Surgery indicated for phimosis pathological forms of narrowing of the foreskin, when the exposure of the glans impossible, too painful, violates the sexual life, frequently provokes inflammatory processes. The most common treatment can be considered circumcision, which today is carried out not only in the traditional way, known since ancient times, but with the help of modern technology and laser surgery.
Phimosis is pathological when the foreskin is not able to move to a full exemption from the skin of the glans penis. As a physiological phenomenon, it is typical for the newborn period and early childhood, but becomes pathological in adults, men and teenagers after puberty, including on the background of cicatricial and inflammatory changes.
Types of interventions and methods of pain relief
Surgical treatment when the disease phimosis is the only drastic measure of getting rid of pathology. According to statistics, about a quarter of adult men have undergone circumcision for this reason. In this disease there are several types of operations, depending on age period, type and severity of disease, medical training and equipment operating.
In our day practice:
Treatment can take place traditionally, i.e. using a scalpel, a modern way laser. Traditional therapy is available, relatively cheap and can be done in any hospital where a urologist, but it does have limitations:
- A long recovery due to higher trauma;
- Higher risk of complications;
- The need for long sexual life;
- The risk of scarring in the place of suturing.
Indications and contraindications for surgery
The indication for surgical treatment is considered pathological phimosis in boys and adult males, all of the complicated forms of the disease in patients of any age, and relapses inflammation of the foreskin and the glans of the penis condylomatous, foreign objects under the foreskin.
Among the obstacles:
- Severe decompensated pathology of the internal organs until the stabilization of the disease;
- Acute infection;
- Pathology of hemostasis;
- Ulcerative skin lesions in the area of the foreskin (temporary contraindication);
- Structural changes of the penis (Hypo - and epispadias) — required plastic;
- Infection of the urinary tract and genital organs (acute or chronic relapse) — to cure.
Preparing for surgery
Before planned surgical treatment of phimosis of the child or adult is assigned a list of required examinations — blood tests, urine, ECG, chest x-rays, studies for infection, etc. depending on age. They can be completed at the place of residence in the clinic. Mandatory detention therapist or pediatrician about the absence of common contraindications. When planning General anesthesia, the patient consults another and the anesthesiologist that revealed the presence of allergies, experience with anesthesia in the past, the names of medication.
2 weeks prior to the treatment of canceled funds that make the blood more liquid. The house on the morning of the intervention need to carefully wash the genitals with warm water and mild soap, in adult men, hair from the pubic area and the crotch are removed independently at home, avoiding breaks in the skin, or in the hospital, parents take kids to the clinic for diapers, wipes and other necessary baby toiletries. If the planned intervention under General anesthesia for 8 hours before and the morning immediately before surgery can not eat or drink.
After admission, you will need to sign the relevant documents, sign a written consent (the patient or the parents of the boy), to communicate with the urologist and anesthesiologist, which may take 2-3 hours, so arrive there early. Working patients-men must release this day from work, because even if quickly carried out the procedure, immediately "ran" the operation is unlikely to succeed.
Adult men are informed that after removal of the phimosis they will not be able to drive not only due to surgical trauma, but even to a greater extent due to the introduction of sedatives or drugs for anesthesia. In this connection, you need to consider in advance how you will get home.
The technique of operations
During the procedure, the patient lies on back with legs divorced. The surgeon proceeds to the manipulations after the onset of full anaesthesia. In the case of local anaesthetic gel, it is applied in advance, and in the blockade of nerve roots at first limited to the operating field, the skin is treated with antiseptic, and then in a nerve injected anesthetics.
Regardless of the chosen technique removal of the phimosis, the operation area is treated with iodine, and the surgeon is not limited to penis — need to treat and stomach, and the skin of the scrotum and thighs. After that, the patient harboring sterile linen, leaving closed only the place where will be held manipulation.
To expand the narrowed openings of the foreskin, the surgeon takes clips. Then take the skin back to the exposure head on, in the presence of adhesions — they are worth sharing. If you plan on cropping, then after these actions, the specialist determines the line, which will continue to operate with a scalpel.
One of the most ancient and widespread interventions, which is used for the treatment and prevention of phimosis, and on religious grounds, is pruning. Developed many techniques of conducting, but the choice always remains with the surgeon, who evaluates the clinical situation and the technical possibilities of treatment.
Types of pruning:
- Method dorsal slit;
- Operation with the use of a clamp;
- Circular resection.
The indications for the use of the dorsal slit are phimosis and paraphimosis. Advantages of this surgery are the possibility of carrying out alone without a second surgery and low risk of complications, but there is a serious drawback: the surgeon should be experienced and possess the appropriate skills for this type of operation.
The dorsal slit technique involves several steps:
- Overlay clips on the foreskin;
- Dissection of the skin on the conditional 12 hours;
- The leather trim on the marked line, stitches.
During the manipulation of the vessels are combined and then laid on the wound sterile dressing is applied.
Application of clip is considered a technically simple method of operation that does not require the presence of a second surgeon, however, the disadvantage of it is considered probable unsatisfactory aesthetic result some time after the intervention.
In applying the clamp, the surgeon first grasps the skin with clips, pull it to the desired length for trimming. Then direct clamp fixes the foreskin and cuts it off close to the head of the penis. After clipping, the skin is moved back and fixed with sutures. In the conclusion of a careful hemostasis sterile bandage.
Circular resection technique is very accurate, but requires a good command of the surgeon, its features and the presence of an assistant. It is used in the development of the subcutaneous veins, as it provides a lower risk of bleeding.
With circular resection of the first, the surgeon marks incision lines on the edge of the head and at the point of attachment of the foreskin, then makes an incision along these lines skin flap, separating it from the penis. After removal of skin sutures, uniting the vessels, the wound is covered with sterile cloth.
In newborns and children of first years of life surgeons try not to use traumatic varieties with the use of special clamps.
The clip is a plastic device for single use, which resembles a bell. This technique is attractive because it does not need stitches. During the surgery the urologist makes a vertical incision from the free edge of the skin in the direction of the root of the penis on a mental 12 hours, then pointing to the head of the clip, which hides the skin is fixed by string. The excess foreskin is cut off, and the handle "bell" is. After about a week the plastic ring itself subsides.
The clips are designed for repeated use, however their use in pathological form of the disease is very limited. Today the specialists-urologists resort to them less often. The children in applying these clips, the seams do not overlap, and adults the causes of the possible erection necessary the edges of the wound to close.
Circumcision alternative method of surgical treatment of phimosis is considered praeputium, which is limited to cases where cicatricial changes touched only the tip of the foreskin. This operation for phimosis outpatient basis, takes about 20 minutes and gives fewer consequences and a less pronounced pain.
A contraindication to plastic surgery of the prepuce may become excessive contraction and fibrosis, where such an operation could trigger a relapse of the disease.
Technique praeputium includes a number of sequential steps:
- conduct a small longitudinal incision of the foreskin towards the root of the penis, the magnitude of the cut should ensure the free exposure of the head from the skin during its backward movement;
- in the case of cicatricial phimosis, the surgeon in parallel with the skin incision dissecting fibrous adhesions;
- suturing on the skin, which provides exposure head on.
Meatoplasty is a method of surgical correction narrowing of the orifice of the urethra. It serves as a complement to other procedures, when phimosis occurs with narrowing of the urethra in its final part. This happens in cases of severe phimosis as the result of obliterating balanite.
When Meatoplasty surgeon produces a cystoscopy to examine the urethra endoscopic and eliminate the stenosis in the other sites. If such is found, the patient will need surgery to expand the urethra – stenting.
Treatment of phimosis laser
In recent years, medicine widely used laser, and urology is no exception. Laser technology removal of phimosis involves the use of a laser instead of a scalpel and scissors. Luminous flux causing heating of the tissue, evaporation of water and destruction of the cells, acting like a cutting tool. The technique of operation is similar to that in conventional circumcision.
Laser circumcision has a number of important benefits:
- Gives fewer complications (infection, bleeding);
- The pain is less pronounced;
- It has high accuracy;
- The rehabilitation period is shorter (3-4 days vs a week and a half in normal operation);
- Shorter duration of the intervention (up to half an hour).
Experts say that laser treatment prevents injury of blood vessels with heavy bleeding as the light beam heats and seals their walls, so this method is selected in the pathology of clotting in a patient or a high risk of bleeding. By the way, it was first applied in Israel for the treatment of a boy with hemophilia.
Disadvantages of laser treatment are considered to be low availability due to high cost of equipment, which can afford a single clinic, the need for specialists who know the technique of laser treatment of phimosis, as well as the high cost of the operation for the patients.
When the surgery is completed, operated transportyou to the recovery room stay, where he spends a few hours in the absence of any complaints or signs of complications. If all goes well, it will go home the same day. Otherwise, the hospital will have to stay.
Operative treatment of phimosis is not considered traumatic and it does not restrict the activity of patients, but experts-urologists still recommend for the first few nights lying in bed: lying down reduces swelling of the genital organs. For fixation of the penis will need to wear tight underwear.
Regardless of the chosen technique, each type of operation will involve wearing a bandage (bandage). He need to be in the first several days to protect the penis from dirt and also to prevent strong swelling. A bandage is applied so that the opening of the urethra was not closed and provided urination.
After a few days the bandage can be removed by a doctor or by the patient (parents). If she had time to dry and adhere to the skin, it should be moistened with antiseptic (chlorhexidine, for example) and only then carefully separated. Careless and forced removal of dressings can cause damage to the mucous membranes of the body and complications.
The bandage is removed after a few days. The penis will be swelling, increased somewhat, that should not cause fear. Swelling may last a week, but then gradually go away. Surgeons usually use threads that do not need to be removed, as they resolve themselves, but if they are not resolved after the 10 day recovery period, they must be removed at the doctor.
Regular stitches after surgery removed at the end of the first week or a little later. Better if you remove them the surgeon who performed the intervention. He still will control the process of regeneration.
The effect of treatment can be assessed not at once, because you need to restore a quite a long time — sometimes up to six months. At this time, possible complications — abscess, hemorrhage with bruising, soreness during erection, severe scarring along the seam.