CO₂ laser circumcision

When it is indicated, adults included

There is a widespread notion that circumcision is something done to newborns. In a urology clinic, most of the patients who need it are adults, and they arrive after years of putting up with a problem that can be solved in half an hour.

• Phimosis. The foreskin will not retract, or retracts painfully or with tearing. It is the most common indication in adults.
• Recurrent paraphimosis. The foreskin retracts and will not return, constricting the glans. It is an emergency when it happens and an indication for surgery when it recurs.
• Recurrent balanitis and balanoposthitis. Repeated inflammation and infection of the glans and foreskin, common in patients with diabetes.
• Lichen sclerosus. A skin condition that progressively hardens and narrows the foreskin. Here circumcision does not merely relieve symptoms: it is usually the definitive treatment.
• A short frenulum causing pain or tearing during intercourse. Sometimes a frenuloplasty is enough and no circumcision is needed.
• Recurrent urinary tract infections in selected cases, and human papillomavirus lesions that keep returning beneath the foreskin.
• Persistent difficulty with hygiene, with odour or chronic irritation.
• Personal, cultural or religious choice, with no underlying disease.

What the procedure involves

It is performed in a day-case theatre under neuraxial anaesthesia —a spinal block— with optional sedation if you would rather not be awake. It requires neither general anaesthesia nor an overnight stay. Unlike a local penile block, neuraxial anaesthesia leaves the whole area completely numb throughout the operation, which allows the foreskin and the frenulum to be dealt with unhurriedly without you feeling anything.

• Duration: between 15 and 30 minutes, depending on the anatomy and on whether the frenulum needs attention.
• The excess foreskin is removed, the vessels are sealed and the edges are brought together with absorbable sutures, which do not need removing.
• A dressing is applied and removed after 24 to 48 hours.
• You go home the same day, once the block wears off and you can pass urine without difficulty. That means a few hours in recovery, and you leave with written instructions and a follow-up appointment.

CO₂ laser, scalpel or stapler

All three techniques pursue exactly the same thing: removing the excess foreskin, controlling bleeding and leaving an edge that heals well. What differs is how they get there.

Recovery, without the gloss

This is the part most often dressed up online, and the one I am asked about most. Here is what actually happens.

• The same day. A few hours in recovery until the block wears off and you pass urine normally. Discomfort is mild.
• Days 1 to 3. Mild, occasionally moderate pain, well controlled with paracetamol or an oral anti-inflammatory. You can shower the following day.
• Going back to work. Two or three days for desk work. Seven to ten days if it involves physical effort.
• Swelling of the edge. One to two weeks, sometimes a little longer. It is normal and settles on its own.
• The stitches. They are absorbable and fall out on their own between the second and fourth week. Nothing needs removing.
• Night-time erections. The most uncomfortable part of the first few nights. Nobody warns you, and it is worth knowing.
• Sexual activity and masturbation. Four weeks. Not sooner: it is the commonest reason a wound opens up.
• Sport. Two weeks for light activity; four for hard exercise or cycling.

Risks, because there are some

It is minor surgery, but it is surgery. Complications are uncommon and almost always manageable:

• Bleeding or haematoma in the first hours. The most common, and usually settled with compression.
• Wound infection, infrequent and treatable with antibiotics.
• Partial opening of the wound, above all when sexual activity is resumed too early.
• Removing too much or too little skin. This is the error that matters most in the long run, and the one that depends most on the surgeon's judgement.
• Narrowing of the urinary meatus, uncommon.