Apr 9, 2019
Adult circumcisions are common in the Mid-Atlantic for men who never received a circumcision as a baby boy. The reasoning? Some men feel self-conscious about the way they look, while others develop skin conditions. Dr. Krishnan Venkatesan discusses the procedure and what men can expect during recovery.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan.
Dr. Krishnan Venkatesan: Hi. Thank you for having me.
Host: Today we’re discussing adult circumcision, a reconstructive procedure that, while not widely discussed, is growing in popularity among men in the Mid-Atlantic region. Dr. Venkatesan, could you start by explaining what circumcision is for listeners who might not know?
Dr. Venkatesan: Of course. Circumcision is basically removal of excess foreskin from the shaft of the penis. It can be done for many different reasons, which I think we’ll delve into later in this conversation.
Host: So, in the U.S., circumcision is typically performed on baby boys, so why are more men requesting the procedure, as adults, when they’ve been uncircumcised all their lives?
Dr. Venkatesan: There could be many reasons to undergo circumcision as an adult. Sometimes there are specific medical conditions. One is called phimosis, where the foreskin is actually tight and can trap urine underneath the skin and cause inflammation or infection of the head of the penis or the skin or even in the urinary tract. Sometimes, if they have warts or genital warts, men may want circumcision to have those removed. There are also other skin conditions. Lichen sclerosus is an immune mediated skin condition. We actually don’t know exactly what causes it, but basically, it can cause some scarring of the foreskin so the skin gets very tight around the shaft of the penis and onto the head of the penis and some patients may even feel that the head of the penis itself, the skin has lost its elasticity and instead of having a lot of small folds, it’s very flat and shiny, and some patients even will experience itching of the head of the penis, especially after sex, or even some fissures, like cracks in the skin, that can get very irritated after sex or even if the area is manipulated too much. In about twenty percent of those patients, they can also involve the opening of the penis where men urinate from and this can have other implications along the urinary tract, as well. All in all, circumcision is popular here in the U.S. and it’s not practiced that widely in the rest of the world. So, there are otherwise some social reasons that men tend to request circumcision, mainly because they’re self-conscious about being in a locker room or in a team shower or something, if they play sports, where some men may be circumcised, and some are not and they don’t really want to stick out.
Host: Do you ever have men come in who are concerned what their partners might think or their sexual partners might think? Could you address that?
Dr. Venkatesan: Yeah, absolutely. And that kind of goes along that social line that because, overwhelmingly, large number of men are circumcised in the U.S., men may worry that female partners may find it unusual or abnormal and because of that, they may feel more self-conscious about it. And they may also find that it’s less pleasing in intercourse or, in some cases, they may find that it’s uncomfortable for intercourse because the skin is getting irritated or something.
Host: If a man grows up this way his whole life, he’s uncircumcised his whole life, if he chooses to remain uncircumcised, are there any health implications to be concerned about there?
Dr. Venkatesan: No. There is evidence that suggests that circumcision at a young age, before puberty, can have some protective effect as far as decreasing the risk of penile cancer. But, in adult men who have already undergone puberty, there’s no significant benefit to circumcision at that point. The cancer of the penis is very rare, regardless, so as long as they maintain good hygiene and examine themselves reasonably frequently, then they should be able to avoid any serious problems from something like cancer of the penis. I would also like to say that, in other parts of the world, not the U.S., that circumcision sometimes is used as a means of HIV prevention or prevention of transmitting any other sexually transmitted diseases. That has been shown to have a benefit in places where HIV is endemic, like in Africa, but from a medical standpoint, otherwise, there’s no reason that it has to be done in childhood.
Host: Approximately how many adult circumcisions are performed at MedStar Washington Hospital Center each year?
Dr. Venkatesan: I’d say we probably do somewhere between fifty and a hundred a year, between myself and all of my colleagues. Like I said, there’s a wide number of reasons that we do them. Some are more for social reasons and others are for specific medical problems.
Host: Could you describe your patient population for adult circumcision? Are these men young adults, middle-aged, teenagers?
Dr. Venkatesan: Yeah. There’s a wide range of men who come in seeking circumcision. Quite often, there are young men in their late teens or early twenties who were not circumcised as children but, as they are moving out of home or becoming sexually active and exploring that realm, so to speak, they recognize that they’re different from their friends or colleagues and they want to have less inhibitions or less to be self-conscious about it, and they come in seeking it. And, similarly, there are men with medical conditions that can occur at any age, including tightness of the foreskin, or other skin conditions like lichen sclerosus, that need circumcision for actual medical treatment. And there’s no specific age range where it’s right or wrong for them to come in to seek that treatment.
Host: What questions do patients or their partners ask about adult circumcision?
Dr. Venkatesan: The main question they ask, of course, is whether it will be painful. And, like any surgery, there will be some discomfort initially, but typically the healing period is relatively short and within a month after surgery most men are back in normal function and form. I think the main other questions are whether it will cause any effect on sexual function or urination. And, typically, it shouldn’t have any effect of either of those things.
Host: What are some of the risks that are involved with adult circumcision?
Dr. Venkatesan: The risks involved with circumcision include general risks of any surgery, like infection and bleeding, and then, of course, risks associated with the specific area we’re operating on. So, there’s always a risk of needing further surgery if the patient is not happy with the cosmetic outcome. And also, risks of the stitches coming apart or having some scarring requiring further surgery. There’s a pretty low chance of any deeper structures in the penis being affected, like the urinary tract, or any nerves that would provide some function for sexual function or anything like that or sensation. Of course, there are risks with any anesthesia, as well.
Host: What does a patient have to do to prepare for this procedure?
Dr. Venkatesan: I would think that the main preparation really ought to be consulting with their urologist beforehand and understanding the risks of the procedure, the indications for the procedure, and the expected recovery. But other than that, there’s nothing they need to do at home as far as physical preparation or diet or anything like that.
Host: Could you describe how the procedure’s performed?
Dr. Venkatesan: Yeah, absolutely. We basically make two parallel incisions around the circumference of the penis - one upstream from the skin we want to remove and one downstream from the skin we want to remove. And, then we basically unwrap that part of the skin off of the shaft of the penis. And, then the two edges that are remaining, we sew them back together.
Host: What does recovery entail? For example, are there restrictions for having sex, using the bathroom, or exercising?
Dr. Venkatesan: The recovery usually does entail some activity restrictions. We don’t typically leave a catheter or anything like that, so the patient should be able to urinate on their own immediately after surgery and use the restroom, otherwise, without difficulty. I do typically ask my patients to refrain from any sexual activities for about four weeks while the stitches and the incision are healing up. And similarly, for that first couple of weeks, I’d like them to avoid any heavy exercise mainly to avoid any sweating or strain or stress on the incision that might affect it’s healing. We typically do send patients home with some pain medication and some antibiotics. The expectation, for the most part, is that patients generally will not need any narcotic pain medication beyond one week after surgery. By that point, they’re usually up and around doing most of their normal activities, aside from the other activity restrictions that I had described. And, usually by that point, aside from specific, unique jobs that may require further activity restrictions, most patients will usually be able to go back to work within that one week.
Host: Could you share a story from your practice? Perhaps you had a man come in requesting this procedure and was incredibly happy with the results?
Dr. Venkatesan: Yeah. I can recall specifically one man who was in his 50s and diabetic and, as I had described earlier, he had a very tight foreskin so he was getting frequent infections with urine getting trapped between the skin and the head of the penis. And, once we did a circumcision, he was basically infection-free and symptom-free and he was able to maintain much better hygiene there and, overall, was quite happy with the results within a month after surgery.
Host: Like anybody, men would have a specific hygiene regimen prior to being circumcised. Is there anything in that regimen that would have to change or that they would do differently after they were circumcised?
Dr. Venkatesan: No. So, I suspect and expect that hygiene maintenance after circumcision should actually be easier than before circumcision basically because, before circumcision, men would have to pull back the foreskin and really ensure that every crevice and fold of skin is properly cleaned and scrubbed. After circumcision, there’s no excess skin, so the skin covering the shaft of the penis basically has a very smooth transition and should be very easy to clean. Everything’s that there, visible to the eye, can be cleaned easily and there’s... much easier not to miss anything.
Host: Why is MedStar Washington Hospital Center uniquely positioned to take care of men who want to have circumcision as an adult?
Dr. Venkatesan: I think we’re in a strong, unique position to take care of adult men requiring circumcision because we are a tertiary care referral center in our Dept. of Urology. We see patients with very complex problems including complicated skin conditions that require circumcision and reconstruction of the penile shaft and skin. And we see a wide range of men, even ranging to men with no significant problems but who have straightforward circumcisions. But, based on our skill set and the complexity of things that we do and the volume that we do, I think that we are positioned well to offer patients good preoperative counseling and good postoperative outcomes.
Host: Thanks for joining us today, Dr. Venkatesan.
Dr. Venkatesan: My pleasure.
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