Plastibell Circumcision

Circumcision
Dr Hasan Nugud
Circumcision
Circumcision
• Male circumcision is an ancient practice, perhaps
dating back to the Stone Age.
• Herodotus, the Greek historian of the fifth
century BCE, noted the antiquity of the custom
in his time and speculated that it had originated
in Egypt and spread from there outward across
the Levant. Egyptian tomb scenes from the Old
Kingdom show priests performing the ritual on
young nobelmen.
Circumcission
• Syrian warriors with circumcised genitalia are
depicted on artifacts from the third millennium
BCE, or five thousand years ago,
• The Israelites practiced the custom beginning,
according to the book of Genesis, with the
circumcision of Abraham at the age ninety-nine,
• Arabian tribes followed similar practices, a
tradition recorded in the circumcision of Ismael.
Circumcision
• Circumcision has been widely practiced since
ancient times. In many cultures, including
ancient Egypt and Sumeria as mentioned above,
• Circumcision was done at puberty as a right of
passage to adulthood,
• Neonatal circumcision was first practiced by the
ancient Hebrews. Many religious and cultural
groups still practice circumcision,
• Jews perform the procedure in a ritual called
“berit mila” on the 8th day of life.
Circumcision
Congenital
Circumcission
Or born with
Insufficient
foreskin
Circumcision
• Every day across the world hundreds of thousands
or millions of newborn babies are strapped naked
to a board and assaulted in their genitals by ritually
attired practitioners known as physicians.
• Although the operation is painful, it is performed
w/o anaesthetic and the baby’s cries are interpreted
as signs of healthy lungs, and his subsequent
traumatized sleep explained as proof that, the
operation caused no discomfort.
Circumcision
• Memories of the pain may impair his intellectual or
emotional development,
• And the procedure although safe as surgeries go, it
is not risk free. Hemorrhage, infection, ulceration,
urethral meatus narrowing due to scarring, the
penis may be bent forward or backward, penile
torsion right or left, amputation, burn. Even if the
surgery goes well, the boy ends up with genitals
that are structurally altered. Hence, he has been
mutilated .
Circumcision
• During the 19th and beginning of 20th centuries, in
a remarkably brief period of time, circumcision
became ubiquitous, first as a remedy for disease,
and later as a prophylactic procedure administered
within few days after birth and became nearly
universal specially in the united states.
• Circumcision is said to protect against penile
cancer and UTI and lately to reduce the risk of
HIV infection but deterring masturbation and
spermatorrhea (wet dreams) were discredited.
Circumcision
Penile abnormalities
to be diagnosed
before circumcision
is started
Micropenis
Torsioned penis
Webbed penis
Megalopenis
Circumcision
Penile abnormalities
to be diagnosed
before circumcision
is started
Chordee with hypospadiasis
Circumcision
• Traditional cultures offer a number of
rationales for circumcision ;
• It is said to be a deeply rooted part of the
people’s history,
• The procedure may be necessary in order to
marry.
• It cements mutual respect among men,
• It wards off evil or appeases supernatural forces.
Circumcision
• It contributes to social stability and coherence,
marks identity, and confers honor.
• It protects against sexually transmitted diseases,
enhances fertility, promotes hygiene, confers
purity, and controls sexuality,
• Whatever the rationale, the traditions of male
genital surgeries are deeply embedded in the
cultures where they flourish.
Circumcision
• Routine circumcision is widely practiced because
of cultural imperative, and potential health
benefits and risks of circumcision are balanced.
• The decision to do circumcision for none ritual
reasons should be made by the parents after they
have been fully educated,
• Circumcision is done with the Gomco bell,
plastibell, Morgen clamp, bone cutter or by
routine freehand approach.
Circumcision
(a)- plastibell
Circumcision
(b)-Trimming
of foreskin
circumcision
Circumcision
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Circumcision
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Circumcision
• Christianity does not practice circumcision. The
unity of the early Christian church was threatened
and probably fractured over the issue. Paul the
apostle to the Gentiles viewed circumcision as
meaningless and irrelevant. Jews opposed Paul’s
efforts. The church abandoned circumcision
under the doctrine that Christ had abolished
circumcision and other ritual separations between
Jew and Gentile.
Circumcision
• In neonates general anaesthesia is not used, local
anaesthesia with a form of nerve block or an
eutectic mixture of local anaesthetics or (EMLA)
cream should be encouraged,
• In older children, circumcision should be done
using a freehand approach under general
anaesthesia.
Circumcission
Penile block
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Circumcision
• For Jews, circumcision was by far the most salient
mark of identity. It was the feature that
distinguished a Jew from other peoples, a
covenant demanded by God for all Jews. It was a
reliable indicator of a person’s Jewish identity
because it was painful, hence, people would not
readily counterfeit a Jewish identity for such a
price. Therefore it was for Jews an essential mark
of self and, accordingly, was highly esteemed
within Jewish culture.
Circumcision
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Bonecutter Circumcision
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Bonecutter Circumcision
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Circumcision
• Circumcision is an option for the management of
phymosis, paraphymosis, infections of the
foreskin, such as balanitis or balanoposthitis,
• Contraindications are children with hyposapadiasis (foreskin is used in reconstruction),
• Risks of circumcision include; bleeding, infection,
damage to the glans, urethra, removal of too little
or too much foreskin.
Circumcision
Hypospadiasis sine
hypospadiasis
(Split foreskin without
displacement of the
Meatus)
Circumcision
can be done
by trimming
of split
foreskin
Circumcission
Incomplete circumcision
Circumcision
Smegma inclusion cyst
Circumcission
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Epispadiasus
Epispadiasis
repair
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Circumcision
Buried penis
repair
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Buried penis
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Circumcission
Buried penis
Circumcision
• Female’s Genital Mutilation where it refers to :• The cutting of the tip or the whole of the clitoris,
There are, however, other more radical and
harmful mutilations which can be relatively minor
or extremely serious, includes a wide range of
ritual and non-medical operations undertaken on
women’s genital organs, which include their total
or partial removal and amputation or incisions in
the interior of the vagina.
Circumcision
• According to WHO Female Genital mutilation
can be classified into three major types :• Type I or Clitoridectomy ; removal of the tip of
the clitoris,
• Type II ; cutting of the clitoris and all or part of
the labia minora,
• Type III or Infibulation or pharaonic
circumcision ; in which the clitoris is cut together
with part or the whole of labia minora and incisions
are made on the labia majora.
Circumcision
• Incase of type III, the edges of the wound are
often tied up leaving a small opening through
which urine and menstrual blood can flow.
• The resulting mass of scar tissue which covers
the urethra and the upper part of the vagina
completely closes the vulva. If the opening is
wide enough, sexual intercourse may take place
after gradual dilatation of days weeks or even
months, but if the opening is too small to allow
sexual intercourse it must be widened surgically.
Circumcision
• Phymosis :• Is defined as a nonretractable foreskin.
However, this finding is normal and is not an
indication for surgery , unless it is associated
with obstruction of the urinary stream,
• The retractability increases during childhood,
• The foreskin should be fully retractable by
puberty.
Circumcision
Phymosis
Circumcision
Penile torsion
Circumcision
• Non-surgical treatment of phymosis include
repeated forcible retraction and the use of
topical steroid cream,
• Surgical options include dorsal slit, ventral slit,
and circumcision
Circumcision
• Paraphymosis :• The foreskin is not replaced back after retraction e.g.
after a bath or catheterization,
• The prepucial ring becomes tight, and the glans swells,
leading to pain and ultimately to vascular compromise
(treatment requires placing the foreskin back into its
normal position often under GA,
• A similar condition may occur as a complication of the
plastibell clamp, if the plastic ring slips downward onto
the penile shaft.
Circumcision
• Balanitis :• Inflammation of the glans, which may also be
associated with inflammation of the inner surface of
the foreskin (balanoposthitis),
• Both conditions are relatively rare in children,
• Most cases are infectious (adults). Other causes
include allergy, contact irritation or trauma,
• Treat underlying problem. In recurrent cases
circumcision is recommended.
Circumcision
Phimosis
Balanitis
Phimosis is stenosis of the
preputial orifice caused by
ill-advised forceful retraction,
recurrent balanitis, ammoniacal
dermatitis (nappy rash).
Accumulation of smegma and urine
leads to further attacks of balanitis.
Ballooning of foreskin on micturation
is a sign of urinary obstruction
requiring circumcision.
Circumcision
Phimosis
Paraphymosis
Paraphymosis
When foreskin is pulled behind the glans and cannot be returned
to its normal position due to glans oedema or tight foreskin due to
present phimosis. It is painful and micturation is difficult.
Digital reduction followed by circumcision is the treatment.
Circumcision
• Meatal stenosis or Atresia :• Meatal stenosis is an acquired narrowing of the
glanular orifice that is found in circumcised
patients (mainly adults). It results from
ammoniacal dermatitis or ischemic injury at the
time of circumcisionThe diagnosis is made by
appearance of the meatus or by observing the
urinary stream,
• Treatment ; dilatation, meatotomy or -plasty.
Circumcision
Preputal atresia
Circumcision
Preputal
atresia
Circumcision
Penoscrotal web (P.S.W)
Circumcision
Penoscrotal web release
Circumcision
• Routine circumcision is widely practiced because
of cultural imperative, and potential health
benefits and risks of circumcision are balanced.
• The decision to do circumcision for none ritual
reasons should be made by the parents after they
have been fully educated,
• Circumcision is done with the Gomco bell,
plastibell, Morgen clamp, bone cutter or by
routine freehand approach.
Circumcision
B
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Circumcision
Buried penis
Circumcision
Thorough examination of the penis prior
commencement of any type of circumcision
such as complete retraction of foreskin cleaning
and examination for anomalies such as
hypospadiasis, meatal anomalies, penile torsion
and urethral diverticulum is of paramount
importance.
Circumcision
Urethral diverticulum
Circumcision
Other penile abnormalities
which should be noticed
and evaluated before
circumcision is decided
Ambiguous genitalia
Circumcision
Ambiguous genitalia
Circumcision
Complications
Post plastibell complication
Circumcision
Complications
Post circumcision fistula
Circumcision
Complications
Complete disruption of the urethra
and most of the penile shaft
Circumcision
Complications
The complication was due to a tight dressing and un awareness of the parents
about the importance of the instructions in the handouts and strictly following
Them specially about the time of dressing removal or plastibell fall off.
Circumcision
Complications
The resulting complication as a mid shaft acquired
hypospadiasisis mainly due to improper examination prior
circumcision, or circumcision not done by experienced surgeon
or the care after circumcision was not followed as required.
Circumcision
Complications
Urethral
injury and
subsequent
stenosis
Circumcision
• Conclusions :• Today both female and male genital mutilation
are particularly common in poor, developing
countries with wide traditional communities, but
these practices have also been maintained in
many modern Western multicultural societies.
Circumcision
• Conclusions :• Despite global and local attempts to end genital
mutilation, in their various forms, whether of
males or females, the practice has persisted
throughout human history in most parts of the
world. Various medical, scientific, hygienic,
aesthetic, religious, and cultural reasons have
been used to justify it.
Circumcision
• The campaigns against MGM have not been as
vigorous as those against FGM since FGM is in
general considered to be more violent and
socially suppressive practice than MGM,
• In addition FGM has more serious and
damaging physical as well as psychological or
social implications,
• On the other hand, the operation itself has no
medical justification.
Circumcision
• Conclusions :• From human rights perspective both male and
female genital mutilation, particularly when
performed on infants or defenseless small
children, and for non-therapeutic reasons, can
be clearly condemned as a violation of children’s
rights whether or not they cause direct pain,
Circumcision
• Conclusions :• Parent’s rights can not override children’s rights,
• If we allow parents to decide what is best for
their children on the basis of children’s religious
or cultural identity, we would have no
justification for stopping them cutting off their
children’s ears, fingers, noses , even cannibalism
or human sacrifice if their religious and cultural
beliefs demands this.
Circumcision
• In American, market oriented society, male
circumcision became a form of commercial
exploitation of children when physicians, in
cooperation with transnational biotechnology
corporations, looked for the sales of marketable
and economically profitable products made
from harvested human foreskins that could
further be used in the pharmaceutical industry.
Circumcision
• Men who remain uncircumcised in the societies
in which the practice is common are made to
feel somehow abnormal and/or not equal to
those who have undergone the operation,
• Just to make few examples :• In East Africa, for instance, men of the Masai
tribe see uncircumcised men as adolescent,
spineless and timid cowards who do not have
full male qualifications.
Circumcision
• Within the Cameroonian Nso tribe the three main
rationalizations for male circumcision have been ;
• Firstly, the belief that circumcision prepares the
penis, puts it in a state of readiness for coitus and
procreation,
• Secondly, that it tests the courage and endurance
of a boy at the threshold of adulthood,
• Thirdly, but rather in contradiction of the first
claim, it is thought to tame and moderate the
sexual instinct, thereby, helping a man to act more
responsibly.
Circumcision
• It may seem inconsistent to require genital
mutilation on a religious basis since this is
perfecting the work of God by cutting off,
modifying or redesigning any part of a human body
which has been created by God,
• The Human ability to find the needed false reasons,
however, is boundless, in the case of genital
mutilation the attempt to reduce sexual pleasure and
to maintain chastity is seen not only as an
improvement of God’s work, but also as showing
obedience to whatever is believed and interpreted to
be God’s will in any given culture.
Circumcision
• In traditional Judaism, male circumcision is a
means to moderate the sexual pleasure and their
attraction to women,
• In Islam, similar views of reducing the sexual
pleasure rather than fully suppressing it, is
presented, however, is used more frequently in
the case of female genital mutilation,
• As for Jews and Muslims, Circumcision is also a
mark that distinguishes the believer from the
non-believer.
Circumcision
• In Africa, for instance, the history of female genital
mutilation dates back to 4000 years BC, even today
in Africa FGM is still practiced in at least 27
countries and every year two million girls at least are
exposed to sexual mutilation,
• Those women who themselves have not undergone
any FGM, may prefer circumcised men as sexual
partners, either because their performance in sexual
intercourse lasts longer or because they consider a
circumcised penis to be more hygienic and/or more
aesthetic than an uncircumcised one.
Circumcision
• Clitoridectomy was, for instance, used in both
Europe and in America by qualified doctors for
hygienic reasons, as a medical cure for
masturbation, and for mental disorders such as
hysteria,
• This shows that science can be a double edged
sword that readily lends itself as an alibi for
strongly held preferences and cultural biases.
Circumcision
• Human sexuality and the attempts to control it,
particularly to reduce or add sexual pleasure, have
been, in one way or another, a part of all known
cultures and civilizations. Thus in this regard one
cultural tradition cannot be said to be better than
another,
• Rather, with further education and knowledge,
the cultural smokescreen around the real reasons
for the maintenance of the practice can be
overcome in all societies no matter what their
cultural background.