Presentation on theme: "Circumcision Definition:"— Presentation transcript:
1Circumcision 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.
2Retractability of the foreskin Birth 5%6months 15%1year 50%,3years 90%.
3Potential benefits of circumcision Protection against penile cancer.Protection against urinary tract infection.Protection against sexually transmitteddiseases.Protection against carcinoma of the cervix.
4Indications Medical Religious Pathological Phimosis White, scarred prepuce (BXO - absolute)May cause ballooning, bleeding, dysuria or retentionAlternatives are preputioplasty / steroid creamRecurrent BalanitisExclude diabetesUrinary Tract Infection ProphylaxisProtects against UTI in infants with VUR, PUJ, posterior valves and hydronephrosis 1In VUR: 63% v 19% of circumcised boys suffered UTIsReligious1 Herden CDA. J Urol 1999
5Contraindications to circumcision Hypospadias.Other associated genital anomalies.Unstable or sick infant.Family history of bleeding tendency.
7Complications 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.
8Complications Chordee Urethrocutaneous Fistula Necrosis Secondary to circumcision is related to excess skin removalUrethrocutaneous FistulaUrethral injury during excision of prepuceNecrosisMay occur secondary to surgery or infectionOnly use bipolar electrocautery sparingly and never with a ‘clamp’ deviceAmputation of GlansMay occur using a ‘clamp’ device
9Complications Death Bleeding (2-5%) Suture sinus tracts Infection (2%) Phimosis and concealed penisAdhesionsMeatal stenosisChordeeUrethrocutaneous fistulaNecrosisAmputationHypospadiasMeatitis
10Surgical techniquePrinciples: freeing the foreskin, identifying the meatus, retracting the foreskin, identifying the coronal sulcus.Anesthesia: Local, General, None.Instruments: Gomco clamp, Plasty bell, etc.
11The ideal circumcision Neonatal age.Local anesthesia.Selective delay for those who need so.Instruction to parents about risks.infection, bleeding.Follow up.
12HYPOSPADIAS Hypo- below, Spadon- orifice Urethral meatus opens on ventral side of the penis, proximal to the tip of glans penisIncidence ……..1/125 to 1/250
13HypospadiasDefinition: 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.
21ClassificationAnterior 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.
22Associated anomaliesUndescended 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.
23ASSOSIATION WITH OTHER DEFECTS Renal agenesis, dysplasia, refluxProstatic utricleHernia : 9%Cryptorchidism : 9%Father : 9%Siblings : 14%
24Treatment 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.
25OperationsUtilization 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.
26Results & complications Success rate70-100% depends onThe severity of the hypospadiasThe surgical techniqueThe surgeon.
27HYPOSPADIAS & INTERSEX ? Form of androgen insufficiencyMixed gonadal dysgenesisAndrogen insensitivityTestosterone synthesis defects5 alpha reductase defects