**4. Indications of circumcision**

#### **4.1 Phimosis**

It is a condition in which the contracted foreskin cannot be retracted over the glans and the commonest cause is chronic infection from poor local hygiene. In diabetic older men, balanoposthitis may lead to phimosis (Eiger, 1972). Congenital narrowing of the preputial orifice associated with long foreskin leads to ballooning out of the prepuce on micturition with a thin weak stream of urine leading to difficult micturition with residual urine, hydroureter and hydronephrosis but more often occurs as a result of atresia meati which may lie hidden by phimosis (Blandy et al, 1968, Bailey & Love's, 1992). It is reported that most cases of phimosis occur in uncircumcised males although excessive skin left, which may become stenotic lead to phimosis.

Circumcision has been the traditional treatment for phimosis but not the only management option; the best of which appears to be gentle physical retraction combined with topical steroid treatment of the unretractable foreskin (Dewan et al., 1996).

Circumcision for phimosis in infant and young boys is done due to a request by the patients (religious and personal), or due to recurrent balanitis with inability to retract the prepuce and rarely due to a very long prepuce. In adults, it is done due to inability to retract for intercourse, tight frenum, balanitis and sometimes, prior to radiotherapy for penile carcinoma.(Bailey& Love's, 1992).

#### **4.2 Paraphimosis**

Tight prepuce has been retracted and cannot be returned to its normal position. This is due to chronic infection under the redundant foreskin which leads to contracture of the preputial opening (phimosis) and formation of a tight ring of skin when the foreskin is retracted over the glans. The skin ring leads to venous congestion which leads to engorged oedematous glans making the condition worse. As the condition progresses, arterial occlusion and necrosis of the glans may occur. Treatment can be done by firm squeezing of the glans for five minutes to reduce tissue oedema and to decrease the glans size then the skin can be drawn forwards over the glans. If this is unsuccessful, general anaesthesia must be given and the constricting band is incised and circumcision is done to trim the redundant skin later on and antibiotics should be given (Bailey & Love's, 1992).

#### **4.3 Trauma**

44 Complementary Pediatrics

in the-one continent of Africa, only certain tribes circumcise e.g., Zulo, Xahsa, Bechuana and Falasha while among its many Christian communities; circumcision has a religious

The glans is covered by the prepuce which is formed of two layers of skin reflected at the neck of the penis behind the corona glandis; the inner layer of the prepuce is confluent along the line of the neck with thin skin-which covers and adheres firmy to the glans on the undersurface of the glans penis, a small median fold passes to the deep surface of the prepuce (frenulurn). The prepuce is separated from the glans by a potential space (preputial sac) which presents two shallow fossae on either side of the frenulum. On the corona glandis and on the neck of the penis, there are numerous small preputial sebaceous glands which secrete smegma beneath the foreskin (a mixture of sebaceous material and shed keratin). It has a peculiar odor, and may be seen exiting from the foreskin tip or accumulate

It is a condition in which the contracted foreskin cannot be retracted over the glans and the commonest cause is chronic infection from poor local hygiene. In diabetic older men, balanoposthitis may lead to phimosis (Eiger, 1972). Congenital narrowing of the preputial orifice associated with long foreskin leads to ballooning out of the prepuce on micturition with a thin weak stream of urine leading to difficult micturition with residual urine, hydroureter and hydronephrosis but more often occurs as a result of atresia meati which may lie hidden by phimosis (Blandy et al, 1968, Bailey & Love's, 1992). It is reported that most cases of phimosis occur in uncircumcised males although excessive skin left, which

Circumcision has been the traditional treatment for phimosis but not the only management option; the best of which appears to be gentle physical retraction combined with topical

Circumcision for phimosis in infant and young boys is done due to a request by the patients (religious and personal), or due to recurrent balanitis with inability to retract the prepuce and rarely due to a very long prepuce. In adults, it is done due to inability to retract for intercourse, tight frenum, balanitis and sometimes, prior to radiotherapy for penile

Tight prepuce has been retracted and cannot be returned to its normal position. This is due to chronic infection under the redundant foreskin which leads to contracture of the preputial opening (phimosis) and formation of a tight ring of skin when the foreskin is retracted over the glans. The skin ring leads to venous congestion which leads to engorged oedematous

steroid treatment of the unretractable foreskin (Dewan et al., 1996).

significance only in Ethiopia (Blandy et al., 1968).

in clumps beneath the foreskin (Gray's Anatomy, 1950).

**4. Indications of circumcision**

may become stenotic lead to phimosis.

carcinoma.(Bailey& Love's, 1992).

**4.2 Paraphimosis** 

**4.1 Phimosis** 

**3. The prepuce (what is removed during circumcision?)**

It is a rare indication for circumcision (Blandy et al., 1968).
