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Anesthesia can be accomplished by administering a dorsal penile nerve block, with or without a ring block.7 The penis is innervated by the left and right dorsal nerves; these are branches of the pudendal nerves.8 The dorsal penile nerve is blocked by injecting a local anesthetic solution deep to Buck's fascia where the nerves emerge from under the pubic bone. After preparation of the skin, two injection sites are identified over the inferior edge of the pubic bone at approximately 10 o'clock and 2 o'clock relative to the base of the penis.

A 27-gauge, 1.5-in needle is inserted, directed ventrally, until the pubic bone is contacted.

Recurrent balanitis and posthitis (inflammation of the prepuce), preputial neoplasms, excessive prepuce redundancy and tears in the frenulum are also medical indications for adult circumcision.5Patients may have social, religious or personal reasons for requesting a circumcision.6 It is important to explore these reasons with the patient to ensure that he has a thorough understanding of the risks and benefits of circumcision and alternatives to the procedure.

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The sleeve technique may provide better control of bleeding in patients with large subcutaneous veins.

A dorsal penile nerve block, with or without a circumferential penile block, provides adequate anesthesia. Possible complications of adult circumcision include infection, bleeding, poor cosmetic results and a change in sensation during intercourse.

The procedure is commonly performed using either the dorsal slit or the sleeve technique.

The dorsal slit is especially useful in patients who have phimosis.

Sterile draping of the area should be used to identify the surgical field.

An electrocautery unit should be available to provide hemostasis.All family physicians should be prepared to advise their patients about the indications for adult circumcision and, if necessary, make appropriate referrals for the procedure.Although there are numerous medical indications for adult circumcision, none of them is very common.3 The most frequent indication is phimosis, a tightness of the prepuce that prevents its retraction over the glans.4 A patient may also complain of pain with erection or during intercourse.The needle is “walked” caudad off the pubis and through Buck's fascia.After aspiration, 5 m L of local anesthetic is injected at each site.Preparation of the surgical site includes a thorough surgical scrub of the genital area with a povidone-iodine preparation.

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