Surgical decisions and procedures for phimosis and paraphimosis

Do phimosis and paraphimosis always require surgery?

Congenital phimosis in infants and young children without complications does not require treatment, and the vast majority of cases do not require surgery. If difficulty urinating occurs, manual dilation can be performed. For children with balanitis, topical medications are applied during the acute phase. After the inflammation subsides, manual separation and dilation of the foreskin can be attempted; if ineffective, circumcision should be considered. Acquired phimosis always requires surgery.

Does phimosis always require surgery? Traditionally, doctors have generally believed that phimosis can directly lead to penile cancer and is prone to recurrent infections, therefore surgery is necessary. However, with in-depth clinical research, it has been found that the probability of simple phimosis leading to penile cancer is extremely low. Therefore, the current view is that simple phimosis without recurrent inflammation does not require surgery; maintaining good hygiene and regularly cleaning the secretions from the foreskin cavity is sufficient. If a man with phimosis experiences recurrent balanitis, surgery is best performed after controlling the acute inflammation. Some studies suggest that from the perspective of preventing sexually transmitted diseases such as HIV/AIDS, circumcision helps reduce the chance of HIV/AIDS infection. Therefore, in areas where HIV/AIDS is prevalent, circumcision for men with phimosis has positive significance. Additionally, circumcision may be performed for religious purposes such as "circumcision."

If paraphimosis occurs, it requires emergency treatment, and most cases can be reduced manually. If manual reduction fails or the paraphimosis has been present for a long time, a dorsal circumcision should be performed. If the paraphimosis has ruptured or the condition permits, an emergency circumcision can be performed.

What are the different methods of circumcision?

The surgical treatment for phimosis and paraphimosis is circumcision. Circumcision involves surgically removing a ring of foreskin from the penis, including part of the outer and inner foreskin. The ring is then closed to fully expose the glans penis, thus reducing the risk of infection. There are many methods of circumcision available, differing mainly in the methods of removal and closure. Broadly, they are divided into the incision and suture method and the stapler method.

The circumcision method involves removing excess foreskin with a scalpel or scissors, then suturing the foreskin edge back together with absorbable or regular silk sutures. Common types include dorsal circumcision and sleeve circumcision. Many hospitals now use laser circumcision, which is essentially replacing the scalpel with a laser. This method also falls under the category of circumcision and offers advantages such as less intraoperative bleeding, ease of operation, shorter surgery time, and less postoperative foreskin edema.

The stapler method involves placing a disposable stapler over the foreskin. The pressure between the inner and outer rings of the foreskin ring causes the distal foreskin to necrotize and detach, while the wound heals simultaneously. The Han's ligation method is commonly used, and similar ligation instruments are now available from domestic companies. Compared to the suture method, the stapler method offers advantages such as ease of operation, no need for sutures or ligation of bleeding points, shorter operation time, less pain, lower complication rate, and higher aesthetic satisfaction. However, its disadvantages include relatively slower skin healing and more pain during ring removal.

Most circumcision surgeries can be performed on an outpatient basis without hospitalization. However, if the foreskin and glans penis are tightly adhered in a patient with phimosis, the surgery is more difficult because it requires separating the inner foreskin from the skin on the penis and glans. In such cases, urethral meatus reconstruction surgery may be necessary, and hospitalization may be required.

The timing of surgery is also a major concern. If paraphimosis occurs, immediate manual reduction or surgery is necessary; patients with acquired phimosis should undergo surgery as soon as possible; for children with phimosis or redundant foreskin, surgery is best performed before puberty; for adults with phimosis, surgery should be performed after acute infection has been controlled.

A special reminder: some patients who appear to have phimosis (tight foreskin) do not actually have phimosis, but rather other conditions (such as concealed penis). In these cases, circumcision should not be performed alone; corrective surgery is required. Therefore, do not consider phimosis a simple condition, nor should you think of circumcision as a minor surgery. Always have it done at a reputable hospital.