Preparation of the surgical site includes a thorough surgical scrub of the genital area with a povidone-iodine preparation.Shaving and clipping of the pubic hair should be avoided to minimize the possibility of infection.All family physicians should be prepared to advise their patients about the indications for adult circumcision and, if necessary, make appropriate referrals for the procedure.Although there are numerous medical indications for adult circumcision, none of them is very common.3 The most frequent indication is phimosis, a tightness of the prepuce that prevents its retraction over the glans.4 A patient may also complain of pain with erection or during intercourse.Anesthesia can be accomplished by administering a dorsal penile nerve block, with or without a ring block.7 The penis is innervated by the left and right dorsal nerves; these are branches of the pudendal nerves.8 The dorsal penile nerve is blocked by injecting a local anesthetic solution deep to Buck's fascia where the nerves emerge from under the pubic bone. After preparation of the skin, two injection sites are identified over the inferior edge of the pubic bone at approximately 10 o'clock and 2 o'clock relative to the base of the penis.A 27-gauge, 1.5-in needle is inserted, directed ventrally, until the pubic bone is contacted.Adult circumcision is usually performed in the outpatient setting by urologists.However, family physicians who practice in isolated or rural areas and who are adequately trained may also offer this procedure.
Nonmedical reasons may be social, cultural, personal or religious.
Recurrent balanitis and posthitis (inflammation of the prepuce), preputial neoplasms, excessive prepuce redundancy and tears in the frenulum are also medical indications for adult circumcision.5Patients may have social, religious or personal reasons for requesting a circumcision.6 It is important to explore these reasons with the patient to ensure that he has a thorough understanding of the risks and benefits of circumcision and alternatives to the procedure.
There are no specific contraindications to adult circumcision in the literature; however, patients with active infection, possible squamous cell carcinoma of the penis or anatomic abnormalities of the external genitalia should be referred for a urologic consultation.
The needle is “walked” caudad off the pubis and through Buck's fascia.
After aspiration, 5 m L of local anesthetic is injected at each site.