Circumcision

Circumcision — surgical removal of the prepuce — is among the most common urologic operations, performed for religious, social, and medical reasons. Medical indications include phimosis (inability to retract the foreskin), paraphimosis, recurrent balanitis/balanoposthitis, and hygiene, and circumcision reduces the relative risk of urinary tract infection, sexually transmitted infection, and — in randomised trials — HIV acquisition in adult men. For men who must treat phimosis but wish to keep the foreskin, a dorsal slit or preputioplasty is an alternative. Foreskin disorders and their non-operative management are covered in the Penis & Urethra Surgery topic; this page is the operative reference.

Indications and Preoperative Assessment

• Medical indications — phimosis, paraphimosis, recurrent balanitis/balanoposthitis (a tight phimotic band retaining secretions can form a preputial-cavity abscess), poor hygiene, and prophylaxis against UTI/STI/HIV.
• Examine for anomalies first — the single most important pre-operative step. Exclude hypospadias, megameatus, webbing, penile torsion, and chordee; confirm an intact foreskin, a straight shaft with equal dorsal and ventral skin, and a defined penoscrotal junction. Missing hypospadias is the key avoidable error, because the foreskin is needed for its repair. Take a bleeding history and obtain informed consent (mention the possibility of finding a megameatus).
• Non-surgical option for phimosis — topical betamethasone, a thin coat daily for about 2 weeks, can loosen a mild phimotic ring enough to retract; do not continue beyond 2 weeks (no added benefit, risk of systemic absorption).

Anesthesia

• Infants — a penile block with 1 mL of 1–2% lidocaine without epinephrine (or 0.25% bupivacaine) through a 26-gauge needle, aspirating before injecting; topical EMLA needs 15–30 minutes and under-anesthetises the glans tip and inner prepuce. Never use epinephrine — glans/shaft necrosis can result.
• Older boys — general anesthesia is usually preferred. Adults — local (a dorsal penile nerve block plus circumferential infiltration), spinal, or general; a base tourniquet can aid hemostasis but is usually unnecessary.

Circumcision Techniques

Sleeve (Double-Incision)

The technique for adults and children beyond infancy.

1. Expose and inspect — retract the foreskin (make a dorsal slit first if it is too fibrotic), take down adhesions, clear smegma, and re-examine the glans and meatus for anomalies before any shaft incision.
2. Frenulum — crush it with a fine clamp for 10 seconds, then divide it sharply or with cutting cautery, staying off the ventral glans.
3. Mark — the outer incision at the coronal sulcus and the inner incision 0.5–1 cm from the glans, following the glanular curve (a common error is drifting too close to the glans).
4. Incise and deglove the strip — cut both lines with a #15 blade on taut skin, avoiding a deep ventral cut into the urethra; divide the isolated skin collar into a strip and free it off the dartos, securing hemostasis (5-0/6-0 ligature).
5. Reapproximate — sew shaft skin to the preputial collar with fine absorbable suture (6-0 for infants/children, 5-0 for older patients), placing stay sutures at 12 and 6 o'clock to prevent torsion. A subcuticular closure or 2-octyl-cyanoacrylate skin glue avoids suture tracks — but avoid glue-only closure in peri- and post-pubertal boys (erection-related dehiscence).

Gomco Clamp (neonatal)

1. Premedicate (oral acetaminophen 10 mg/kg, topical EMLA), papoose restraint, iodine prep, and a ring block (1 mL 1–2% lidocaine without epinephrine).
2. Most infants take a 1.1- or 1.3-cm bell (keep 1.45 and 1.6 cm available) sized to fit over the glans only; make a dorsal slit, retract, clear smegma, and expose the whole corona.
3. Draw the foreskin evenly through the baseplate (no twists), seat the clamp, and leave it on for 5 minutes for hemostasis; cut against the bell with a fresh blade. Never use electrocautery with the Gomco.

Plastibell (infants only)

1. Block as for the Gomco; mark the coronal-sulcus level; crush the dorsal midline for 10 seconds, divide it, retract, and clear adhesions/smegma.
2. Choose the bell that covers the corona; tension the prepuce so the skin mark sits at the bell groove; tie 5-0 plain gut tightly in the groove with a surgeon's knot; excise the distal prepuce and snap off the handle.
3. The ring falls off in a few days — arrange follow-up within 1 week; a retained ring deforms the glans and is removed with bone-cutting forceps.

Dorsal Slit and Preputioplasty

Foreskin-sparing options for phimosis/paraphimosis when the prepuce is to be preserved, or as access for other operations.

Dorsal Slit for Phimosis

Dilate the opening and free adhesions; mark a dorsal-midline vertical line extending about halfway to the coronal sulcus; clamp along it for 10 seconds; cut with scissors or needle-point cautery while guarding the glans; close the edges with interrupted 5-0/6-0 absorbable suture.

Dorsal Slit for Paraphimosis

When manual reduction fails, an emergency dorsal slit or circumcision is required. For the dorsal slit, incise the dorsal midline at the constricting ring (the junction between the shiny inner and dull outer skin) to release it, extending until the prepuce slides freely over the glans — stop before the coronal sulcus — and close the incision transversely with 5-0/6-0 absorbable suture.

Preputioplasty

Multiple slits lengthen the circumference of the opening: triradiate incisions at 12, 4, and 8 o'clock, or a Y-V preputioplasty — a full-thickness dorsal midline cut across the phimotic band, extended laterally 1–2 cm into a Y, with the triangular flap advanced down and closed. Expect 2–4 weeks of postoperative edema.

Revision Circumcision

• Residual/redundant foreskin — re-mark and excise as for a sleeve.
• Buried penis — deglove, let the penis straighten, and redistribute skin (align suture lines to the natural raphe).
• Shaft–prepuce disparity — deglove and redistribute the skin; a Heineke-Mikulicz incision at the penoscrotal junction frees 1–2 cm of ventral length.
• Post-circumcision phimosis — dorsal slit or re-excise the constricting skin, but suspect balanitis xerotica obliterans when scarring is unusual.

Complications

• Failure to recognise hypospadias — the most important and most avoidable complication; repair is harder once the foreskin is gone.
• Bleeding/hematoma — the most common immediate complication (skin edge, perforating shaft vessels, or frenulum); control with pressure, suture ligature, or fine cautery, and suspect a bleeding disorder in a child.
• Skin/glans necrosis — from epinephrine in the block or injudicious cautery (never cautery with a Gomco or Plastibell).
• Meatal stenosis — a long-term complication in up to 7% of circumcised neonates.
• Glans laceration/amputation — with blind techniques or the Mogen clamp; immediate re-anastomosis usually succeeds.
• Other — Plastibell ring retention (deforms the glans), wound separation (usually heals with ointment alone), skin bridges/adhesions, penile torsion/chordee, inclusion cysts, urethrocutaneous fistula (a too-deep ventral cut or a suture catching the urethra), and suture tracks (prevented by buried closure).
• Infection is rare, but Fournier gangrene, though exceptional, needs parenteral antibiotics and debridement. In teenagers and adults, prescribe an agent to suppress erections during recovery.

Uncircumcision (Foreskin Restoration)

A one-stage Lynch–Pryor reconstruction: a circumferential incision at the penile base, reverse degloving toward the glans, four small evenly spaced circumferential incisions tagged to define a neopreputial opening, the shaft skin advanced upward to form a neoprepuce, and a dartos-pedicled midline scrotal flap wrapped around the base to cover the lower-shaft defect; leave a urinary catheter for 1 week.