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.

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

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

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

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

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

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.

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

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

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.

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

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

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.

Subcoronal hypospadias

Types of hypospadias

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

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

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

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

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

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.

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.

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

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.

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.

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

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

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