Congenital Inguinal hernia and

other types of hernia, phimosis

BOUNDARIES OF INGUINAL CANAL
CONTENTS OF INGUINAL CANAL
 INGUINAL TRIANGLE (HESSELBACH’S TRIANGLE)

● Inguinal triangle is present in

groin region which is bounded:

1. Laterally: Inferior epigastric

artery
2. Medially: Rectus abdominis
muscle
3. Inferiorly: Inguinal ligament
.
 CLINICAL RELEVANCE : INGUINAL HERNIA
A hernia is defined as the protrusion of an organ or fascia through the wall of a
cavity that normally contains it. Both types of inguinal hernia can present as
lumps in the scrotum or labia majora.Hernias involving the inguinal canal can be
divided into two main categories:

● Indirect inguinal hernia

○ Enters the deep inguinal ring and passes through inguinal canal and
emerge through superficial inguinal ring. In men, may extend to scrotum

● Direct inguinal hernia

○ Pushes forward through posterior wall of inguinal canal (Hasselbach’s
triangle), medial to inferior epigastric artery through the superficial
inguinal ring.
FEMORAL TRIANGLE
o The femoral triangle is a wedge-
shaped area located within the
superomedial aspect of the anterior
thigh.

o It acts as a conduit for structures

entering and leaving the anterior thigh.

BORDERS OF FEMORAL TRIANGLE

o Superior border – inguinal ligament.

o Lateral border – medial border of the

sartorius muscle.

o Medial border – medial border of the

adductor longus muscle. The rest of
this muscle forms part of the floor of
the triangle.
FEMORAL TRIANGLE
FLOOR OF FEMORAL TRIANGLE

o Pectineus
o Iliopsoas
o Adductor longus muscles.

ROOF OF FEMORAL TRIANGLE

o Fascia lata.
 CONTENTS OF THE FEMORAL
TRIANGLE
• Femoral nerve

FEMORAL SHEATH

• Femoral artery
o Can be palpated inferior to
inguinal ligament and midway
between ASIS and pubic
symphysis

• Femoral vein
• Deep inguinal lymph nodes
o Located in femoral canal

Acronym for the contents of the femoral

triangle (lateral to medial) – NAVEL
 FEMORAL CANAL
• The femoral canal contains lymph
nodes and lies at the medial edge of
femoral sheath which contains
femoral artery and vein.

• A femoral hernia passes through the

femoral canal into the medial aspect
of anterior thigh.

• The neck of femoral canal is extremely

narrow which leads to trapping of
bowel within the sac.

• Hence, femoral hernias are

irreducible and susceptible to
bowel strangulation.
 HERNIA
● A hernia is the protrusion of an organ or part of an through it’s containing
wall.
● for an organ or tissue to herniate, there must be a weakness in the
retaining wall.
● can be due to congenital abnormality, may be related to normal anatomy
or due to trauma or disease
● hernias are more common in men than woman COMMON (9% of HERNIAS
males and 1% of
females develop inguinal hernia at some point •in life
inguinal
• umbilical/paraumbilical
• incisional
• femoral
BASIC FEATURES OF ALL HERNIAS • epigastric

• they occur at a weak spot RARE HERNIAS

• they reduce upon lying down, or with manipulation • spigelian
• they have an expansile cough impulse • obturator
• lumbar
• gluteal
 THE SITE OF HERNIAS
COMMON CAUSES OF
ABDOMINAL HERNIA

• congenital anatomical
defect alongside
structures penetrating
the abdominal wall
• acquired weakness
from trauma, previous
surgery or disease
• associated with raised
intra-abdominal W
pressure
INDIRECT AND DIRECT INGUINAL HERNIA EXAMINATION OF INGUINAL HERNIA
• can descend into scortum • ask the patient the stand
• reduces upwards then laterally and backwards • examine the lump from the front
• controlled after reduction by pressure over the • feel from the front
internal inguinal ring • feel from the side
• after reduction, the bulge reappears in the middle • expansile cough impulse
of the inguinal region and flows medially and • is the swelling reducible?
obliquely towards the scortum • remove hand and watch the hernia reappear
• found in all age groups • feel the other side
• examine the abdomen
DIRECT INGUINAL HERNIA
• does not go down into the scortum
• reduces upwards and then straight backwards
(direct)
• not controlled after reduction by pressure over the
internal inguinal ring
• after reduction bulge comes directly forwards
• rare in children and young adult.
a) LEFT INDIRECT INGUINAL HERNIA

b) DIRECT RECURRENT INGUINAL HERNIA

 inguinal hernia DESCRIPTION OF HERNIAS
IRREDUCIBLE :
● content of hernia cannot be replaced
● can appear at any age into the abdomen
● more common in manual worker than office INCARCERATED :
worker (physical effort) ● content are imprisoned in the sac of
● LOCAL SYMPTOMS : painless swelling, the hernia but alive and functionally
dragging or aching sensation in the groin normal
(gets worse by day) ● non tender hernia
● OTHER BOWEL SYMPTOMS : change in OBSTRUCTED :
bowel, conditions that increases abdominal ● a loop of bowel that is trapped within
pressure (carcinoma of left colon, the sac of the hernia
diverticular disease, chronic bronchitis with ● lumen is obstructed, not the blood
presistent coughing, difficulty in supply
micturation) ● patient will have signs of intestinal
● EMERGENCY PRESENTATION : groin obstruction
swelling that will not reduce (or painful and ● hernia will be unduly tender
tender), colicky abdominal pain, vomiting, STRANGULATION :
distention, absolute constipation ● compromised blood supply to content
● EXAMINATION(EMERGENCY) : colour, of sac(ischaemic/infarcted)
temperature, tenderness, reducibility ● patient will be unwell and swelling will
be acutely tender
 INGUINAL HERNIA IN FEMALES

● round ligament that connects the uterus

● indirect and sacs passes obliquely towards
labium

HYDROCELE OF THE CANAL OF NUCK

● fluid filled distal sac that is too narrow to
admit bowel
● analogous encysted hydrocele in boys
● presents with smooth fluctuant swelling
without cough impulse (transilluminate)

HEMATOCELE OF ROUND LIGAMENT

● distended with multiple small sacs of
bloodstained fliud
● presents in pregnancy with soft sausage-like
swelling in groin extending into labium
● weak cough impulse,feels spongy and reduces
in size
 ENCYSTED HYDROCELE OF THE CORD :
inguinal hernia in children • narrow necked patent processus that does not reach the
testis becomes dilated distally and filled with fluid.
• presents as discrete swelling in the spermatic cord below
● always indirect and caused by the external inguinal ring and above testicle
• transilluminates and has no cough impulse
failure of processus vaginalis to
obliterate after testicles enters the
scortum

INFANTILE HYDROCELE :
● fully patent processus vaginalis,
too narrow to admit to bowel but
fluid from peritoneal cavity INGUINAL HERNIA :
• content will reduce easily and swelling does not transilluminate
accumulate within it • occasionally irreducible but strangulation is rare
● present at birth or shortly after
with scortal swelling that is large,
tense, and translucent (often
bilateral)
 FEMORAL HERNIA EXAMINATION :
● position
● colour
● protrusion of extraperitoneal fat, a ● temperature
● tenderness
peritoneal sac, abdominal content ● shape and size
through femoral canal ● surface
● femoral canal provides space for ● reducibility
femoral vein to expand and ● cough impulse
contains loose ereolar tissue and ● relations
gland of Cloquet ● local tissues
● femoral canal cannot distend
easily, so sac will be stiff, narrow
neck and it’s content will be at risk
of strangulation
● rare in children but common
among those who are 50 years and
above
● more common in females than
males
● patient will present with swelling
 prevascular hernia

● rave variety of femoral hernia

● femoral canal expand laterally
under inguinal ligament in front of
the femoral artery and vein
● has wide neck and flattened wide
sac, which bulges downwards and
laterally
● reduces and have cough impulse
● rarely strangulate
 congenital umbilical hernia
● can be present at birth
● common among Afron-caribbean people
● hernia will be visible and children can complain
of ‘tummy ache’
● hernia will resolve by itself, if presist after age of
4, operation is advised
EXAMINATION :
● Shape and size
● composition (soft, compressible, easy to reduce)
 PARAUMBILICAL HERNIA
● appears through a defect EXAMINATION :
adjacent to umbilical scar ● position
● does not bulge into the centre ● surface and edge
of the umbilicus ● composition
● umbilical skin not attached to ● cough impulse
the centre of sac ● relations
● usually develop in middle age
and old age
● causes swelling and discomfort
 EPIGASTRIC HERNIA
● protrusion of extraperitoneal fat
and small peritoneal sac through
defect in linea alba (between
xiphisternum and umbilicus)
● patient will usually complain of
epigastric pain
● firm, do not usually have a cough
impulse, cannot be reduced
 3A) MANAGEMENT OF INGUINAL HERNIA

Pt presented w/ Inguinal hernia

SYMPTOMATIC ● Assess hernia reducibility & signs complication ASYMPTOMATIC

● Consider USG of groin if uncertain clinical dx
(if complicated: CTAP + IV contrast may needed)
● ABCDE & resuscitation if needed; NPO status, supportive care

1) Weigh PROS & CONS tx mode

a) Obstructed & b) Incarcerated c) Reducible/ 2) Discuss with pt on choice tx
Strangulated Uncomplicated IH
MANUAL REDUCTION
C/I: strangulated hernia Willing for surgery NOT willing for
(or) surgery (male only)
b.1) Irreducible b.2) Reducible Cosmetic improvement

Successful: close
Failed reduction: monitoring 12-24h
urgent surgery elective surgery during COUNSEL pt on:
same admission - S/S
EMERGENT ELECTIVE SURGERY - NON-OPERATIVE Mx (conservative)
SURGERY (Laparoscopy/ Open)
(Open)
3A) MANAGEMENT OF INGUINAL HERNIA (cont.)

A) CONSERVATIVE (NON-OPERATIVE) MANAGEMENT OF INGUINAL HERNIA (IH)

CONSERVATIVE MX EDUCATE INDICATIONS & C/I CONS

● WATCHFUL WAITING S/S B. obstruction INDICATIONS: ● Discomfort

- Irreducible hernia ● Asymptomatic/ minimally symptomatic ● Testicular
● ADVICE: avoid lifting heavy - 4 cardinal signs ● Completely reducible IH (male) pain
weights, return if worsen s/s (-->) PVDC: pain, vomit, ● Uncomplicated IH & unfit for surgery/ ● Atrophy
distension, anaesthesia - severe comorbidities, underlying ms
● SYMPTOMATIC MX - constipation elderly with less life-expectancy → poor
- 1) Analgesics: for pain S/S strangulation ● Chronic cough/ constipation wound
- 2) Truss/ belt undergarment: - Sudden onset pain, healing post-
I. Indication: in asymptomatic freely redness, swelling C/I: op
reducible hernia, to prevent groin mass ● S/s significant & limits daily activities ● If truss of
abdominal content protrusion but not ● Complicated IH (irreducible) incompletely
definitive tx ● Femoral/ Sliding hernia reduced IH =
ii. Need: proper counselling on ● Female (mostly femoral hernia, greater = strangulation
method Truss & maintain hygiene risk Cx hence all female pt undergo content
iii. Method: applied once swelling elective surgical repair of groin hernias ● Hygiene issue
completely reduced; throughout the w/out watchful waiting)
day exc. night ● Undescended testis *Pt eventually
- 3) Tx potential RF hernia: eg. ● Hydrocele require surgical
chronic constipation/ cough ● Pt unable to be educated on Truss repair (definitive)
Pic 1: Truss belt
 3A) MANAGEMENT OF INGUINAL HERNIA (cont.)

B) MANUAL REDUCTION OF INGUINAL HERNIA

PROCEDURE OUTCOMES INDICATION & C/I

● Bedside procedure, hernia ● SUCCESSFUL REDUCTION (REDUCIBLE) INDICATION:

contents manually guided into 1. Monitor pt 12-24h with serial abdominal exam Temporary measure
abd cavity tru inguinal fascial 2. If s/s improve: schedule ELECTIVE before surgery in
defect SURGERY during same admission/ if INCARCERATED
● Prep: NPO, parenteral discharged, after a few days hernia +/-
analgesia, procedural sedation 3. If s/s worsen: immediate surgical consult: OBSTRUCTION
(alternative: OT under GA) - Recurrence
● Procedure: - Reduction en masse: existing peritoneal C/I:
1. Place pt in 20° Trendelenburg sac + constricting neck is reduced into abd STRANGULATED
position (*Children: unilateral w/out relieving constriction = progressive hernia
frog-leg position) abd pain but no visible inguinal hernia after → necrotic bowel/
2. Apply ice pack to affected area manual reduction - risk peritonitis & sepsis omentum pushed
to reduce swelling ● FAILED REDUCTION (IRREDUCIBLE) into abd cavity & risk
3. Manually guide hernia tru Max 2x → URGENT SURGERY peritonitis
fascial defect with slow, steady
pressure
3A) MANAGEMENT OF INGUINAL HERNIA (cont.)

B) MANUAL REDUCTION OF INGUINAL HERNIA

Pic 2: Manual reduction inguinal hernia in children - frog leg technique

 3A) MANAGEMENT OF INGUINAL HERNIA (cont.)

C) SURGICAL REPAIR OF INGUINAL HERNIA (DEFINITIVE TX)

EMERGENCY SURGERY (5%) ELECTIVE SURGERY

● Mx same for both direct & indirect
inguinal hernia - definitive → surgical
Indications: Indications:
repair
● Complicated inguinal hernia ● Significant inguinodynia limiting
● Goal hernia surgery: reinforce
- Strangulated IH daily activities
posterior wall of inguinal canal with - Obstructed IH / Incarcerated IH ● Female pt, femoral hernias
synthetic mesh/ by primary tissue failed manual reduction ● Pt prefer surgery
approximation Pre-op: ● Worsening s/s during watchful
● Various approaches & methods but - Adequately counselled (fam & pt) waiting
similar 5 basic principles - - Precautions (well-resuscitated, ● Successful manual reduction of
1. Asepsis rehydration, IV broad antibiotics), incarcerated hernia
2. Reducing contents hernial sac into - Adequate post-op high dependency/ ● Uncomplicated inguinal hernia
abdomen intensive care (if needed) (reducible)
3. Closure defect by reconstructing post.
wall inguinal canal
Within hours Timing based on convenience of pt &
4. Use prosthetic material (suture/ mesh)
- to reduce risk gangrene (infarction may surgeon (on same day admission/ few
to reinforce area of weakness occur within 6hr strangulation) days after)
5. Maintain “tension free” repair - to reduce need for bowel resection
● Pre-op: Tx underlying cause of
increased intra-abdominal P (eg
Higher risk Cx (next slides) Preferred if it is an option
chronic cough/ straining)
Open anterior hernia surgery - mostly Laparoscopic/ Open surgery
&Anaesthesia (LA in uncomplicated/ open hernioplasty mesh repair
GA in IO)
 3A) MANAGEMENT OF INGUINAL HERNIA (cont.)

C) SURGICAL REPAIR OF INGUINAL HERNIA (DEFINITIVE TX) - TYPES/ METHOD OVERVIEW

C1) HERNIOTOMY C2) HERNIORRHAPHY (suture repair) C3) HERNIOPLASTY (mesh repair)

Neck of sac ligated/ closed + sac HERNIOTOMY + HERNIORRAPHY +

excised/ removed without repair Post. inguinal wall repair by sutures (strengthening Post. wall repair reinforced with
inguinal canal post. inguinal wall) using autologous tissue synthetic mesh

- in infants & children (congenital) - in adults, risk recurrence if herniotomy alone *Gold std, tension-free post. wall,
- in pt high-risk surgical-site infection (C/I in mesh) prevent recurrence, faster post-op
- open / laparoscopic recovery
- open/ laparoscopic

Michaelis plank operation ANTERIOR APPROACH (open suture repair) 1. Lichtenstein’s **

(herniotomy) 1. Bassini’s (open flat mesh repair)
2. Shouldice’s (modified Bassini’s) 2. Rive’s
3. McVay’s 3. Stoppa’s
(open preperitoneal repair)
POSTERIOR APPROACH: 4. Laparoscopic repair: TAPP, TEP*
1. Laparoscopic repair: TAPP, TEP
2. Nyhus’
 3A) MANAGEMENT INGUINAL HERNIA (cont.) - surgical repair: open vs laparoscopic

OPEN SURGERY (pain) LAPAROSCOPIC SURGERY

Preferred in - Preferred in - B/L or recurrent inguinal hernia after open surgery

1) Complicated inguinal hernia Aim -
2) C/I for laparoscopic surgery - - Reduce hernia & sac in abdomen
● High anesthesia risk (laparoscopic: GA) - Place 8x15cm mesh in preperitoneal space (but different methods), just deep to
● Previous abdominopelvic surgery eg. abd wall, across midline into retropubic space & 5cm lateral to deep inguinal ring
hysterectomy, prostatectomy - Mesh covers: Hasselbach’s triangle, deep inguinal ring & femoral canal

A) HERNIOTOMY (Michaelis plank HERNIORRAPHY & HERNIOPLASTY

operation) 2 TYPES LAPAROSCOPIC APPROACH -
B) HERNIORRAPHY - a) TAPP - transabdominal preperitoneal repair
● Bassini’s, Shouldice’s, McVay’s - Laparoscopic, preperitoneal mesh implementation btw parietal peritoneum &
C) HERNIOPLASTY - transverse fascia
● Lichtenstein’s, Stoppa’s, Rive’s - Enters peritoneal cavity, incise peritoneum above hernia defect (from median
umbilical ligament to ASIS)
**Laparoscopic (-->) - Sac reduced + Mesh placed above peritoneum & fixed all sides
Cons: longer to perform, careful for - Peritoneum then sutured
“Triangle of Doom & Triangle of Pain”
Pros: b) TEP - total extraperitoneal repair (**more used - minimal invasive)
●Reduced pain after surgery & 5yr later - Laparoscopic, extraperitoneal mesh implementation btw parietal peritoneum &
●Faster wound healing transverse fascia
●Reduced wound Cx infection, bleeding, - Incision made lateral to umbilicus & dissected til preperitoneal space reached
seroma (without entering peritoneal cavity), space widen using balloon
●Better visualisation anatomy - Hernia reduced/ cleared + Mesh placed & anchored all sides
3A) MANAGEMENT OF INGUINAL HERNIA (cont.) - SURGICAL Post-Op care & Cx

POST-OP CARE
1. Rest few hours
2. Discharged same day/ day-care
3. Early mobilization, safely ambulate on
evening of operation
4. If GA/ regional anaesthesia -
hospitalised few days
5. Post-op pain - analgesics
6. Dressing removal - post-op D5
7. Stitches removal - post-op D7
8. Avoid strenuous activities few weeks;
light-work after 1w, heavier jobs after 6w
9. Male pt - monitor testicular atrophy (BV
injury/ obstruction spermatic cord)
10. Development nerve pain - eg nerve
entrapment in suture material
11. Monitor recurrence (inadequate repair,
wound infection, chronic straining dt
cough/ constipation/ urination)
Pic 12: Complications of hernia surgery
3B) MANAGEMENT OF FEMORAL HERNIA

All femoral hernia -

surgically repaired dt
high risk Cx
→ Femoral canal small
diameter: higher risk
incarcerated &
strangulated (ischemic)

LA GA *Non-complicated:
Early elective surgical
repair by mesh
hernioplasty (tension-
free repair)

*Complicated:
herniorrhaphy (non-
mesh)

Pic 13: Overview of Femoral hernia & its Management

3C) MANAGEMENT OF UMBILICAL HERNIA

1) Congenital umbilical hernia - 90% spontaneous closure by 2yr age

→ If no spontaneous closure by 5yr age → surgical

2) Small hernia <1cm, asymptomatic → conservative mx

3) Larger umbilical hernias (>1.5-2cm in >2-3yr children) & obstructed/ strangulated → surgical

SURGICAL REPAIR OF UMBILICAL HERNIA -

1) MAYO’S TECHNIQUE -
→ hernia <2cm, incised, inspected, non-viable tissue ligated & excised, sac removed & flaps of linea alba
double-breasted

2) OPEN HERNIOPLASTY / MESH REPAIR

3) LAPAROSCOPIC HERNIOPLASTY
 COMPLICATIONS OF HERNIA

TYPE COMPLICATIONS

PRE-OPERATIVE ● Irreducibility: In this case, contents cannot be returned to the abdomen but there is no evidence of
other complications → usually due to adhesions between the sac and its contents or overcrowding
within the sac → predisposes to strangulation
● Obstruction: an irreducible hernia containing obstructed intestine, with no interference in blood
supply to the bowel → symptoms: nausea, vomiting, colicky abdominal pain and tenderness over
hernia site
● Strangulation: when blood supply of hernia contents is seriously impaired, resulting in ischemia →
gangrene may occur 5-6 hours after onset of first symptoms: nausea, fever, vomiting, sudden pain
that quickly intensifies, a hernia bulge that turns red / purple / dark.
→ frequent in femoral hernia explained by the narrow, unyielding femoral ring
REQUIRES EMERGENCY SURGERY WITHIN HOURS TO RELEASE TRAPPED TISSUE AND RESTORE
BLOOD SUPPLY
 COMPLICATIONS OF HERNIA

TYPE COMPLICATIONS

INTRA- ● Haemorrhage → injury to inferior epigastric or iliac vessels /

OPERATIVE femoral vessels / spermatic vessels
● Injury to the vas deferens
Herniorrhaphy → common cause of iatrogenic vas injury
Can be caused by cutting, crushing, or overstretching
● Neuropathy → injury to ilioinguinal nerve / iliohypogastric
nerve / lateral cutaneous nerve of the thigh / femoral nerve /
genitofemoral nerve

POST- Early complications

OPERATIVE
● Bleeding and haematoma formation
● Seroma formation
● Scrotal edema
● Urinary incontinence
● Paralytic ileus
● Wound infection
 COMPLICATIONS OF HERNIA

TYPE COMPLICATIONS

POST- Late complications

OPERATIVE
● Testicular atrophy & Ischemic orchitis → injury to testicular artery
● Chronic pain
● Dysejaculation
● Recurrence → straining, chronic cough, chronic constipation, obesity,
lifting heavy weights, etc
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

INTRO When the prepuce (foreskin) is too tight to be retracted to reveal the glans penis
→ often a presenting complaint by the parent / guardian

A) Physiologic phimosis:
● occurs naturally in newborn males
● results from adhesions between epithelial layers of the inner prepuce and glans
● they spontaneously dissolve with intermittent foreskin retraction and erections
● resolves with age

A) Pathologic phimosis:
● Inability to retract the foreskin after it was previously
retractable or after puberty
● Usually secondary to distal scarring of the foreskin

A) Paraphimosis:
● Entrapment of a retracted foreskin behind the coronal sulcus
● In uncircumcised or partially circumcised males
C
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

AETIOLOGY ● Poor hygiene

● Recurrent episodes of balanitis or balanoposthitis → leads to scarring of the
preputial orifices
● Stenosis scarring → can be caused by balanitis xerotica obliterans (BXO):
chronic skin condition histologically identical to lichen sclerosis, and is an
indication for circumcision at all ages
● Forceful retractions of the foreskin → microtears at the preputial orifice that
also leads to scarring and phimosis
● Advanced age → loss of skin elasticity and infrequent erections

COMPLICATION Phimosis or paraphimosis

S ● Recurrence
● Posthitis: inflammation of the foreskin as a result of poor hygiene, bacterial /
fungal infections, allergies and STIs
● Necrosis or gangrene of the glans
● Autoamputation (rare)
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

HISTORY PHYSICAL

CLINICAL Physiological phimosis: Physiological phimosis:

FEATURES - Inability to retract foreskin - Foreskin cannot be retracted proximally over the glans penis
during routine bathing / - Preputial orifice unscarred and appears healthy
cleaning
- “Ballooning” of the prepuce Pathological phimosis:
during urination → normal - Contracted white fibrous ring may be visible around preputial
finding orifice

Pathological phimosis: Paraphimosis:

- Painful erections - Foreskin retracted behind the glans penis and cannot be
- Haematuria replaced to its normal position
- Recurrent UTIs - Foreskin forms a tight, constricting ring around the glans
- Preputial pain - Flaccidity of the penile shaft proximal to the area of the
paraphimosis is seen (unless there is accompanying
Paraphimosis: infection of the penis)
- Painful, swollen glans - The glans becomes increasingly erythematous / edematous
- The glans penis is initially a pink hue and soft to palpation,
the colour changes to blue / black and becomes firm to
palpation
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

TREATMENT ● Manual reduction

- Placing both index fingers on the dorsal border of the
penis from behind the retracted prepuce and both thumbs
on the end of the glans
- The glans is pushed back through the prepuce with the
help of the constant thumb pressure with the index fingers
pull the prepuce over the glans
- May be facilitated by using ice and/or hand compression
on the foreskin, glans, penis → to minimise oedema
● Osmotic method
- Substances with high solute concentration can be used to
osmotically draw out fluid from the edematous glans and
foreskin prior to manual reduction
● Puncture method
- Requires using 21- to 26-gauge needle to puncture
openings into foreskin to allow edematous fluid too escape
from puncture sites during manual compression
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

TREATMENT ● Aspiration
- Aspiration of blood, a tourniquet is applied to the penile shaft
- A 20-gauge needle is used to aspirate 3-12 mL of blood from
the glans, parallel to the urethra → reduces volume of the
glans enough to facilitate manual reduction
● Vertical incision (release incision) → until circumcision
available
- If none of the above methods are successful
- The constricting band of the foreskin is incised using a 1-2
cm longitudinal incision between 2 straight hemostats placed
in the 12 o’clock position
- Frees the constricting ring and allows for easy reduction
- The incised margins can then be re-approximated
- Restores circulation and reduces risk of complications
● Medications:
- 95% cases responded to topical steroid use →
*betamethasone valerate 0.1%, 0.2%
*0.2% used in combination with hyaluronidase
 PHIMOSIS: PHYSIOLOGIC, PATHOLOGIC, PARAPHIMOSIS

TREATMENT ● Circumcision
Indicated in
- true phimosis caused by BXO
- Recurrent attacks of balanoposthitis
- Recurrent UTIs / obstruction to urinary flow

Full circumcision → removing all of the foreskin

- Lengthwise cuts are made into the tight
foreskin in 2 or 3 places then these cuts are
stitched close
- Operation carried out under general
anaesthesia in paediatrics, local in adults
SIDE EFFECTS (rare): Bruising, bleeding,
inflammation, curving of the penis, tightening of
the urethra opening

Partial circumcision → removing only the

constricting part of the foreskin
COMPLICATIONS: recurrence → second operation
is done to fully remove the foreskin
 REFERENCES

- O'Connell, P.R., McCaskie, A.W., & Williams, N.S. (Eds.). (2018). Bailey &
Love's Short Practice of Surgery, 27th Edition (27th ed.)
- Sabiston’s Textbook of Surgery, 20th Edition.
- S. Das’s Concise Textbook of Surgery, 10th Edition.
- Ghory, H. Z., MD. (2022, December 9). Phimosis and Paraphimosis In the ED:
Practice Essentials, Epidemiology, Prognosis.
https://emedicine.medscape.com/article/777539-overview
- McPhee AS, Stormont G, McKay AC. Phimosis. [Updated 2022 Aug 8]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK525972/