Posted in Patient Information

Penile Adhesions in Male Children

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.

Causes

Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).

Symptoms

The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.

Cicatrix

Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Posted in Procedures

Newborn Circumcision

Consent Form

Post Procedure Handout

Equipment List

  1. Gomco circumcision clamps:
    • 1.1 bell + 1.1 base (1 each)
    • 1.3 bell + 1.3 base (1 each)
    • 1.45 bell + 1.45 base (1 each)
    • 1.6 bell + 1.6 base (1 each)
    • Yoke (2 yokes)
    • Nut (2 nuts) 2, because these are easy to drop
  2. Mosquito forceps, curved (2 pair)
  3. Mosquito forceps, straight (1 pair)
  4. Iris scissors, straight (1 pair)
  5. 18 gauge 1.5 inch needle (1)
  6. 27 gauge 1.5 inch needle (1)
  7. Safety pins (2 pins)
  8. 15 Blade disposable scalpel (1)
  9. ChloraPrep 3 ml stick (1)
  10. 1% Lidocaine (withOUT epinephrine) (1 vial)
  11. EMLA Cream (1 tube), if EMLA cream is not available, then 2% Lidocaine hydrochloride jelly is acceptable replacement
  12. Petroleum ointment (Vaseline) (1 tube)
  13. Circumstraint papoose board (1 board) + Leg Straps (1 pair)
  14. Exam-room sheet (1 sheet), or baby blanket (2 blankets)
  15. Nitrile exam gloves (1 pair)
  16. Sterile gloves (2 pair)
  17. Plastic sterile drape with fenestration (1)
  18. Blue sterile drape (1 drape)
  19. Sterile 2×2 gauze (5)
  20. Sterile 4×4 gauze (5)
  21. Alcohol swabs (4)
  22. 1 ml syringe (1)
  23. Xeroform sterile petrolatum gauze dressing (1 package)
  24. Sweet-ease® Sugar Water (1)
  25. Bulb suction device (1)

Pre Procedure Preparation

Sterile Area:

In sterile fasion, place Gomco, sterile gauze, scalpel, safety pins, and all sterile surgical equipment (hemostats, scissors, etc…) on a blue sterile drape.

Non-Sterile Area:

In the 1 ml syringe, draw up 1 ml of 1% lidocaine WITHOUT epinephrine. Label the syringe with the contents (write: 1% lido w/o epi). Keep all remaining equipment unopened in the non-sterile area. Prepare the Papoose board with the leg restraints. Have the Sweet-ease and bulb suction at the head of the board for easy access.

Procedure Note

CIRCUMCISION, GOMCO TECHNIQUE

Parents of infant were counseled on the procedure, and all questions answered. Parents voiced their desire to proceed with the circumcision. Infant was placed on the Papoose board, legs secured with restraining straps, and infant’s upper torso and upper extremities were secured by swaddling with a baby blanket. Timeout performed. After cleansing skin with alcohol swab, 1 mL of 1% lidocaine without epinephrine was injected with a 27 gauge needle in a combination dorsal penile/ring block. Surgical site was sterilized with ChloraPrep and draped in sterile fashion. The foreskin was grasped at 3 and 9 o’clock with the curved mosquito hemostats. The preputial opening was stretched and the synechial adhesion were broken with a straight hemostat. The midline foreskin was clamped for 30 seconds, then a midline dorsal slit was made. The bell-shaped plunger was placed over the glans covering the entire glans. The shaft skin below the corona remained relaxed and supple. The plate of the clamp was applied at the level of the corona. Once in proper alignment the clamp was tightened and a circumferential incision was made with a cold knife. The clamp was left in place for 5 minutes to allow for clotting and coagulation to occur. The clamp was then removed and iodoform gauze was placed at the crush line. Good cosmesis and hemostasis was obtained. Size of Gomco: _. Amount of bleeding: < 1mL. Complications: none.

The infant was observed after the procedure, no further bleeding was noted. One time dose of 10 mg/kg oral baby acetaminophen (160 mg/ml concentration) was given. Handout on circumcision care given to parent, all questions answered. Infant allowed to return to care of parents with return precautions.

References

Newborn Circumcision Techniques – American Family Physician

Posted in Procedures

Vasectomy

Consent

Patient Information

Equipment List

  1. Vasectomy ring clamp (2)
  2. Vasectomy dissector (1)
  3. Mosquito forceps, curved (2 pair)
  4. Mosquito forceps, straight (1 pair)
  5. Iris scissors, straight (1 pair)
  6. Needle driver (1 pair)
  7. Nitrile exam gloves (1 pair)
  8. Sterile gloves (3 pair per provider)
  9. Sterile medium drape (3)
  10. Suture: 4-0 vicryl (2)
  11. Sterile towels (5 towels)
  12. Cautery pen (1)
  13. ChloraPrep 26 ml stick (1)
  14. Foam tape (1 new roll)
  15. Sterile 4×4 gauze (20)
  16. 1% lidocaine without epinephrine (1 vial with minimum 20mL remaining)
  17. 10 ml syringe (2)
  18. 18 gauge 1.5 inch needle (2)
  19. 27 gauge 1.5 inch needle (2)
  20. 15 Blade disposable scalpel (1)
  21. Exam-room sheet (1 sheet)
  22. Chux pads (2)
  23. Formalin cups (2 cups)

Room Preparation

  • Remove any unnecessary items from the room (stool, vitals machine)
  • Clean the room: wipe down all surfaces and wait the appropriate amount of contact time. Vacuum the floor.
  • Ensure the room temperature is set to 70 degrees Fahrenheit.
  • Turn on the surgical light.
  • Prepare a surgical tray in sterile fashion:
    • Medium drape
    • All sterile tools
    • Suture material, cautery pen, ChloraPrep stick, 10 cc syringes, 18 and 27 gauge needles (1 each)
  • Have all other equipment available on top of a chux pad, on top of the equipment drawers.

Patient Preparation

  • Check the patient in, and bring them to an exam room to review and sign the consent form. Once they have had a chance to ask any questions, bring them into the procedure room.
  • Make sure a chux pad is on the procedure table. Have the patient remove pants and underwear, and cover themselves with the sheet.
  • Have the patient apply foam tape to penis securing it against the abdomen.
  • Once provider enters, ensure TIMEOUT occurs.
  • Put on non-sterile gloves. Once provider starts, assist by elevating the scrotum while the provider sterilizes the skin with ChloraPrep. Provider will then place blue towels under and around the region, and finally cover the entire area with a a medium sterile drape to create a sterile field.

After the Procedure

  • Assist the patient with placing gauze over the scrotum and securing it with tape.
  • Answer any last questions, and assist the patient back to the waiting area, ensuring their driver is available or on the way.
  • If specimens were collected, check that they are labelled correctly and bring them to lab.

Procedure Note

VASECTOMY

Pre-procedure counseling completed, including risk discussion of bleeding, infection, need for repeat procedure, chronic pain, failure of sterilization. Timeout completed and documented on paper chart.

An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.

Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed

Under sterile conditions, a 1-2 cm wheal was made at the desired incision site with 1% lidocaine without epinephrine, administered to provide local skin anesthesia. The needle was then advanced through the wheal parallel and adjacent to the _left vas and toward the external inguinal ring. After gentle aspiration to ensure the needle is not in a blood vessel, _ cc of 1% Lidocaine without epinephrine was injected into the external spermatic fascia.

The vas was maneuvered to the desired location, and vas clamp was applied to isolated vas. The soft tissue was then bluntly dissected with a fine cured hemostat. The left vas was elevated and exposed. The vas was hemi-transected. Thermal cautery applied to a 1 cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred. The vas was then completely transected and facial interposition achieved with a metal clip over the prostatic end and the testicular end. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The procedure was repeated on the right vas. The estimated blood loss was <2 cc. Petroleum jelly applied over areas of dissection to provide barrier protection. The patient tolerated the procedure well.

Patient instructed to return 8-12 weeks post procedure for semen analysis, after minimum of 25 ejaculations. Patient agreed and voiced understanding that sterility not confirmed until lab evaluation shows no sperm.

Posted in Patient Information

Vasectomy Patient Information

About the Procedure

A vasectomy is an elective and permanent surgical procedure for male sterility. This procedure may not be the right form of permanent birth control for every man or family. Before getting this procedure an appointment is required to evaluate the following:

  1. The person undergoing the vasectomy expresses a certain level of maturity and understanding about the procedure.
  2. The person undergoing the vasectomy is satisfied with their current number of children and his present personal relationship.

This appointment is also a time when counseling regarding alternative birth control methods, relative risks, benefits, complications, details of the procedure, informed consent and instructions before and after the surgery. After the screening and counseling appointment is completed, a procedure date will be scheduled.

What is a Vasectomy?

A vasectomy is a minor surgical procedure that makes a man sterile (unable to make a woman pregnant). Each year approximately half a million American males undergo a vasectomy.
To begin with, you should have some basic knowledge of the anatomy and physiology of the male reproductive system. Sperms are made in the testicles and are stored next to the testes in tubules called the epididymis. During intercourse, sperm travel from the epididymis through small tubes (vas deferens) to join the seminal and prostate fluid, thus becoming the ejaculate. When the physician performs a vasectomy the vas deferens is cut and the two remaining ends are secured. The object of the procedure is to make it impossible for sperm to become part of the ejaculate. Without sperm in the ejaculate conception cannot take place.

How is the vasectomy done?

The vasectomy is performed in the clinic’s procedure room. Before surgery, a local painkiller will be used to make a portion of the scrotum numb. Your doctor will then make a small opening (incision) in the scrotum. Through this small opening, your doctor gently lifts out each vas deferens and cuts it. The procedure usually takes 40 minutes and causes little pain.

Will I be sterile as soon as the operation is over?

No. Contrary to what many people believe, you will not be sterile immediately after the operation. This is because there are some sperm residing above the area where the vas deferens is cut. Until all the sperm cells have been ejaculated, you will be fertile. In general it takes between 20 to 25 ejaculations following a vasectomy for the sperm to disappear. Most physicians who perform vasectomies require that their patients bring a sample of ejaculate to the office about 12 weeks after surgery. The seminal fluid will be examined under a microscope to be sure that no sperm are present. Only when this has been confirmed can you be sure that the surgery was a success.

Are the effects of surgery permanent?

Yes. Once the surgery has been declared successful, you will be permanently sterile. It should be understood that while this procedure assures sterility initially, in a very small percentage of men the tubes could grow back together. Once a vasectomy has been performed, a reversal procedure would be needed to restore fertility. Reversal is complex, expensive and does not guarantee fertility.

How will the procedure affect my sex life?

Although the vasectomy will make you sterile, it will have no effect on your libido (desire to have sexual intercourse) or on your potency (ability to have sexual intercourse). In fact, many couples find that their sex life improves after the vasectomy because they no longer worry about the surprise of an unwanted pregnancy.

Will I still ejaculate in the normal manner?

Yes. Most of the seminal/prostate fluid, in which the male ejaculates during intercourse, is produced by the seminal vesicles and the prostate gland. Only 5% of the total ejaculate consists of sperm. Therefore, after a vasectomy, ejaculation will take place in the same way as it did before. The only difference is that there will be less fluid ejaculated, and this difference is barely noticed.

Is a vasectomy painful?

As with any operation, no matter how minor, there will be some discomfort associated with it. However, with proper anesthesia, this discomfort will be kept to a minimum. Local anesthesia is used. The vasectomy is done under local anesthesia and with proper anesthesia, the discomfort is kept to minimum. If you are particularly anxious about the procedure, your physician may prescribe a mild sedative for you to take prior to the procedure.

Are there any complications associated with a vasectomy?

The problems that occur after the operation are usually minor. There will be some pain and tenderness in the area where the surgery is performed. There may also be some swelling and discoloration in the area of the surgical site. Your physician may prescribe some type of pain medication to keep the post-surgical discomfort to a minimum.

There are two common complications that may occur shortly after the procedure. As with any surgery, the possibility of infection is always present. In 1 to 3% of patients, infection may occur around the scrotal stitches or in the epididymis. The majority of these are resolved by removing the infected scrotal stitch and rendering local skin care. Rarely, antibiotics may be needed for deeper infections. In a very small percentage of patients (1%), a blood vessel inside the scrotum continues to bleed after the operation. If this happens, the scrotum will swell and become tender. Should you experience this problem, contact your physician. He/She may have to re-open the scrotum to tie off the bleeder. This could require a visit to the hospital and the administration of general anesthesia.

Other complications may arise weeks later. Sperm granuloma which is a lump caused by sperm leaking from the tied end, occurs in 3 to 25% of vasectomies. These usually resolve on their own. Congestive epididymitis (inflammation of the epididymis) or orchitis (inflammation of the testes) are related to lymphatic and vascular congestion. These are treated with an anti-inflammatory medications and resolve in 5 to 7 days. Sperm antibodies may develop which is your body’s response to absorb sperm protein. These are not harmful to you, but may affect the results of the vasectomy reversal procedures. Reunion of the tubes are rare: 1 in 4,000.

Are there any long term complications?

As far as medical science can determine, there are no long-term complications associated with vasectomies.

How soon after the operation can I have sexual intercourse?

You may resume your normal sexual activity as soon as you feel well enough to do so. This will probably be within a few days of the surgery. Remember, however, you may not be sterile until some time after the operation (20-25 ejaculations), and therefore, you should continue to use some form of birth control until you have confirmed all sperm have disappeared from your semen.

Is there anything special I should do before the surgery?

Once you have elected to have the surgery; first, you should discuss it with your spouse. Secondly you should make arrangements with work for 3 days off and light duty for 11 more days. Please read the patient instructions below and follow them carefully.

What about after the operation?

More detailed instructions are below. Basically, for 3 days after the procedure you should be sedentary (sitting, doing very little physical activity). You may then increase activity over the next 2 weeks. You may shower one day after the procedure.

On choosing to have a vasectomy.

The choice to have a vasectomy is a very personal one. Talk with your partner, and think about what is best for you and your family.

• Vasectomy is safer and cheaper than tubal ligation (blocking the fallopian tubes to prevent pregnancy) in
women.

• The one-time cost of a vasectomy may be cheaper over time than the cost of other birth control methods, such as
condoms or the pill.

• A vasectomy does not protect against sexually transmitted diseases (STDs). Use condoms to protect against STDs.

  • Lastly, it is important to note vasectomy is a permanent
    method of birth control. This may be a plus or a minus based on your own situation. You should not have a vasectomy if you may want to father children in the future. While it is
    possible to have a vasectomy reversed, this is more complex and costly. Also, reversing or “undoing” a vasectomy does not always result in pregnancy. So it is important to think through all your choices carefully before deciding to have a vasectomy. Be sure to bring up any questions you may have about the procedure before the surgery takes place.

Patient Instructions

Before the Procedure

  • If you can not be here for your appointment call the clinic so we can reschedule your procedure for another date.
  • The vasectomy is an elective procedure and you must inform your command of your surgery date and obtain permission via special request chit for two (2) days of bed rest and (11) days of light duty. During this period there will be **NO RUNNING, LIFTING (over 15 lbs.), CLIMBING OR PROLONGED STANDING.**If you are on flight status, you will be grounded for 2 weeks and will be required to see your flight surgeon afterwards for an up chit.
  • DO NOT take Aspirin or Ibuprofen (Motrin/Advil) for one full week before your procedure because it can interfere with your body’s ability to effectively stop bleeding.
  • You must bring the following items with you for your surgery:
    • Jock strap or scrotal support.
    • Some one to drive you home.
  • The night before your surgery, shave your scrotum. Take your time and work carefully being careful not to nick the skin. A few warnings:
    • *Do not use Nair or any other hair removal products, unless directed by your physician.
    • *Do not use an electric razor.
  • Take a shower the morning of your procedure.
  • Wear comfortable (loose) clothing the day of your procedure. The uniform of the day is NOT required.
  • Please inform the technician if you have any injuries or infection of your reproductive organs or if you have any medication or solution allergies.

After the Procedure

  • Go directly home after your procedure and remain there on bed rest for at least twenty-four (24) hours. You can get up to go to the bathroom and to eat.
  • You may wash off the surgical disinfectant with a wash cloth when you get home. You may take a shower the next day. Avoid baths for 2 to 3 days.
  • Apply ice to your scrotum for about 20 to 30 minutes every 2-3 hours while awake, for the first 3 days. Then in the evening a couple times each day for the next week. This will reduce swelling and discomfort. Make sure you have a washcloth, towel, etc. between the ice pack and your skin. You should be able to feel the coldness of the ice, but you must avoid freeze injury to the skin.
  • You can take two to three Acetaminophen (Tylenol if you have no allergies to these medications) 325 mg tablets every 4-6 hours as needed for discomfort. This is usually sufficient for any discomfort you will have. If your discomfort is still not well controlled, your physician may also give you a stronger pain medication to take in case of significant pain.
  • You should wear the bulky gauze dressing for 24 hours. After that, the only dressing needed is a dab of bacitracin on each wound with a circular bandaid-which you should change twice per day until sutures are gone.
  • You will begin your light duty the day you return to work following your vasectomy. Remember, NO RUNNING, NO PROLONGED STANDING, NO CLIMBING OR LIFTING (over 15 lbs.).
  • You may have a small amount of bleeding or oozing from your incision. There may also be some bruising or discoloration in the scrotum. If you develop severe pain or significant enlargement of the scrotum contact your provider, go to urgent care, or the ER if unable to reach provider!
  • Your stitches/sutures (if placed) will dissolve in about 7 to 14 days. You may notice a small amount of brownish drainage (usually a few spots on your underwear as the stitch dissolve).
  • Inspect the vasectomy incision daily for signs of infection. The signs of infection are: fever, redness around the incision, tenderness, pus or drainage, or pain (significantly greater than what you have been experiencing after the procedure).
  • Wait one week, then you may resume sexual activity when you feel comfortable. Do not forget to use some form of birth control until you get the results of your semen analysis.
  • After 12 weeks, return to the lab to submit a semen specimen for analysis. Only after the results show no sperm is the procedure considered a success.