Circumcision in Croatia

Is this for me?

When a non-retractable foreskin is normal, and when it is phimosis

Phimosis is a condition in which the foreskin — the prepuce, in professional terms — cannot be retracted over the glans. However, a non-retractable foreskin does not mean the same thing in a child and in an adult man. That is why, before any decision about treatment, physiological non-retractability is distinguished from pathological, or scarring, phimosis.

Physiological phimosis in boys

Almost all boys are born with a foreskin that cannot be retracted, because its inner surface is still attached to the glans. The separation takes years and progresses at each child’s own pace. Large studies show that the frequency of phimosis decreases with age: it is present in around 8 percent of boys aged 6 to 7, around 6 percent aged 10 to 11, and around 1 percent aged 16 to 17. Adhesions between the foreskin and the glans last longer, and at seventeen they are present in around 3 percent of young men.

In the great majority of boys, this is a developmental stage. The foreskin is soft and stretchable, the opening widens when retraction is attempted, and it may balloon slightly during urination. If the child has no symptoms, infections, or difficulty urinating, observation without surgical treatment is recommended.

The foreskin must not be forced back. Doing so can cause tears, bleeding, scarring, and paraphimosis, and increase the likelihood that surgical treatment will be needed later.

Scarring phimosis calls for a different approach

Scarring — professionally, secondary — phimosis is the result of recurring infections, injuries, or a skin disease. It is recognized by a firm, whitish ring at the tip of the foreskin that does not stretch. It does not resolve on its own and worsens over time, because each new infection leaves more scar tissue, the opening narrows further, and the next infection becomes more likely.

According to the European urological guidelines, scarring phimosis is an absolute indication for surgical treatment.

In adults

Why adult men decide on circumcision

In adults, the cause of the phimosis needs to be established, because at that age it is often a matter of scarring changes after recurring infections, a skin disease, or a condition associated with diabetes. The symptoms can include tearing and bleeding of the foreskin during intercourse, redness, recurring infections, difficult hygiene, pain during erection, or inability to have intercourse.

Alongside medical reasons there are also other personal ones. Circumcision is performed for religious reasons, for easier hygiene, and for aesthetic motives.

The possible preventive benefits of circumcision should be interpreted in relation to the specific indication. The procedure reduces bacterial colonization of the glans, and in some boys with congenital urinary tract disorders it can reduce the frequency of urinary infections. The European guidelines nevertheless state that routine circumcision of newborns to prevent penile carcinoma is not indicated, because a meta-analysis found no elevated risk in uncircumcised men without a history of phimosis. Chronic inflammation of the foreskin is associated with risk and should be treated — but that is not a reason for the routine circumcision of all men.

Paraphimosis is an emergency

Paraphimosis occurs when a narrowed prepuce is pulled back over the glans and can no longer be returned to its original position. It can happen during hygiene, during erection, or during intercourse. The resulting ring cuts off the drainage of blood and lymph, so the glans and foreskin swell more and more; the condition is very painful and requires urgent medical care. It is treated by returning the foreskin to its normal position and, if that fails, with a small surgical procedure that releases the ring. Complete circumcision is then performed later, once the condition has settled.

How we work

What circumcision looks like

In adults, the procedure is performed under local anesthesia as a rule. The scope of the preoperative tests depends on the chosen form of anesthesia. When general anesthesia is used in a child, preparation as a rule includes a pediatrician’s examination and the prescribed laboratory tests.

After the anesthetic is administered, the excess foreskin is removed, bleeding is stopped, and the wound is closed with resorbable sutures, which do not need to be removed later. The procedure takes about half an hour and is performed on an outpatient basis. After recovering from the anesthesia, the patient goes home with written wound-care instructions and a scheduled follow-up examination.

In the first days, the wound is dressed and cared for according to the written instructions received after the procedure. The instructions cover hygiene, how to dress the wound, and the possible topical use of a prescribed ointment.

Duration

about half an hour

Anesthesia

in adults most often local; in children, general anesthesia is used as a rule

Recovery

back to work within a few days; complete healing in 4–6 weeks

Performed by

Duško Maletić, MD, MSc, specialist in surgery and urology

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Open about the risks

Possible risks and complications

Circumcision is one of the most frequently performed surgical procedures in the world, but complications do exist. A systematic review and meta-analysis of published research recorded approximately four complications per hundred procedures, with procedures performed for a medical reason having a higher rate, around 7.5 percent, than those performed without a medical indication, around 3.3 percent. The most commonly cited are:

• bleeding and bruising
• wound infection, reported in adults in approximately one to two per hundred patients
• impaired healing or partial opening of the wound
• adhesions and narrowing of the urethral opening
• a more prominent or uneven scar, for which a correction may rarely be needed

The risk of complications depends on the indication, the patient’s age and health, the surgical technique, wound healing, and adherence to the postoperative instructions.

Recovery

Recovery, step by step

• The first 24 to 72 hours — the area is sensitive, a dressing is worn as instructed, and rest is recommended. Snugger cotton underwear can help hold the dressing in place and reduce swelling.
• 1–2 weeks — swelling and bruising gradually subside. Most people return to office work within a few days, while physically demanding work may require a longer break.
• 2–6 weeks — the resorbable sutures gradually break down and fall away. The return to sport, lifting, and cycling depends on healing and the physician’s recommendation.
• 4–6 weeks — most of the healing process is completed during this period. Sexual intercourse and masturbation must be avoided for at least 4 weeks, and as a rule 6 weeks, or until the physician confirms the wound has healed.
• Several months — the scar gradually fades, and the tissue softens and regains elasticity.

Returning to daily life is not the same as complete healing

The timeframes of a few days and of 4 to 6 weeks refer to different phases of recovery. Normal walking, showering, and a return to office work are possible well before tissue healing is complete. The British urological guidance for adults states that healing at the suture line takes approximately 4 to 6 weeks.

Sexual activity is postponed until the wound has healed, because early mechanical strain can cause pain, bleeding, or partial separation of the wound.