Non-surgical Separation of Preputial Adhesions

Lancet, Volume 8398, Issue 2, Page 344. Saturday, 11 August 1984.

Griffiths DM, Freeman NV

Sir, - We should like to report our outpatient technique for the separation of preputial adhesions using specially prepared lignocaine cream 25% (1 g lignocaine hydrocloride in 4 g cetomacrogol) in a tube with a long nozzle.

An explanation is given to the parents and child and the child placed on a couch. The parent stands at the head of the couch, holding the boy's hand and trying to distract his attention. An important point is to warn the boy that the procedure may sting or hurt a little. We talk to the child, reassuring him all the time whilst applying the cream to the juncture of foreskin and glans and under the foreskin if any separation has occurred. A momentary stinging sensation may be felt on application (mainly at the area of the urethral meatus) or on freeing any adhesions, but one cream is applied to the raw area anaesthesia is almost instantaneous. Separation is done, until the entire glans is exposed, by retracting the foreskin from the glans using a gauze swab or the nozzle of the tube as a probe. As each area separates more cream is applied; usually 0.5-1.0 g is needed. No side effects of lignocaine absorption have been noted. Most mothers and children tolerate the procedure well. Afterwards, the mothers are instructed to wait 24-36 h and then continue with full retraction daily after a hot bath. Chloramphemicol eye ointment is applied to the raw surface of the glans and foreskin for 2-3 weeks, to prevent readherence while epithelialisation occurs.

Since Gairdner's classic paper,¹ most people would agree to leaving the foreskin alone until the age of 3-4 years. After this gentle retraction should be started to separate any remaining normal preputial adhesions to allow routine penile hygiene. To facilitate this, Gairdner used a probe with no anaesthetic whereas others use a general anaesthetic.²

Note:

The authors rely on Gairdner's 1949 data, which we now know is incorrect. The normal infant preputial fusion with the glans frequently lingers into late childhood and adolesence without adverse effect. No treatment is necessary in the absence of symptoms.

The procedure we describe is safe, simple, relatively atraumatic, cheap, and easily repeated if adhesions recur. Only 4 boys (2.5%) came to circumcision and can be regarded as failures. Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1.

Wider adoption of this procedure would save money spent on hospital admissions and anaesthetics and possibly reduce the number of unnecessary circumcisions.

References

Gairdner D. The fate of the foreskin. Br Med J 1949; ii, 1433.
Cooper G C, Thompson GJC, Raine PAM. Therapeutic retraction of the foreskin in children. Br Med J 1983; 266: 186-87.

Citation:

Griffiths DM, Freeman NV. Non-surgical Separation of Preputial Adhesions. Lancet. 1984-08-11;8398(2):344.

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