Penile surgery

Circumcision is the surgical removal of the skin covering the head of the penis. It may be done for cultural or medical reasons. Non-medical circumcisions are performed most commonly in the USA, Middle East and South Korea. In New Zealand, it is estimated that the rate of non-medical circumcision is around 10%.

Medical indications for circumcision include phimosis, recurrent balanitis, penile cancer and paraphimosis.

Phimosis is where the foreskin is too tight to be pulled back over the head of the penis and can lead to recurrent infections, difficulty passing urine, pain with erections and splitting of the skin with sexual intercourse. This is sometimes due to Balanitis Xerotica Obliterans (BXO) a progressive scarring condition. Balanitis is the condition in which the skin and head of the penis become infected. Paraphimosis is a situation in which the skin can’t be returned to its normal position causing pain and swelling. If severe and left for too long, blood flow can be impaired to the skin and head of the penis resulting in tissue loss. Circumcision is also sometimes necessary for the treatment of penile cancer.

Circumcision may be beneficial by making it easier to wash the penis. In some cases, it may help prevent infections both in the urinary tract and from sexual transmission. If phimosis is severe enough to cause urinary retention, circumcision may allow relief of urinary symptoms and particularly post-void dribbling. The risks of not being circumcised at birth are not only rare but generally avoidable with proper care of the penis and personal hygiene.

Circumcision is usually performed under general anaesthetic. It involves making an incision around the area of the foreskin where it joins the skin that covers the shaft of the penis. The foreskin is then carefully pulled away from the tip of the penis and cut away down to the level of the initial incision. The skin covering the shaft of the penis is sewn back underneath the head of the penis using dissolvable sutures. The local anaesthetic block is injected to give pain relief for the first few hours after surgery and a compressive dressing is applied to protect the wound and reduce the risk of bleeding. Ideally, the dressing will stay in place for 48 hours however it does not matter if it falls off before that time.

Although circumcision is considered a minor procedure there are some risks associated with it. Bleeding and infection are the most likely problems however removing too much or too little skin is possible as is scarring or wound separation. A change in sensation is expected with the removal of the sensitive foreskin. Very occasionally a further procedure may be required to correct any problems.

The operation takes less than an hour to do and you will be able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic). After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient.

It usually takes at least 10 days for the penis to heal after circumcision. You should remove the dressing after 48 hours. This is made easier by soaking it in the shower before removal. Wearing loose-fitting clothing for the first few days will help to avoid irritation to the wound. Vaseline may also help to reduce sticking to the underwear. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

You should anticipate a week off work or school to recover and should not have any sexual activity for at least 4 weeks after the operation as it can lead to tearing of the sutures.

The frenulum is the bridge of tissue on the underside of the penis that runs between the head of the penis and the skin of the shaft. Trauma and infection can lead to it becoming scarred. Repeated tearing especially during intercourse may result in pain, bleeding and infection.

Frenuloplasty is a short procedure that involves the division of the tethered band and resewing in such a way as to restore the length of the frenulum. The operation takes around 10 minutes to do and you will be able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic). After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient.

It usually takes at least 10 days for the penis to heal after frenuloplasty. Wearing loose-fitting clothing for the first few days will help to avoid irritation to the wound. Vaseline may also help to reduce sticking to the underwear. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

It is usually not necessary to have more than 24 hours off work or school to recover however you should not have any sexual activity for at least 4 weeks after the operation as it can lead to tearing of the sutures.

Peyronie’s disease is a benign (not cancerous) condition resulting from fibrous scarring of the penis. This can result in pain and penile curvature with erections. It is thought to happen due to the healing of microtrauma to some of the deeper penile tissues. Typically there is an acute phase with pain from inflammation that lasts up to a year followed by a chronic phase where the pain has settled but curvature continues to progress for the next 2 years or so.

Numerous medical treatments have been recommended over the years however these treatments tend to be of little benefit. Surgery is recommended only once the curvature has stabilised. The aim of surgery is correct curvature enough to allow sexual intercourse.

Nesbitt’s procedure is the most commonly performed operation for Peyronie’s disease although a number of other procedures exist. Also called penile plication, it involves placing sutures into the longer side of the penis (i.e. the side without scarring) straightening the penis. This procedure will not correct notches or waisting and may result in shortening of the penis. The local anaesthetic block is injected to give pain relief for the first few hours after surgery and a compressive dressing is applied to protect the wound and reduce the risk of bleeding. Ideally, the dressing will stay in place for 48 hours however it does not matter if it falls off before that time.

The operation may take 1-2 hours to do and men are often able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic).

Although penile plication is considered minor surgery there are risks which include bleeding and bruising, infection, swelling, discomfort and scarring. The deep permanent sutures are sometimes able to be felt underneath the skin. Erectile dysfunction (inability to get an erection) is associated with Peyronie’s disease but can also happen as a consequence of the surgery. Rare complications include the wound opening or the sutures cutting out with a recurrence of the curvature. If done too early (before curvature has stabilised), the bend can progress and occasionally further surgery may be necessary.

After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient.

You may shower 24 hours after surgery but do not take a bath for the first week. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

Ice packs or a bag of frozen peas may be useful to help with swelling and discomfort (don’t apply ice directly to the skin as it will stick and cause damage to the tissues).

After your surgery, you may feel more tired than usual and have some mild groin pain for several days. Your penis, groin and scrotum may be swollen or bruised. This usually gets better in 2 to 3 weeks.

You will need to avoid strenuous exercise (cycling, jogging, aerobic exercise, contact sports) and heavy lifting for 2 weeks. Heavy lifting means anything heavier than 5kg (such as heavy grocery bags, briefcases, backpacks and children) If you have a physically demanding job, you may need up to two weeks to recover before returning to work.

Each person recovers at a different pace so rest when you feel tired. Getting enough sleep will help you recover. Try to walk each day and gradually increase the distance each time. Walking boosts blood flow and helps prevent pneumonia and constipation.

You should anticipate a week off work to recover and should not have any sexual activity for at least 6 weeks after the operation as it can lead to tearing of the sutures.