Penile adhesions (a.k.a soft penile adhesions): foreskin that is attached to the glans penis, but that can be pulled back without creating bleeding or having to incise/cut anything (releasing penile adhesions is painful for the patient, so I would not recommend doing it beyond the first few months of life). An instrument cannot be passed under penile adhesions like with bridges.
Penile skin bridge: scar tissue originating at the circumcision line attaching to the glans penis that cannot be released without causing bleeding or without cutting it. When the bridges are small, is easy to pass an instrument under them. Some bridges can be hidden by soft penile adhesions in the first few years of life, when soft adhesions are common.
Circumcised versus uncircumcised penis
Penile skin bridges do not occur on uncircumcised penises. Penile adhesions, on the other hand, are normal in the uncircumcised penis up to a certain age. I personally would not recommend doing anything about soft penile adhesions in uncircumcised penis if no pain or bother at least until puberty.
One not often discussed complication of circumcisions is penile skin bridges. The incidence is not well documented but based on my practice they appear to occur with more frequency than meatal stenosis, which itself occurs after 7% of circumcisions.
Penile adhesions in circumcised boys are very common as shown in this paper from the Journal of Urology: Penile adhesions after neonatal circumcision.
Who “needs” treatment
It’s reasonable to take care of penile skin bridges at some point when is convenient. The ideal age for this is before 1 year of age or after 3 years of age since the easiest way to take care of these is in the clinic under topical anesthesia (toddlers are not great for office procedures but they are ok). Many surgeons would take patients to the operating room to take care of bridges but I consider that to be unnecessary in 90% of patients. I will admit that EMLA does not completely numb the area, especially if you don’t apply it under the bridge, but the procedure is so fast that most families are ok putting up with a little pain if you explain it well before the procedure.
I recommend treatment of bridges because many teenagers with them request to have them removed. This means that they do not go away and cause bother.
Some large penile bridges would be difficult to remove in the clinic and thus require general anesthesia (if the patient is not old enough to tolerate a penile block in the office). This large bridge was addressed under brief general anesthesia:
Penile adhesions, on the other hand, I would not treat under most circumstances because of the following reasons:
- Is normal to have them
- They tend to come back if you treat them unless the family is diligent at pulling the foreskin back.
- They cause no harm. Occasionally you will see episodes of foreskin infection (balanoposthitis) that could be blamed on the adhesions but infections can also happen without them so who knows for sure how much blame they deserve.
- If the adhesions are still there after puberty or are associated with pain with erections, what the patient needs is to clean his penis. The lack of hygiene causes irritation, which causes pain. Pain then causes the patient to not clean his penis, creating a vicious cycle which ultimately could cause cancer in uncircumcised patients.
And the most important part: how to prevent penile skin bridges and penile adhesions in circumcised patients
There is an easy way to prevent penile skin bridges and penile adhesions: see the patient 1 week after the circumcision and make sure you can see the entire corona of the penis circumferentially.
If not, it should be early enough that you could just pull the skin back quickly and release all the attachments, instruct the parent to pull back with diaper changes/apply vaseline and check on the patient again 1 week later. If next week you can see the entire corona then that is it. Just instruct the family that they need to see and clean the corona once a day. If they do that, I do not think it would be possible to end up with a penile skin bridge.