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Adhesions - What are They?
"The new study by Van Howe just out in the BJU found that 29.7% of circumcisedboys under three years of age have adhesions or skin bridges. They are acomplication 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 circumcisedpenis is maintenance free and do not attend to penile hygiene when theirson is circumcised. The foreskin has protective functions that are not availablewhen the boy is circumcised.
The penis is still in a developmental stage when boys are born. The foreskinand the underlying glans develop as one unit. They are bonded together bya common membrane. When left alone they naturally separate into separateparts after the boy is three or more years old.
When an infant circumcision is performed these parts, which are united andbonded together must be torn apart as one tears Velcro apart. This leavestwo raw surfaces - the surface of the glans and the inside of the foreskin.This part of the circumcision is called a synechtomy because the synechialmembrane, which joins the two tissues is removed.
When a circumcision on an infant boy is done, good procedure calls for theforeskin to be cut short enough that it will not overlay the glans. If theforeskin is cut long, the two raw surfaces will heal together and cause anadhesion. This adhesion has no interstitial synechial membrane and will notbreak down.
A normal healthy circumcision, even with a long residual foreskin, wouldleave 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 bepresent 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 adhesionswithout pain. Adhesions can be separated non-surgically.EMLAcream, a topical anesthesia, is applied to the penis. After one hourthe doctor breaks the adhesions. Then the glans is kept coated with vaselinefor 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 iscomplete one would think that there would be no further problem with adhesionsforming. But that may not be the case. It seems that adhesions may reformlater even though the area has healed.
There is little medical advice available on this problem but Dr. Van Howewrites that "the circumcised boy needs to have any skin overlaying the glanspulled back and cleaned regularly until 15-18 months of age to prevent adhesionsfrom reforming and debris from accumulating." He says the debris consistsof "lint, dirt, talc, stool and detritus." He found strong association betweencoronal adhesions and the presence of subpreputial debris. Dr. Van Howe statesthat most preputial adhesions in circumcised boys resolve by 24 months "afterparents 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 thanthe intact normal penis which is protected by the preputial spincter andis cleaned by the swirling urine, and thus requires no special care, accordingto Dr. Van Howe.
The foreskin is relatively longest at birth; as the penis grows the apparentlength of the foreskin lessens. Circumcised baby boys who have a coveredor partially covered glans probably will lose that coverage as they mature.Parents should be aware that the appearance of the penis in infancy doesnot reflect the appearance of the penis in later life. Dr. Van Howe statesthat "revision of the circumcision for purely cosmetic reasons should bediscouraged on both medical and ethical grounds."
Parents of circumcised children will also want to obtain the new PamphletNumber 5 about the circumcised penis from NOCIRC, P. O. Box 2512, San Anselmo,CA 94979-2512. It was published in October 1997. The phone number is415-488-9883.
George Hill, a NOCIRC representative
Reference:
British Journal of Urology, Volume 80: pages 776-782. (November 1997)
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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 synichiae (spelling?) betweenthe inner lining of the prepuce and the glans and fall apart spontaneouslybetween 3 and 10 years of age. Rinse the area with warm water.
I have actually seen more trouble with subpreputial debris in circumcisedboys than in boys left alone. The reason is simple, the sphincter at theopening of the prepuce prevents outside crud from getting in. A circumcisedboy has this protective sphincter cut off.
He is also more likely to get an infection in that area than an intact boyfor the same reason. These can be treated topically." Dr. Robert VanHowe
<<<Yes he is circumcised. He is 21 months old. His penis is quitesmall. He is a big boy, so he has that extra layer of fat there. His skinseems to come back up and almost cover the head. But like I said, the headwon't "pop" all the way out. I have not tried to force it so far. I was assumingthat since it would naturally retract if he had been intact, that maybe thatis what it will still do.>>>
No, the foreskin that is left intact is naturally fused to the glans. Retractionoccurs gradually in stages. Usually, full retraction is not possible untilsomewhere between the ages of 3 and 5. It can take much longer though andthat in itself is not a problem.
First, I will remind you that I am not a doctor or medical professional.It is difficult to say with complete certainty exactly what your son’ssituation is with limited information sight unseen. It sounds like the foreskinremnant is trying to do its job of protecting the glans. This seems to bea very common complication of circumcision.
According to a study conducted by Dr. Robert Van Howe, it appears that inmost cases the situation corrects itself as the child grows older. From whatlittle you've described, it very possible that your son may have no problemat this point. If he has a good bit of foreskin remaining, you might be ableto treat him the same way you would if he were intact. In a separate e-mail,I can send you a pamphlet on care of the uncircumcised.
But if you are concerned, to ease your mind, it may be a good idea to seea doctor. Be forewarned, however, that some doctors will attempt to forcefullyseparate the remaining foreskin. This could cause a great deal of pain, bleedingand damage. I would try to find a “foreskin friendly” doctor.Otherwise, you may end up with a doctor who wants to do something radical,painful (physically & pshychologically) and unnecessary. This is a repeat that follows: Some are likely tosuggest additional surgery even though there is a simple in-patient techniquethat separates adhesions without pain. I can send you information on thetechnique if you are interested, which you could then pass on to your doctorif he was not aware of it.
Additionally, I sent you a separate e-mail. In it, people sought and receivedadvice from others regarding this problem. I know I sent you a similar setof notes the other day, but this one is in addition to the previous one.
A Personal Account
My husband and I have adopted six children, four boys and two girls. Ourfirst son came to us intact, which was quite rare with that agency at thetime. When we applied for our second child, I told the social worker thatwe absolutely would not want a boy of ours circumcised. My wishes were givenno consideration what ever.
In the months before Allan was born, I had dreams kind of like the one youdescribed, of my baby being circumcised. I would see him strapped down ina surgical suite. I was standing in the doorway, but others were holdingme so that I could not get to him. When they started cutting, Allan startedto scream and so did I, but I was rendered totally helpless to save him.The other people there were just going about their business, acting as ifthey couldn't even hear the screams.
When we got Allan, I found that the dream had actually taken place. My babyhad been circumcised. After that, instead of calling us to come get him,the agency decided to put him in a foster home. They did not call us to pickhim up until he was four weeks old.
When I first saw him, I couldn't tell for sure if he had been circumcisedfor sure. This was partly because the only intact baby I'd seen at that timewas my first son, whom I have since learned had a shorter than average foreskin,and partly because most of his glans was covered.
I took him to our pediatrician, whom I thought was educated about littleboys' penises, since he had never advised forcing back my first son's foreskin.When he saw Allan, he told me that the foster mother hadn't taken care ofhis circumcision properly and he would have to break the adhesions. Withouteven giving me a second to think, he started pushing and pulling. Allan screamedhis heart out and his penis bled. I knew that what I was witnessing was onlya small part of what had taken place earlier. I felt so helpless that someonehad intentionally done such a thing to my child, despite my efforts to protecthim. If the social worker who was responsible for him being circumcised hadwalked through the door at that moment, I think the 120 pounds of me wouldhave strangled the 6'6", 250 pound of him!
The pediatrician told me to push back the foreskin stump every day and putointment on it. I did this for a few weeks, but it had always started tostick back down. Allan always screamed and I always felt the same helplessnessand anger. Finally, I decided that I was just not going to do it anymore.I wondered if Allan's foreskin, what was left of it, was just trying to developnormally . I also decided that, even if it meant more intervention in thefuture, I was not going to allow him to have his penis hurt anymore. I leftit alone and the foreskin stump stuck back down. The redness went away and,for the first time, his penis did not hurt him. By the time he was three,it had unattached itself.
I tell this story when I get the chance because I know that there are lotsof boys who are being tortured in this manner. It is enough that they havebeen circumcised! It is totally unconscionable that they are put throughrepeated trauma.
I feel pretty confident now, advising parents that what is left of theirsons' foreskin may try to develop as if the rest of it were intact and thatthey do not have to keep hurting their sons. Dr. Robert Van Howe has toldme about other such cases too.
Feel free to quote me, and I am happy to be identified. Although I understandwhy some people don't want to be identified, I think being willing to beopen about it lends more credibility.
Sstar@vii.com (Darillyn Starr)
6/8/97
Last Revised: 4/1/98