected substances mistaken for anaesthetic solution.⁵⁴

In the newborns, treatment consists of proper systemic antibiotics and local wound care with saline dressing three times daily. But such injuries in the adults may be managed conservatively if the defect is less than half of the total penile skin.

Complete denudation is managed by split thickness skin grafting for optimum cosmesis and functional results or burial of the penis in a tunnel of scrotal skin even in children^20,90.

Concealed Penis

This is a rare consequence of excision of excess preputial skin. Niku et al ⁶⁰ opined that although an excess skin is removed, not enough inner preputial epithelium is excised.

The new preputial orifice is therefore distal to the glans. As healing and fibrosis occur the penile shaft is forced into a suprapubic fat with the resulting preputial ring at the level of the skin of the mons pubis. ^20,72 Treatment of the condition, is plastic urological correction^60,92.

Scarring

When excessive tissue is excised from the infant’s penis, it may heal with fibrotic scar, which tether the skin of the shaft, resulting in lack of mobility during erection of the circumcised penis.⁷²

Scarring can be simple or extensive like that of extensive burns. It may be hypertrophic or keloidal depending on stage and age of patient.

The skin of the penis is very resistant to formation of keloids ^69. Only very few cases had been reported in literature. The first case of true keloid of the penis following circumcision was reported from Sierra Leone in 1993. Another case was reported in the Annals of burns and fire disasters in September 1999 from Egypt⁶⁹ A six year old boy from

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upper Egypt had circumcision done for cultural reasons by an inexpert surgeon who removed excess penile skin causing long lasting infection. This healed with hypertrophic scar that spread to involve the dorsal penile skin leaving a huge mass. When all conservative measures (pressure dressing, irradiation) failed, complete exisional biopsy, reconstruction of the supra pubic region and coverage with split thickness skin grafting were performed with good result.