What are the considerations for a 20-year-old male with a history of coronal hypospadias and left varicocele undergoing elective circumcision for cosmetic purposes?

From the Guidelines

For a 20-year-old male seeking elective circumcision for cosmetic purposes with a history of coronal hypospadias and left varicocele, we should discuss several important considerations, prioritizing his morbidity, mortality, and quality of life outcomes. First, we should explain the circumcision procedure, including the surgical technique, expected recovery time of 2-3 weeks, potential pain management with over-the-counter analgesics, and wound care instructions, as informed by general medical knowledge and guidelines such as those from the British Association of Dermatologists 1. We should thoroughly review potential complications such as bleeding, infection, pain, altered sensation, and cosmetic outcomes. Given his history of coronal hypospadias, we should discuss how circumcision might affect the appearance of the hypospadias and whether addressing both issues simultaneously might be beneficial, considering the potential for lichen sclerosus, a condition associated with hypospadias and phimosis, as noted in studies 1. The presence of left varicocele should be addressed separately, explaining that while it typically doesn't interfere with circumcision, it may require its own treatment if causing symptoms or fertility concerns, based on the principles of managing varicoceles in the context of fertility and testicular health. We should clarify that circumcision is permanent and ensure he has realistic expectations about cosmetic outcomes. Finally, we should discuss the timing of the procedure, post-operative restrictions including sexual activity (typically 4-6 weeks abstinence), and follow-up care, emphasizing the importance of follow-up for monitoring potential complications and managing any recurrence of conditions like lichen sclerosus, as suggested by guidelines for the management of lichen sclerosus 1. This comprehensive discussion will help ensure informed consent and appropriate management of his multiple urological conditions, prioritizing his overall health and well-being. Key points to consider include:

• The potential impact of circumcision on his coronal hypospadias and left varicocele
• The risk of complications such as bleeding, infection, and altered sensation
• The importance of follow-up care for monitoring and managing potential complications
• The need for realistic expectations about cosmetic outcomes and the permanence of the procedure
• The potential for lichen sclerosus and its management, including the role of topical corticosteroids and the possibility of circumcision as a treatment option for phimosis caused by lichen sclerosus 1.

From the Research

Discussion Points for Elective Circumcision

The patient, a 20-year-old male with a history of coronal hypospadias and left varicocele, is considering elective circumcision for cosmetic purposes. The following points should be discussed with the patient:

• Benefits and Risks of Circumcision: The patient should be informed about the potential benefits of male circumcision, including the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer, as stated in the study by 2. However, the patient should also be aware of the potential risks and complications associated with the procedure.
• Hypospadias Considerations: The patient's history of coronal hypospadias should be taken into account when discussing elective circumcision. According to the study by 3, hypospadias can be corrected at any age with comparable complication risk, functional, and cosmetic outcome. However, the patient should be aware that long-term complications, such as urinary tract symptoms and sexual and cosmetic issues, can still occur.
• Varicocele Management: The patient's left varicocele should be evaluated and managed accordingly. As stated in the study by 4, varicoceles are associated with pain, testicular atrophy, and reduced fertility rates. The patient should be informed about the treatment options available for varicoceles, including surgical repair, and the potential success and complication rates associated with each approach, as described in the study by 5.
• Adult Circumcision Procedure: The patient should be informed about the adult circumcision procedure, including the techniques used, such as the dorsal slit or sleeve technique, and the anesthesia options available, as described in the study by 6. The patient should also be aware of the potential complications associated with the procedure, such as infection, bleeding, and poor cosmetic results.
• Informed Consent: The patient should provide informed consent for the elective circumcision procedure, taking into account the potential benefits and risks, as well as the patient's personal preferences and values.

Key Considerations

• The patient's history of coronal hypospadias and left varicocele should be taken into account when discussing elective circumcision.
• The patient should be informed about the potential benefits and risks associated with male circumcision.
• The patient should be aware of the treatment options available for varicoceles and the potential success and complication rates associated with each approach.
• The patient should provide informed consent for the elective circumcision procedure, taking into account the potential benefits and risks, as well as the patient's personal preferences and values.