Pearly pink papules (PPP)

October 12, 2014

 I have pearly penile papules (PPP) and I’d like them removed. What’s involved?

Lester

Good morning Lester,

Glad we talked.

Pearly penile papules (PPP) are considered a normal variant of penile anatomy and appear as minute little somewhat flat pink skin tags on the rim of the glans.  They occur somewhat more frequently in uncircumcised men, and usually once formed remain stable in number and appearance.  They will not hurt you or your partner and in no way are communicable.

They are easily treated in our practice with local anesthesia and pin point needle electro-desiccation.  You will have numerous little black spots where they formerly existed and that is a crust which falls off in a few days.  You will not have pain once the anesthetic wears off and no dressing is required.

We would prefer not to zap a long contiguous line of these as leaving some healthy skin on either side facilitates wound healing.  Within a week to 10 days, you should look very well.  Gentle sex is possible in about 12 days.  If some residual lesions are left, we’ll tackle those in about a month.

To review consultation 250, removing most if not all papules 250.  If you elect circumcision revision which could be as high as 1750, PPP removal is free, including followup care. When patients are having a circumcision, they are removed gratis.

With kindest regards,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

Mr. D seeks adult circumcision revision for aesthetic reasons. Remove frenulum?

October 4, 2014

Dear Dr. Reed,

I was never circumcised and seek adult circumcision now.  Will I encounter any pain?

Mahmood

 

Good morning Mahmood,

We start out by applying numbing cream to the penis so you do not feel
the local anesthesia.  We don’t rush, this gives the anesthesia a chance
to work.  If you have a loved one who wants to be present, we would welcome that.

Patients smile as they leave the office, and by and  large remain free of serious discomfort
as evidenced by our  followup contact with them.  The best investment you can provide yourself
to reduce discomfort is to be on  bed rest for 2 days afterwards.

After seeing so many circumcised men who look very  much like they were done later in life, because
of large suture tracts, and irregularly meeting  skin, I developed perhaps a unique approach to
be sure this did not happen to my patients,  and have found no need to vary over the past 15
years.

If there is further interest please call and ask  for Anne our amiable office manager who
will assist with arrangements.

We hope to have the pleasure of serving you  whenever your travel plans include the South
Florida area.

With kindest regards,

Harold M. Reed, M.D.
305-865-2000

P.S.   Take a look at this unsolicited web-site
constructed by a patient of mine.  Is this
what you have in mind?  Especially the
photos taken 60 days post-op.

http://www.circlist.com/considering/davids_freehand_circumcision.html

Also view:  http://www.circlist.com/considering/findphysician.html
and read several unsolicited recommendations.


 

Wrinkles after a circumcision

October 3, 2014

Dear Dr. Reed,

Had an adult circumcision few years ago but have longitudinal wrinkles distal to the incision.  Is this normal and can it be corrected.

Candido

Good morning Candido,

You are not alone.  Remember the foreskin may be very loose and its circumference may be larger than shaft skin.This is why we have a hand held mirror in the operating room for our patients. If you can see it, I can see it.

The remedy it to cut a strip of skin out from the underside and redo perhaps the lower half of your circumcision.  The recovery should be a lot easier this time.

Hoping this is of help.

Harold M. Reed, M.D. FICS

Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America
305-865-2000

Considering a vasectomy in Miami, how often does chronic pain afterwards occur

October 3, 2014

Dr. Reed,

Would like a vasectomy.  My wife and I think it’s about time.  We have 3 beautiful and well behaved children. I have heard that some patients may have lingering pain afterwards.  Could you please comment.

Clinton

Hi Clinton,

These reports are real, but occur very infrequently.    Please review our web-site http://www.penisdoctor.com/vasectomy.htm   5% of men who have never had a vasectomy have complaints of scrotal pain at times.  In  part the pain may be attributable to testicular congestion syndrome and if conservative treatment does not work, and local anesthetic injection of the cord removes the pain, then perhaps a vas reversal can be done.  If the patient has a chronic epididymitis, a structure that sits on top of the testicle, the epididymis can be removed.  Sometimes, nerve dissection is helpful.

In 35 years of urological experience no patient has re-approached me complaining of chronic scrotal or testicular pain.

Enjoy your wonderful marriage,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

3 years of 90 degree Peyronie’s and shortening 3 inches

October 1, 2014

Dear Dr. Reed,

Have bad case of Peyronies’s.  A nearly 90 degree bend to the left and if that’s not bad enough lost 3 inches of length.

Really don’t know how it happened but have had this condition for 3 years.  Fortunately am still able to penetrate, but not a happy camper.

How do you think this happened?

My local urologist wants to do suture plication which will shorten me even further.

Any thoughts?

Merv

Dear Merv,

The most common cause of Peyronies’s that I know of is female above trauma or generally speaking sexual trauma.  It hurts, you may have a bruise, and you remember the event.  Another siltation is rolling over on a nocturnal erection.  You may not recall that.

If your rigidity is good, then maybe a trial of Xiaflex injections, very costly (thousands) if you don’t have insurance.  Auxilium the manufacture describes a successful result as an improvement and that may not be satisfactory to you.  There are also the unfortunate complications of penile rupture less than 1%, and hemorrhage maybe 3 to 4%.

Xiaflex (Collagenase) will “melt” the tensing collagen scar tissue fibers.

Another option is traction, a vacuum erection device, perhaps 5 PDE inhibitors such as Cialis, Viagra.  If your erections are weak, surely consideration can be given to a  penile implants and simultaneous repair of the constricted area,.  Another option is to repair the scar now with a graft.  Graft success is less than plication which is almost uniformly successful. But certainly a worthwhile option to consider.  If the corporal tissue (spongy erectile tissue) inside has been injured also, the erections may be somewhat hinged, as a good outer tire without a good inner tire is not going to provide the rigidity you desire.

Hoping this is of help,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

The underside of my penis was not properly aligned

 

September 30, 2014

Dear Dr. Reed

Had an adult  circumcision and the underside of my penis is not lined up properly.  Can this be corrected.

Phil

Good morning Phil,

The guideline structure on the underside is called the raphe or pigmented line that  extends to the scrotum.  Going distally it continues on the underside right out to the frenulum.

In some men’s penises the raphe takes a random walk and is not perfectly straight, but never beyond reach of rejoining properly.

When doing a circumcision closure this is the first suture placed so I am absolutely sure these lines  come together.  We are fussy within less than a 1/16th of an inch.  Then we place along the central suture 2 others for strength.  The next suture is placed on the opposite side.  We say 12 o’clock.  The first sutures were at 6 o’clock and we  continue to bisect all the way around.  This keeps things even.  There are many ways to do a circumcision, but this has always made the most sense to me.

Please call Anne or Nicole at the office for scheduling.

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

Hard scar from previous circumcision

Dear Dr. Reed,

I had an adult circumcision about 6 years ago. After healing and things settled I noticed a hard scar about the size and shape of a grain of rice along the incision line. The incision line otherwise healed very well. The scar I am speaking of is part of, or within, the skin (not attached to actual shaft underneath). It seems as if it were an object trapped in a pocket between layers of tissue as the object can be pinched and “wiggled” around ever so slightly within the skin. My circumcision was done using super fine dissolvable stitches and there were no upsets or other complications during healing. I am wondering if you might have any thoughts or experience on this matter. I am strongly considering a revision that would tighten while also removing this object
Jack

Good morning, good Sunday Jack,

Scars of this type may be related to how surgery was performed, perhaps your underlying suture layer, if one was employed, perhaps a cautery effect.  We also use relatively fine fast absorbable sutures, 4-0 and 5-0 Vicryl Rapide, however, we insist that they be removed on the 12th post-operative day.  We tell patients if you go the many a doctor or urgent care center in your home town they will argue, they’re absorbable they do not have to be removed.  However, 10% of patients that let them melt out have some scarring or white cross hatch marks.

Next, I would ask you to look at any other surgical scars on your body an see how they healed.

You might consider a low dosage (dilute) Kenalog judiciously injected all the way around.  This may also be a remnant of a preputial scar.  We have talked about this before on procircorg.

If this doesn’t, work and the subcutaneous band bothers you enough, this can be revised, by an extremely careful surgeon and you’ll have your desired tightening also.  A cosmetic circumcision.  Loosening can be secondary to weight gain which is noted more if you stand up.  You should be pre-marked in  accordance with your exact wishes.

Please provide a followup.

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America
305-865-2000

 

Can you do a V-cut?

September 27, 20914

Dear Dr. Reed,

Need an adult circumcision.  Do you do a V-cut?

Elliott
Papillion, NE

Dear Elliott,

We can do a V-cut, but I think this confers nothing to the cosmetics of a circumcision.
A V-cut is done on the understudied of the penis, the point being closer to the head.

The concept (perhaps) is that by providing extra skin, there is less of a tendency for a
peno-scrotal web.  Because of the “cocked” position of the head of the penis, the underside always
requires more skin.  What we do is take this into consideration when we make the incision.  More skin
is provided on the underside.  If you insist we’ll do it and we’ve done it before, but you’ll be one out of a 1,000.

Something to think about.

With kindest regards,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

High and tight, really?

September 21, 2014

Dear Dr. Reed,

What are the advantages of a high and tight circumcision?  Not sure that’s the way I want to go.

Merlin

September 21, 2014

Good afternoon Merlin,

“High and tight” and your name seems to be words we just can’t forget.  However, shiny tight (really tight)  is not a style I would recommend.  The reason being it is more predisposed to separating during the first 2 to 3 weeks of wound healing, even despite erection suppressors, and there’s always the possibility you might say, my erections were longer before you made the circumcision so tight.

Who wants to take the blame for that.

High again we do but not my favorite in that preservation of most of the inner foreskin leaves you with the portal for HIV transmission.  If you have any tendency towards phimosis you may develop paraphimosis or a ring like contracture on the mid shaft leading to serious swelling of your distal shaft,  2 other reasons, pulling on the septa, the fibrous strands  that limits skin mobility is not natural.  When a circumcison is performed moderately the septae are pretty much perpendicular to the skin contour.  Lastly there will be more distal swelling which should, but not always recede with time.  Or put another way,  Delayed wound healing.

Take a look at photographic examples  http://www.penisdoctor.com/photo-circumcision.htm

Hoping this is of help,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America

305-865-2000

What is a metoidioplasty

September 21, 2014

Dear Dr. Reed,

I am a genetic female, have never felt comfortable, and am ready for an FTM sex change.  I have no desire for penetrating sex, and would like to consider a metoidioplasty which is a lot less expensive than a phalloplasty.  Yes, I would prefer a stand to void result.  You say urethral extension.  Could you provide some basic information?

 Sammy

September 21, 2014

Good morning Sammy,

Me-toi’-dio-plasty (accent on the second syllable)

Metoidioplasty is taken from the Greek words, meta meaning toward, oidion meaning male organs, and plasty to form.

In  this procedure the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further.   When the female tissues have been primed with testosterone, the clitoral head may resemble an adolescent glans penis, although the proportionality or size may be smaller.  The term “juvenile” sized phallus might be apt.  If you have been on testosterone and experience clitoromegaly, self examination of your glans and clitoral body will give you a very good idea of what to anticipate post-operatively once surgical swelling subsides (6 to 8 weeks).

Although visible engorgement may occur during arousal, the phallus is not suitable for penetration, nor is ejaculation possible.

For those  patients who desire to void standing, the urethra is extended into the neo-penis. This may be accomplished simultaneously or performed secondarily using either a vaginal flap or buccal mucosal graft.  Please understand in  that metoidioplasty involves a fair amount of tissue transfer, some degree of temporary post-operative swelling is expected.  When the swelling subsides, the result will be longer.

Complications may include but are not limited to less than anticipated length, torquing of the clitoris (usually amenable to release), loss of sensation, tissue necrosis, localized infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening which may render the vagina incapable of penile penetration, urethral narrowing, urethral obstruction, and urethral fistula (leakage of urine anywhere along the pathway of urethral extension).  Between the first and second stages leading to urethral extension, voiding patterns and trajectory may be forwards or backwards and may splash wetting perineal, labial and vaginal skin.

Please see our web-site http://srsmiami.com/FTM-female-to-male.html and photographic examples.  Complications that can occur with a urethral extension include structure or narrow of the urinary passage way and urinary fistula.  It is recommended that ideally you have a laparoscopic hysterectomy and removal of the ovaries and tubes first, and then closure of the vagina, colpocleisis.  The incidence of fistulas is reduced.

Have a restful Sunday,

Harold M. Reed, M.D. FICS
Senior Member of the American Urological Association
Member Society of Genito-Urinary Reconstructive Surgeons
Founding Member and Treasurer of American Academy of Phalloplasty Surgeons
Founding Member Sexual Society of North America
305-865-2000