Adhesions - What are They?
"The new study by Van Howe in the BJU found that 29.7% of circumcised boys under three years of age have adhesions or skin bridges. They are a complication of circumcision. They form when two raw surfaces heal together.These tend to interfere with hygiene.
Van Howe reported that balanitis (inflammation of the glans) is more commonin circumcised boys. Perhaps some parents mistakenly believe that the circumcised penis is maintenance free and do not attend to penile hygiene when their son is circumcised. The foreskin has protective functions that are not available when the boy is circumcised.
The penis is still in a developmental stage when boys are born. The foreskin and the underlying glans develop as one unit. They are bonded together by a common membrane. When left alone they naturally separate into separate parts after the boy is three or more years old.
When an infant circumcision is performed these parts, which are united and bonded together must be torn apart as one tears Velcro apart. This leaves two raw surfaces - the surface of the glans and the inside of the foreskin.This part of the circumcision is called a synechtomy because the synechial membrane, which joins the two tissues is removed.
When a circumcision on an infant boy is done, good procedure calls for the foreskin to be cut short enough that it will not overlay the glans. If the foreskin is cut long, the two raw surfaces will heal together and cause anadhesion. This adhesion has no interstitial synechial membrane and will not break down.
A normal healthy circumcision, even with a long residual foreskin, would leave the foreskin freed to be pushed back so it exposes the corona (crown)of the glans penis (head). If you cannot do this, then adhesions must be present to prevent the retraction of the residual foreskin.
Some doctors are likely to suggest additional surgery or a second circumcisioneven though there is a simple in-patient technique that separates adhesions without pain. Adhesions can be separated non-surgically.EMLAcream, a topical anesthesia, is applied to the penis. After one hour the doctor breaks the adhesions. Then the glans is kept coated with vaseline for one to two weeks while healing takes place to keep adhesions from reforming. NOCIRC says this needs to be done at every diaper change. Once healing is complete one would think that there would be no further problem with adhesions forming. But that may not be the case. It seems that adhesions may reform later even though the area has healed.
There is little medical advice available on this problem but Dr. Van Howe writes that "the circumcised boy needs to have any skin overlaying the glans pulled back and cleaned regularly until 15-18 months of age to prevent adhesions from reforming and debris from accumulating." He says the debris consists of "lint, dirt, talc, stool and detritus." He found strong association between coronal adhesions and the presence of subpreputial debris. Dr. Van Howe states that most preputial adhesions in circumcised boys resolve by 24 months "after parents were instructed to apply gentle retraction on the adhesion."
Mothers must not consider the surgically altered circumcised penis to be "maintenance free." The circumcised penis actually requires more care than the intact normal penis which is protected by the preputial spincter and is cleaned by the swirling urine, and thus requires no special care, according to Dr. Van Howe.
The foreskin is relatively longest at birth; as the penis grows the apparent length of the foreskin lessens. Circumcised baby boys who have a covered or partially covered glans probably will lose that coverage as they mature.Parents should be aware that the appearance of the penis in infancy does not reflect the appearance of the penis in later life. Dr. Van Howe states that "revision of the circumcision for purely cosmetic reasons should be discouraged on both medical and ethical grounds."
Parents of circumcised children will also want to obtain Pamphlet Number 5 about the circumcised penis from NOCIRC.
A lot of times children just "outgrow" this condition.
"Until then, gently retract the skin and apply gentle traction on the adhesion.I think these adhesions act like the normal synechiae between the inner lining of the prepuce and the glans and fall apart spontaneously between 3 and 10 years of age. Rinse the area with warm water.
I have actually seen more trouble with subpreputial debris in circumcised boys than in boys left alone. The reason is simple, the sphincter at the opening of the prepuce prevents outside crud from getting in. A circumcised boy has this protective sphincter cut off.
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