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

Tight skin left behind after an adult circmcision for phimosis

 

September 19, 2014

Dear Dr. Reed,

Had phimosis.

I recently had a adult circ done by my local urologist. I may want a Second opininion and discuss possible revisions done based on my concerns. I’m in the third week of healing right now. I’m 31 years old.

He did a sleeve resection from the top and I wanted more removed because a ring of tight skin is left just below the stitch line from phimosis caused by previous issues with Balinitis. If he had gone a bit lower in the cut he could’ve removed that as well as given it a high and tight look even when flacid. I don’t know if you can remove more skin from the top to resolve these issues

So can this be fixed? And how long should I wait before doing a revision? Could I possibly do a high and tight with frenulum removal while ridding this scar tissue ring at the same time?

Murray

September 19, 2014

Good afternoon Murray,

Called at 3:27 EDT and left a message.  Thank you for your interest in what we do.  We have performed over  8000 cosmetic circumcisions and revisions in the past 35 years and usually do several cases every week. The situation you describe is not unfamiliar.

It is very tempting just to remove the preputial (phimotic) ring and think that would be it, but in reality the scarring of a phimotic prepuce extends  upwards on your flaccid penis involving more foreskin that you might imagine.  A prudent urologist can feel this scar and will always remove it so that healthy skin is attached to healthy skin.

Worst case scenario is that you may develop a paraphimosis, a contracture ring in the distal haft that initially will cause swelling and if extensive  may strangulate circulation to the distal shaft and head.

At this time my concern is that the circumferential incision line is not that tight you develop distal swelling (paraphimosis).

Your penis is one of the most important functional and cosmetic features of your body.  Take good care of little Murray.

All the best,

 

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

Keratoses near incision line of a past circumcision

September 19, 2014

Dear Dr. Reed,

Had a circumcision several years ago for phimosis and was told I have keratoses near the suture line.

Could you explain.

Phillip

September 19, 2014

Good morning Phillip,

A keratomas is like a little wart

Keratosis (from keratinocyte, the prominent cell type in the epidermis and -osis, abnormal) is a growth of keratin on the skin or on mucous membranes. More specifically, it can refer to: actinic keratosis (also known as solar keratosis), hydrocarbon keratosis keratosis pilaris (KP, also known as follicular keratosis), and seborrheic keratosis

Actinic keratoses are pre-malignant growths. Seborrheic keratoses are not pre-malignant.

This could represent a residual scar from your phimosis that was never well removed during your initial circumcision, could be a suture reaction, even though the stitches have ostensibly melted or were removed.  Are you a sun bather (in the nude)?

To best advise, I would have to see you at the office.  The remedy could be as simple as pin point cauterization or you may require a revision of that area of your circumcision.

Best wishes,
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

Beliefs about penile size, self evaluation questionnaire

Beliefs about Penile Size: Validation of a Scale for Men Ashamed about their Penile Size
by David Veale, MD FRC Psychology, Ertimiss Eshkevan PhD et al

Journal of Sexual Medicine Volume 11, Number 1, 2014

A questionable entitled Beliefs about Penile Size (BAPS) was developed and 173 participants were surveyed.

The study concluded their is no correlation to penile size and feelings of inadequacy as men with penile lengths less than normal felt adequate and men with lengths above average felt inadequate and ashamed.  In this study erect lengths varied of course but the median was 5.9 inches.   Flaccid circumference median is 3.9 inches.

Comment: These stats are somewhat above the figures we use, average about 5.5 erect and flaccid circumference 3 5/8 inches (3.625).

Still women with perfectly normal sized breasts will see plastic surgeons requesting larger.  My responsibility is to assure patients they are normal or above average when applicable.

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

Adult and adoldescent circumcision, father and son

September 14, 2014

Hi there Dr. Reed,

My family will be here in the states this October.  Would it be possible to do an adult circumcison on myself and one for my son who is 14?   My wife is a nurse with surgical background?

Could she be present?

Drew

September 14, 2014

Good morning Drew,

We have done about 8000 adult and some pediatric circumcisions. We trust your son is in favor of the procedure.

We have found then when a non-hysterical relative or friend is in the operating room, patients are more relaxed and the operation seems to go faster.  In fact we have yet to see a hysterical relative.  Only a few say they’ll sit outside.

Regarding your son, please discuss that this procedure is being done under local (anesthesiology is available but adds 500) to the cost.

I once recall doing an eight year old boy and asked his mother if her son is very mature for his age.  She said “Oh Doctor, Richard is very mature for his age.”   Circumcision proceeded uneventfully and at the end, the patient like an Olympic acrobat spring jumped off the end of the table, landed squarely on the floor without a shake,  held out his hand and said “thank you, doctor.”

At which point I could only say, Mr. Smith, you are right, your son is very mature for his age.

Call Anne on Monday for scheduling.  She will offer some discount as both are being done the same day.

Cheers,

Harold M. Reed, M.D.
“There will always be an England”