1. Circumcision Definition:
Phimosis: stenosis of the preputal ring with an inability to retract the foreskin.
Paraphimosis: retention of the retracted foreskin in a position proximal to the coronal sulcus.
Balanitis: inflammation of the foreskin.
Posthitis: inflammation of the glans.
Meatitis: inflammation of the urethral meatus.

2. Retractability of the foreskin
Birth 5%
6months 15%
1year 50%,
3years 90%.

3. Potential benefits of circumcision
Protection against penile cancer.
Protection against urinary tract infection.
Protection against sexually transmitted
diseases.
Protection against carcinoma of the cervix.

4. Indications Medical Religious Pathological Phimosis
White, scarred prepuce (BXO - absolute)
May cause ballooning, bleeding, dysuria or retention
Alternatives are preputioplasty / steroid cream
Recurrent Balanitis
Exclude diabetes
Urinary Tract Infection Prophylaxis
Protects against UTI in infants with VUR, PUJ, posterior valves and hydronephrosis 1
In VUR: 63% v 19% of circumcised boys suffered UTIs
Religious
1 Herden CDA. J Urol 1999

5. Contraindications to circumcision
Hypospadias.
Other associated genital anomalies.
Unstable or sick infant.
Family history of bleeding tendency.

6. Contraindications Premature Infants Congenital Penile Abnormalities
Hypospadias, episapdias, chordee, penile webbing or concealed penis
Blood Dyscrasias

7. Complications of circumcision.
Serious: life threatening: infection and bleeding. Not life threatening: fistula amputation.
Not serious: Inadequate skin removal (incomplete circumcision). Excessive skin removal. Inclusion cyst. Skin bridges etc.

8. Complications Chordee Urethrocutaneous Fistula Necrosis
Secondary to circumcision is related to excess skin removal
Urethrocutaneous Fistula
Urethral injury during excision of prepuce
Necrosis
May occur secondary to surgery or infection
Only use bipolar electrocautery sparingly and never with a ‘clamp’ device
Amputation of Glans
May occur using a ‘clamp’ device

9. Complications Death Bleeding (2-5%) Suture sinus tracts Infection (2%)
Phimosis and concealed penis
Adhesions
Meatal stenosis
Chordee
Urethrocutaneous fistula
Necrosis
Amputation
Hypospadias
Meatitis

10. Surgical technique
Principles: freeing the foreskin, identifying the meatus, retracting the foreskin, identifying the coronal sulcus.
Anesthesia: Local, General, None.
Instruments: Gomco clamp, Plasty bell, etc.

11. The ideal circumcision
Neonatal age.
Local anesthesia.
Selective delay for those who need so.
Instruction to parents about risks.infection, bleeding.
Follow up.

12. HYPOSPADIAS Hypo- below, Spadon- orifice
Urethral meatus opens on ventral side of the penis, proximal to the tip of glans penis
Incidence ……..1/125 to 1/250

13. Hypospadias
Definition: Is a congenital defect of the penis resulting in incomplete development of the urethra, corpora cavernosa, and prepuce.
Clinically results in deflection of the urinary stream and abnormal appearance of the penis.
Severe hypospadias is associated with chordee which may result in infertility secondary to difficulty in insemination.
Cosmetic and functional defect.

14. Subcoronal hypospadias

15. Types of hypospadias

16. EMBRYOLOGY Cloacal membrane, genital tubercle, labioscrotal swellings
Androgen stimulation…phallus elongation
3 phases of urethral formation
Posterior urethra formation
Anterior urethra formation
Glandular segment formation
Prepuce formation

17. PARTS OF HYPOSPADIAS Meatus … usually non-stenotic
Stenosis more common in distal hypospadias
Megalomeatus intact prepuce

18. SKIN….. Ventral defect & dorsal hood Urethral delta
Hood of monk….Cobra eyes
Defects of spongiosum
Defects of cavernosa
Defective urethral plate

19. CURVATURE Skin attachments Bucks defect Urethral plate
Cavernosa defects
Problems of unhealthy urethra

20. CLASSIFICATION (LOCATION)
DISTAL
Glandular, Coronal, Distal penile
MIDPENILE
Midshaft
PROXIMAL
Proximal penile, Penoscrotal, Scrotal, Perineal

21. Classification
Anterior 50%, the meatus is on the glans, coronal or subcoronal position.
Middle 30%, the meatus is on the shaft of the penis.
Posterior 20%, the meatus is between the perenium and the penoscrotal junction.

22. Associated anomalies
Undescended testis 10-30% depending on the severity of the hypospadias.
Inguinal hernia 10%.
Utricle, remnant of the Mullairian duct system.
Urinary tract anomalies are infrequent in isolated hypospadias.
Hypospadias alone or when associated with hernia do not require further investigations.
Severe hypospadias, specially when associated with undescended testis should be investigated for possible intersex with karyotyping and endocrine workup.

23. ASSOSIATION WITH OTHER DEFECTS
Renal agenesis, dysplasia, reflux
Prostatic utricle
Hernia : 9%
Cryptorchidism : 9%
Father : 9%
Siblings : 14%

24. Treatment Surgery is best performed 6-18 months of age.
Single stage versus multistage repair.
Outpatient versus inpatient.
Goal of repair: normal urethra, normal glans.
Final goal: straight shaft, normal skin normal appearing meatus, normal skin coverage, and normal penoscrotal position.
Correction of functional and cosmetic defect is the goal of hypospadias surgery.

25. Operations
Utilization of local tissue, skin, tabularization, flaps, grafts, urethral advancement.
Utilization of adjacent tissue, skin, prepuce, penile skin scrotal skin in the form of flaps or grafts.
Utilization of remote tissue, skin mucosa, buccal, bladder.
Staged repair.
Operations for chordee correction.

26. Results & complications
Success rate
70-100% depends on
The severity of the hypospadias
The surgical technique
The surgeon.

27. HYPOSPADIAS & INTERSEX
? Form of androgen insufficiency
Mixed gonadal dysgenesis
Androgen insensitivity
Testosterone synthesis defects
5 alpha reductase defects

28. COMPLICATIONS BLEEDING & HEMATOMA MEATAL STENOSIS
URETHROCUTANEOUS INFECTION
URETHRAL DIVERTICULA
RECURRENT CURVATURE / STRICTURE
BREAK DOWN