Male adult circumcision

INTRODUCTION — Male circumcision, consisting of the surgical removal of the penile prepuce (foreskin) [1], has been dated back to the prehistoric era [2,3].

Circumcision is often performed as a part of a religious practice, such as in Judaism [4,5] and Islam [6,7], or as part of a sociocultural practice in many countries worldwide [6,8,9]. Regardless, such practices are most often performed during the neonatal or prepubertal ages.

Male adult circumcision (MAC) is performed for a variety of indications, including penile and preputial pathology, disease prevention (mainly sexually transmitted infections [STIs] and human immunodeficiency virus [HIV]), and sexual dysfunction, as well as personal preference.

This topic will focus on the epidemiology, indications, surgical anatomy and techniques, perioperative care, and special considerations surrounding circumcision for the adult male.

Female circumcision, also known as female genital cutting or female genital mutilation, is a culturally determined practice predominantly performed in parts of Africa and Asia. (See "Female genital cutting".)

Neonatal circumcision is discussed in separate topics:

●(See "Neonatal circumcision: Techniques".)

●(See "Neonatal circumcision: Risks and benefits".)

●(See "Complications of circumcision".)

EPIDEMIOLOGY — By various estimates, 37 to 39 percent of men globally are circumcised [10,11]. The rate of male circumcision varies widely with geographic locations, from 0.1 percent in Armenia, Iceland, several Central and South American and Caribbean countries, as well as several islands of the South Pacific to ≥90 percent in countries with a large Islamic population, located primarily in North and West Africa, the Middle East, and Southeast Asia, as well as in Israel [10-12]. It is estimated that about 80 percent of American men are circumcised [9-12].

Globally, 70 percent of circumcisions are performed for religious purposes, and 30 percent are performed for nonreligious purposes [9]. The United States has the highest rate of circumcision performed for nonreligious purposes. Circumcision gained popularity in the United States in the late 19^th century, with the publication of pro-circumcision literature that promoted circumcision as a means to maintain good hygiene, treat phimosis, and prevent masturbation [13,14]. Circumcision rates in the United States have slightly declined over the first decade of the 21^st century, except for patients covered by private insurance [15].

In an analysis of 202 patients, the most common indications for MAC included phimosis in 46.5 percent, dyspareunia in 17.8 percent, balanitis in 14.4 percent, and both balanitis and phimosis in 8.9 percent [16]. Patients over 50 years of age were more likely to undergo circumcision for concurrent phimosis and balanitis or cancer, whereas most younger patients sought circumcision for dyspareunia.

PENILE ANATOMY — The penile shaft contains three tubular structures, including the dorsal paired erectile bodies (corpora cavernosa) and the ventral central corpus spongiosum, which contains the urethra and forms the glans penis distally (figure 1). The urethra opens within the glans to form the urinary (urethral) meatus.

The paired common penile arteries and terminal branches of the internal pudendal artery (internal iliac artery) trifurcate into (1) the dorsal penile arteries, (2) the cavernosal arteries (central arteries that run through the corpora cavernosa), and (3) the bulbospongiosal arteries (ventral arteries that run along either side of the corpus spongiosum). Along with the dorsal penile nerves and the dorsal vein of the penis, the dorsal arteries form the penile neurovascular bundle. The penile nerves (pudendal nerve branches) run along the penile shaft at 1 and 11 o'clock positions, deep to Buck's fascia, and originate through the Alcock canal on either side. These nerves can be anesthetized by local anesthetic infiltration, providing adequate pain control for performing circumcision under local anesthesia in the adult patient (figure 2) [17]. (See 'Penile nerve block technique' below.)

The penile skin is supplied dorsally by the superficial external pudendal arteries (femoral artery) and ventrally by the posterior scrotal artery (internal pudendal artery). The penile skin folds over itself just proximal to the corona to form the prepuce (foreskin). The foreskin is formed by two outer layers of continuous penile skin, separated by a central layer of Dartos fascia (figure 3). The frenulum is an adherence of skin between the inner layer of the prepuce and the ventral base of the glans, located at 6 o'clock. The penile skin provides continuous coverage of the glans penis. The Dartos fascia, which is continuous with Scarpa's fascia of the abdomen and Colles' fascia of the perineum, is a highly vascular layer of connective tissue that runs under the penile skin and contains the superficial dorsal vein of the penis.

INDICATIONS

Penile pathology — Indications for male adult circumcision (MAC) are vast and consist of infectious, inflammatory, anatomic, or malignant pathologies of the prepuce, the glans, and the urinary tract. All of these pathologies may occur at any age of adult life, although circumcision for phimosis, balanitis, and penile malignancies is performed more often in older men [16,18].

Phimosis — Phimosis, a constriction of the foreskin that narrows its opening and prevents it from being retracted to uncover the glans, is the most common indication for MAC; 44 to 47 percent of MACs performed in non-HIV-endemic areas are due to phimosis [16,19].

Phimosis may be caused by lichen sclerosus or chronic balanoposthitis or may be idiopathic in origin [20]. Phimosis has also been shown to be associated with diabetes mellitus in adults and may be a presenting sign of the disease [21,22]. In a prospective study of 100 patients presenting with adult-acquired phimosis, 12 percent were diagnosed with a de novo disorder of glycemic control [21]. Thus, any patient presenting with adult-onset phimosis should undergo diabetes screening by their primary care provider.

Paraphimosis — Paraphimosis is an emergency condition that occurs when the foreskin is pulled back and cannot be reduced to its anatomic position. It can lead to painful swelling of the foreskin and glans and even ischemia and necrosis of these structures if not treated promptly [22]. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment", section on 'Definition'.)

In adults, paraphimosis may be associated with phimosis and may occur after a forceful attempt to retract the foreskin to expose the glans. Paraphimosis may also occur after sexual activity [23] or may be caused after the foreskin was retracted for cleaning or medical purposes (eg, to place a urinary catheter) and was not returned to its proper position. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment", section on 'Causes'.)

In most cases, paraphimosis may be treated in the emergency department by manual reduction. A dorsal slit or an urgent circumcision may be warranted in cases where manual reduction is unsuccessful or necrosis of the foreskin has already occurred. Elective circumcision may also be considered after a resolved case of paraphimosis, especially if phimosis is present, to prevent recurrence. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment", section on 'Treatment'.)

Balanitis and balanoposthitis — Balanitis is an inflammatory condition of the glans penis that may be acute or chronic. Balanoposthitis occurs when there is involvement of the prepuce. In adult men, balanitis may be caused by poor hygiene, fungal and bacterial infections [24], contact dermatitis [25], or primary syphilis [26,27]. (See "Balanitis in adults".)

Initial treatment of balanitis includes improved hygiene measures, topical antibacterial or antifungal creams, removal of the inciting agent in cases of dermatitis, or treatment of syphilis using systemic antibiotics [24-27]. Circumcision may be considered in cases of recurrent or chronic balanitis. Chronic balanoposthitis may also cause phimosis [28]. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis".)

Lichen sclerosus — Lichen sclerosus is a chronic, inflammatory, idiopathic condition that affects the external genitalia in both males and females. In males, this hypomelanocytic disease causes a characteristic whitish decoloration of the glans and the foreskin and may cause phimosis and meatal stenosis as well. In severe forms of the disease, termed balanitis xerotica obliterans, the fossa navicularis and penile urethra may also be affected, causing urethral stricture [28,29].

Circumcision may sometimes be curative, but long-term prophylactic treatment with topical steroids, or topical tacrolimus in very severe cases, is recommended to prevent recurrence [28,30]. In suspected cases of lichen sclerosus, it is important to send the circumcision specimen for pathologic analysis as the disease has been associated with squamous cell carcinoma of the penis and urethra [31,32]. Long-term surveillance of patients with a history of lichen sclerosus is therefore recommended.

Urinary tract infections and prostatitis — Although circumcision has been shown to decrease the risk of urinary tract infections (UTIs) in male infants [33,34], there is no evidence that MAC decreases UTI rates in males older than one year of age. Phimosis has been shown, however, to increase the risk of bacterial colonization of the prostate, leading to prostatitis [35]. In the setting of recurrent UTIs and obstructive voiding caused by phimosis, MAC may be considered as a treatment option.

Zoon balanitis — Zoon balanitis (plasma cell balanitis) is an erythematous, benign cutaneous disease of the penile glans, which occurs solely in uncircumcised men. These well-circumscribed, shiny red lesions are usually asymptomatic [36,37]. Circumcision is often curative [38,39]. Topical therapies, such as steroids [40,41] and tacrolimus [42,43], and laser therapy using the CO₂ laser [44,45] or the Erbium:YAG laser [46-48] may treat the lesions if the patient is averse to circumcision. A biopsy of the lesion is necessary to confirm the diagnosis of Zoon balanitis as the differential diagnosis includes premalignant and malignant lesions of the penis [28]. (See "Balanitis in adults".)

Genital condyloma — Genital warts, or condyloma, are caused by human papillomavirus (HPV) strains 6 and 11 in 90 percent of cases [49]. A variety of topical and laser treatments are available to treat these lesions [50]. Surgical excision is also a treatment option with good success rates [51] and has been shown to be cost effective [52]. Circumcision may be necessary if there is a significant burden of disease on the foreskin. Furthermore, circumcision has been shown to decrease HPV transmission rates [53-55]. However, the Gardasil vaccine also protects against HPV strains 6 and 11 [49]. (See "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in adult males".)

Malignant lesions of the foreskin — Squamous cell carcinoma in situ of the glans penis and foreskin, named erythroplasia of Queyrat, is a well-circumscribed, erythematous lesion occurring almost exclusively in uncircumcised men [56,57]. If the lesion is limited to the foreskin, surgical excision with 5 mm margins or circumcision may be curative [58]. Untreated lesions may progress to invasive squamous cell carcinoma [32]. Nonsurgical treatment options, including topical creams (5-fluoruracil [5-FU], imiquimod) [59-61], laser ablation (the CO₂ laser has been shown to have the best outcomes) [61-63], and glans resurfacing [64], may be considered if the lesion involves the glans penis.

Prevention

Sexually transmitted infections — Circumcision has been shown to reduce the rates of some sexually transmitted infections, including syphilis and chancroid, and possibly herpes simplex virus type 2 (HSV-2) [65,66]. It is controversial whether or not circumcision is protective against chlamydial and gonococcal infections [66,67]. As previously mentioned, circumcision also decreases transmission rates for HPV strains 6 and 11 [53-55]. Circumcision, however, is not a substitute for safe sexual practices, for which at-risk patients should be regularly counseled. (See "Prevention of sexually transmitted infections".)

HIV transmission — Multiple randomized trials have shown that circumcision reduces the risk of HIV infection by up to 60 percent [68-71], prompting the World Health Organization (WHO) Joint United Nations Programme on HIV/AIDS (UNAIDS) to recommend male circumcision in all countries with high HIV prevalence, mostly located in sub-Saharan Africa [9]. Over the past decade, demand for circumcision has risen in these countries [72], and devices facilitating safe and rapid MAC have been developed [73]. However, circumcision alone is not sufficient, and other preventative measures such as education, condom distribution, and prevention of mother-to-child transmission using antiretrovirals are also necessary to control the HIV epidemic [9]. (See "HIV infection: Risk factors and prevention strategies".)

Penile carcinoma — As mentioned above, penile carcinoma occurs almost exclusively in uncircumcised men [56,57]. However, the role of MAC in cancer prevention has not been established, as the protective effect of circumcision seems to be limited to men who have been circumcised before childhood and adolescence. Furthermore, this protective effect was no longer present when boys with a history of phimosis were excluded [74]. Poor penile hygiene, phimosis, tobacco use, multiple sexual partners, and HPV infection are other modifiable risk factors for penile carcinoma [75-77].

Aesthetics and sexual function — Penile aesthetics and sexual function are popular nonmedical reasons for MAC; 95 percent of men seeking MAC in the private health care sector of the United States are "motivated by cosmetic, aesthetic, and social reasons" [78]. In Canada, where circumcision must be medically justified to be covered by the public healthcare sector, the most common indication for circumcision in young men (aged less than 50 years) is dyspareunia [16].

A study of 42 men undergoing MAC for religious or cosmetic reasons showed no difference in pre- and post-circumcision sexual satisfaction scores on a standardized questionnaire, with the only difference being a longer ejaculatory latency time after circumcision, which can be subjectively perceived as a benefit rather than a disadvantage [79]. It is important to note that, although penile sensation improved in over one-third of men after MAC, 18 percent of patients suffered from decreased penile sensation after circumcision [80], which could explain the increased ejaculatory latency time. This information must be appropriately conveyed to patients before MAC for any indication.

PREOPERATIVE TESTING — Male adult circumcision (MAC) is often performed under local anesthesia in an outpatient setting. In this case, only a complete history and physical examination is required before surgery. History of a personal or familial bleeding disorder is important to elicit. During a mass adult circumcision program in Uganda, three cases of previously undiagnosed hemophilia A were diagnosed by prolonged post-circumcision bleeding requiring hospital admission and blood transfusion [81].

For procedures that will be performed under general anesthesia, routine preoperative testing as recommended by the local facility is sufficient, with additional testing or consultations to be requested according to specific patient risk factors.

SURGICAL TECHNIQUES — Numerous surgical techniques exist for male adult circumcision (MAC), and it is important to choose the technique that the surgeon is most comfortable performing. Although it is a relatively simple and rapid procedure, complications arising from improperly conducted MAC can be disastrous. (See 'Complications' below.)

Standard surgical techniques of MAC were compared with circumcision devices in a 2021 Cochrane review [82]. The use of circumcision devices was associated with a shorter procedure time (by about 17 minutes), lower pain scores during the first 24 hours, and greater patient satisfaction, but more moderate adverse events. No serious adverse events were reported with either method.

Penile nerve block technique — As previously stated, most MAC procedures are performed under local anesthesia. A penile nerve block including a ring block is likely the most effective and complete method of local anesthesia for MAC [17,83,84].

Many types and combinations of local anesthesia have been used to perform a penile nerve block. In our center, we use a combination of a 1:1 solution of a short-acting (1% lidocaine) and a long-acting agent (0.25% bupivacaine) without epinephrine. This allows for rapid onset of the anesthetic agent as well as prolonged postoperative analgesia (four to eight hours). Penile nerve block is traditionally performed with local anesthetic agents not containing epinephrine, although some studies have shown epinephrine to be safe [85].

The penile block is performed in a sterile fashion, using a small-bore needle, typically 23 to 27 G. The penis is put on stretch, and the injection sites are at 1 and 11 o'clock at the dorsal base of the penile shaft (figure 2). The needle is inserted at a perpendicular angle and advanced until contact with the pubic bone is felt. The needle is then pulled back slightly, remaining beneath Buck's fascia where the dorsal penile nerves are located. After aspiration, the solution is slowly injected (approximately 5 mL of solution is sufficient). To perform a ring block, the needle is then pulled back further to the subcutaneous tissues, and circumferential injection around the base of the penis ventrally, laterally, and dorsally is performed, using another 5 mL of local anesthetic. Care is taken not to injure the urethra ventrally. The needle is then removed, and the procedure is repeated on the contralateral side. A total of 20 mL is typically used. This provides rapid and complete local anesthesia to the penis with only two needle punctures. Skin analgesia is confirmed with a "pinch test" using toothed forceps before proceeding with the incision.

In cases performed under general anesthesia, a nerve block should still be performed for postoperative analgesia. In this case, straight bupivacaine may be used.

Sleeve technique — In most cases, we use the sleeve technique for MAC. After local anesthesia and skin asepsis are performed, the two incision sites are marked circumferentially, the first one on the mucosal side of the foreskin with the prepuce in a retracted position, leaving a 5 to 10 mm cuff around the base of the corona, and following the natural V shape of the frenulum on the ventral side. The second skin marking is then made on the outer aspect of the foreskin around the base of the corona while it is reduced back to its normal position (figure 4). It is important not to remove too much preputial skin, as penile shortening and tethering may occur postoperatively.

Both incisions are made with a #15 scalpel blade and carried through the Dartos fascia (figure 3). Extreme caution is necessary when performing the ventral incision with the foreskin reduced as the urethra may be injured if the incision is too deep. The foreskin is then incised in a longitudinal fashion, adjoining both circumferential incisions, and is resected circumferentially using either scissors or electrocautery. The foreskin is usually sent to pathology for formal analysis, especially if there is underlying preputial disease.

Hemostasis is performed using monopolar or bipolar electrocautery. The skin edges are then approximated using interrupted 4-0 or 5-0 resorbable sutures (typically chromic gut, polyglactin 910 [Vicryl or Vicryl Rapide], or poliglecaprone 25 [Monocryl]) on a cutting needle. The frenulum can be elongated by closing its V-shaped edges longitudinally.

Dorsal-slit technique — The dorsal-slit technique is useful for patients with very tight phimosis. After local penile anesthesia and skin asepsis, hemostatic clamps are placed at 3 and 9 o'clock on the distal edge of the foreskin. The foreskin is then "crushed" at the dorsal midline with a straight hemostatic clamp for hemostasis and held for a few seconds. Then a dorsal midline incision using scissors is performed along the crush line until the foreskin can be adequately retracted (figure 5). The glans penis is then cleaned and prepped adequately with betadine. Two circumferential skin markings are then drawn in a similar fashion to the sleeve technique. The two incisions may then be performed simultaneously with scissors while following the lines and keeping the foreskin on traction with hemostatic clamps. Alternatively, the sleeve technique described above may be used to finish the procedure now that the foreskin can be reduced. Hemostasis and skin closure are performed identically to the sleeve technique described above. (See 'Sleeve technique' above.)

Circumcising devices

Clamp devices — Circumcising clamp devices are popular for neonatal circumcision but are not often used by urologists for MAC. The use of the Gomco clamp has been occasionally described in adults in the setting of mass MAC in HIV-endemic countries.

Gomco clamp — Use of the Gomco clamp was first described in the 1950s in the United States for neonatal circumcision [86]. It has since been used successfully in adults and is a useful tool for rapid and effective MAC in the setting of mass circumcision programs in HIV-endemic areas [87-89]. The clamp is a three-piece device, consisting of a bell, a base plate, and a rocker arm (top plate) (picture 1 and picture 2).

After local anesthesia and skin asepsis, a dorsal slit incision is performed (see 'Dorsal-slit technique' above) and an appropriately sized bell is placed over the glans for protection (picture 3). The foreskin and the arm of the bell are then brought through a hole in the base plate (picture 4), and the rocker arm is then fixed to the base plate with a nut (picture 5). The nut is tightened, crushing the base of the foreskin. The foreskin is then removed using a scalpel. The clamp is released, and the penile shaft skin is brought down to its normal position with the incision edge just below the base of the corona [90]. Tissue adhesives have successfully been used in lieu of suturing the skin edges together [87-89].

Excess skin removal and degloving injuries have been reported with the Gomco clamp [91]. (See 'Overzealous or incomplete circumcision' below.)

Unicirc — Unicirc is a single-use surgical instrument that functions like the Gomco clamp. Under topical local anesthesia, the device is applied to the glans and the foreskin pulled over the bell. The device is then tightly screwed and left in place for five minutes to create circumferential compression of the base of the foreskin, which fuses the mucosal and skin surfaces, and allows for excision of the foreskin with a scalpel. The fused skin edges are sealed with cyanoacrylate adhesive [92].

In two trials of adult male volunteers, operative time was less with the Unicirc technique than with the open surgical technique (median 12 versus 25 minutes) [92]. Wound healing, patient satisfaction, adverse events, and cosmetic results were similar in both groups [93]. Unicirc has also been successfully used to circumcise adolescent boys [94]. Unicirc has been used primarily in South Africa [95].

Mogen clamp — The Mogen clamp (picture 6) was designed by a Jewish mohel in the 1950s as a rapid method of neonatal circumcision [96]. It has since been made in larger sizes for adults but is still mostly used in the infant population.

After anesthesia and skin asepsis, the foreskin is put on traction with a hemostatic clamp, and the preputial-glandular adherences (if present) are liberated using the tip of another hemostatic clamp. The clamp is then applied across the foreskin, following the same angle as the corona (picture 7). The skin is crushed between the clamp's jaws, and the foreskin is excised using a scalpel (picture 8). Before the incision is made, one must ensure that the glans is not caught between the jaws, as this may lead to partial or complete glans amputation, a serious complication [91]. The skin is closed using tissue adhesive or resorbable sutures.

Ring devices — Both the Shang Ring and the PrePex devices were developed in response to the World Health Organization (WHO) mass MAC initiative in HIV-endemic countries and are mainly used in this setting. Both devices were designed for rapid and easy use by minimally skilled health care workers [97], and skin suturing is not required for either device, as healing occurs by secondary intention over six weeks following the procedures. Both devices work by causing ischemic necrosis of the prepuce and must be kept in place for approximately seven days [73].

Shang Ring — The Shang Ring is a "collar clamp type" circumcising device that was developed in China. This device does require a sterile surgical field and injection of local anesthesia in the form of a penile block before placement because placement requires a dorsal slit procedure [73]. Good outcomes with minimal complications, as well as device cost effectiveness, have been demonstrated by multiple studies [98-101]. Total procedure time (including application and removal of the device) was 10 minutes for the Shang Ring device, compared with 20 minutes for conventional surgical MAC. Adverse events occurred in 3.2 percent of patients, and no serious adverse events were reported. Mild and moderate complications include pain, infection, skin dehiscence, and insufficient skin removal [73,98-101].

PrePex — The PrePex is an "elastic collar compression type" circumcising device [73]. It does not require a sterile field or injection of local anesthesia for placement. Good outcomes with minimal complications, as well as device cost effectiveness, have been demonstrated by multiple studies [102-106]. There have been rare reports of tetanus associated with PrePex [107].

POSTOPERATIVE CARE

Dressings and wound care — No standard exists for postoperative wound care and dressings after male adult circumcision (MAC). In our center, the circumcision incision is covered by either a petrolatum-based (Xeroform) or a paraffin-based (Bactigras) dressing, then the penile shaft and base of the glans are wrapped in a bio-occlusive dressing. This is kept on for 48 to 72 hours or until the dressing falls off on its own. Once the dressing is removed, topical antibiotic ointment may be applied a few times a day until the incision is completely healed.

Patients may shower with the initial occlusive dressing in place. Once it is removed, patients may continue to shower daily and should gently pat the penis dry, until the incision is healed. Patients should avoid swimming and soaking in hot tubs until the incision is completely healed to prevent wound infections.

Recovery and healing — For surgical MAC, healing occurs over three to four weeks, which is usually the time it takes for the sutures to resorb. Light activities are recommended for the first 48 to 72 hours, after which normal activities may be resumed, including work and school. Sexual activity may resume once the sutures are completely resorbed.

Pain is typically graded as mild to moderate, and higher pain scores are reported in younger patients (aged less than 35 years) [108]. No standard of care exists with regard to prescribing oral analgesics after surgical MAC; however, in our center, we prescribe an opioid-based analgesic for the initial 48 hours (approximately 8 to 10 tablets) but encourage patients to take acetaminophen and ibuprofen as needed.

For MAC using the ring devices, healing takes approximately two weeks longer than for surgical circumcision, and sexual abstinence is recommended for six weeks following the procedure. No opioid analgesics are needed.

COMPLICATIONS — Accurate statistics of complications resulting from surgical or clamp circumcision are not available for adults but have been reported extensively in the neonatal population. Complication rates associated with male adult circumcision (MAC) performed with the ring devices have been extensively reported by the World Health Organization (WHO) in multiple large studies.

Acute complications and management

Bleeding — Postoperative bleeding is one of the most common postoperative complications of MAC (1 percent in a large pediatric study [109]) and can usually be avoided by proper intraoperative hemostasis. A compressive, elastic dressing may be applied for a short amount of time while the patient is in the recovery room but should not be applied too tightly and should always be removed before the patient is discharged home, as cases of penile and glans necrosis arising from compressive dressings have been reported [110].

Bleeding is very rare when using the circumcising ring devices [73], but severe cases have been reported when MAC was performed in patients with undiagnosed hemophilia [81].

Infection — Infection rates are very low (0.2 to 0.4 percent) [68,71], and infections are preventable by using proper sterile technique for all forms of MAC. Severe infectious complications, such as Fournier gangrene, are very rare but have been reported [111].

Wound dehiscence — Wound dehiscence is quite common after MAC as postoperative erections may cause excessive strain on the suture line. Impending erections may be prevented by inhaling an ampule of amyl nitrate. Dehiscence does not usually cause any severe issues, and the patient is counselled to continue routine application of an antibiotic ointment and to allow the incision to heal by secondary intention.

Overzealous or incomplete circumcision — These complications are more common when circumcising devices, rather than surgical circumcision, are used because the incision line is less precise. Incomplete circumcision may require a secondary procedure to remove the residual prepuce. Skin loss due to an overzealous circumcision is a more severe complication as it may result in skin tethering, penile length loss, and even buried penis. Split-thickness skin grafts can be used to correct an overzealous circumcision (picture 9).

Long-term complications

Glans hyperesthesia — Patients may report a hypersensitive glans after circumcision, but this sensation is usually temporary and subsides after a few months as the glans penis keratinizes.

Skin bridges and meatal stenosis — These complications are more common in patients suffering from lichen sclerosus (LS). Routine long-term use of steroid cream is recommended in these patients to prevent recurrence or further complications of their LS. Meatal stenosis is common in patients with LS. Daily meatal dilations using steroidal cream and lubricant are an effective method to preserve meatal patency [112].

We also ask that patients with a prepubic fat pad "exteriorize" their penis daily for proper hygiene to prevent skin bridge formation between the circumcision scar and the surrounding fatty tissue, which can entrap the penis and cause adult-acquired buried penis. This is more common in patients who are overweight or who have obesity (picture 9).

Patient dissatisfaction — Adult patients requesting circumcision for aesthetic and sexual reasons are most likely to be dissatisfied with the postoperative appearance of their penis. Careful preoperative evaluation and counselling and very precise surgical incisions are required in these patients to ensure postoperative satisfaction.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lichen sclerosus".)

SUMMARY AND RECOMMENDATIONS

●Indications – Male adult circumcision (MAC) is indicated for sociocultural and personal preferences, various penile pathologies, and prevention of sexually transmitted infections (STIs) and HIV transmission in endemic countries. (See 'Indications' above.)

•Phimosis – Phimosis is the most common medical indication for MAC and is associated with type 2 diabetes. A patient presenting with adult-onset phimosis should undergo diabetes screening. (See 'Phimosis' above.)

•STI prevention – Circumcision has been shown to reduce infection rates of some STIs, including HIV. The World Health Organization (WHO) recommends male circumcision for all countries with high HIV prevalence, mostly located in sub-Saharan Africa. (See 'Sexually transmitted infections' above and 'HIV transmission' above.)

●Epidemiology – Globally, 37 to 39 percent of men are circumcised. Seventy percent of male circumcisions are performed for religious reasons and 30 percent for medical reasons or personal preference. (See 'Epidemiology' above.)

●Circumcision techniques – Most MAC procedures can be performed under local anesthesia in an outpatient setting. A penile nerve block accompanied by a ring block is an effective method for complete penile local anesthesia. (See 'Penile nerve block technique' above.)

•Open surgical techniques – The sleeve technique is preferred when performing surgical MAC (figure 4). The dorsal-slit technique is useful for patients with very tight phimosis (figure 5). Knowledge of multiple techniques allows the surgeon to be versatile and accommodate the patient's anatomy and pathology. (See 'Sleeve technique' above and 'Dorsal-slit technique' above.)

•Clamp devices – Circumcising clamp devices, such as the Gomco clamp and the Mogen clamp, are popular for neonatal circumcision but are not often used by urologists for MAC. The Gomco-type clamp has been used in the setting of mass MAC in HIV-endemic countries. Proper sizing and knowledge of device/technique are imperative to prevent complications. (See 'Clamp devices' above.)

•Ring devices – Circumcising rings, such as the Shang Ring devices, are most often used for mass circumcision programs organized by the WHO in HIV-endemic countries. These devices are safe, efficient, and effectively reduce HIV transmission rates in these countries. (See 'Ring devices' above.)

●Complications – Complication rates following MAC should be low. However, patients should be made aware of potential acute and chronic complications before the procedure, which include bleeding, glans hyperesthesia, meatal stenosis, and patient dissatisfaction. (See 'Preoperative testing' above and 'Complications' above.)