CIRCUMCISION, NOW AND LATER.

What is circumcision?

The procedure is commonly performed shortly after birth or around puberty.

Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce).

How common is circumcision?

About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty.

Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.

Non-retractable foreskin in children

Contrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies.

About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds.

It's not necessary to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.

The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below). But this persistence is not a reason for circumcision.

A non-retractile foreskin does not of its own accord require circumcision unless it's causing symptoms.

Why circumcise?

Reasons for circumcision fall into three broad groups:

• for an medical indication
• to prevent future disease
• as an act of religious dedication.

Circumcision for a medical reason

Medical reasons for Circumcision include phimosis, acute balanoposthitis or paraphimosis.

Phimosis

In phimosis the opening of the foreskin is narrowed, preventing retraction. Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted.

Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old.

Symptoms can include:

• irritation or bleeding from the edge of the foreskin, particularly during sexual intercourse or masturbation
• stinging or pain on passing urine (dysuria)
• inability to pass urine if the foreskin is very tight.

The changes in the prepuce are due to a condition known as balanitis xerotica obliterans. Circumcision is advisable in most cases.

Acute balanoposthitis

This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans.

Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined.

Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention.

Circumcision is only done for recurrent and troublesome cases.

Paraphimosis

This condition is caused by pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement to its normal position.

The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again.

If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic.

Circumcision is not usually performed at this stage because of the associated inflammation, but may be required later if the foreskin remains tight.

Circumcision to prevent future disease

Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor.

The practice is, more likely, rooted in cultural traditions, although western societies may find this an uncomfortable conclusion.

Penile cancer

Cancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men.

However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection.

Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised.

Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups.

Therefore, routine circumcision cannot be recommended to prevent penile cancer.

Sexually transmitted diseases

Sexually transmitted diseases that cause ulcers on the genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised men.

However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts.

Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.

Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted diseases, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.

Human immunodeficiency virus (HIV) infection

Views conflict on whether circumcision can prevent HIV infection.

A recent review in the British Journal of Urology concluded that there is no link between having an intact foreskin and HIV infection, whereas another paper in the British Medical Journal takes exactly the opposite view.

Circumcision may be appropriate as a routine preventive measure only in regions that have a high rate of HIV infection, such as sub-Saharan Africa. The existing evidence is inadequate to recommend circumcision as an HIV-preventive measure in the UK.

Cervical cancer

A study in 1947 reported that Jewish women rarely developed cervical cancerand the author attributed this finding to the fact that their sexual partners were circumcised.

Further studies over the past 50 years have had contradictory conclusions, with experts enthusiastically championing the case for and against circumcision. The evidence is inadequate to recommend it as a preventive measure against cervical cancer.

Urinary tract infection (UTI)

Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a urinary tract infection (UTI). One in 100 uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised infants.

A UTI is not usually a great risk to health, so it does not seem reasonable to perform a surgical procedure on 100 infants to reduce the risk of one developing UTI.

Circumcision as an act of religious dedication

The circumcision of male children is a central feature of both Judaism and Islam. It is also important in many African and New World cultures.

An increasing number of committed Jewish and Muslim people reject circumcision on ethical grounds, although they are certainly the minority at present.

Attitudes to circumcision may provoke fierce hostility within families and among communities. In the past, wars have been fought, and thousands have died, to preserve the right to circumcise when rulers from other cultures forbade it.

Judaism

In the book of Genesis (17: 10-14), circumcision represents the covenant made by God with Abraham and his descendants.

Traditional religious circumcision is performed by a mohel (pronounced mo-hell in Hebrew or moyle in Yiddish). It is usually carried out on the eighth day after birth, unless there is a danger to the child's health, in which case it should be delayed until that danger has passed. In the UK, mohelim attend 40 to 50 circumcisions and have to pass practical and theoretical examinations during their training before performing circumcision alone.

Islam

The divine law or sharia defines every aspect of Muslim life. It is based upon the Holy Koran, the hadith (the sayings of the Prophet Mohammed) and the sunnah (Prophet's tradition).

All Muslims agree that these are the three sources of Islamic law, but different groups interpret their application in different ways. Circumcision is not mentioned in the Koran, but has the status of sunnah. Only the Shafiite school of law regards circumcision as obligatory (wajib), while the Hanafite, Jafarite, Malikite, Hanbalite and Zaidite regard it as only recommended, because it is sunnah.

Even those who consider circumcision an obligatory duty for themselves do not see it as an essential requirement for others to become a Muslim. However, the procedure is very commonly practised and is certainly seen as an important external symbol of submission to God's will.

Should we avoid circumcision?

The foreskin is not simply a useless piece of skin, to be disposed of without careful thought. It forms the covering of the head (glans) of the penis in men and the clitoris in women. It is very rich in nerves responsible for touch and the movement of the foreskin backwards and forwards over the glans provides some of the pleasurable sensation experienced during sex.

Adult males that were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin.

However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation.

How is circumcision performed?

Circumcision is usually performed as a day case procedure under a general anaesthetic.

There are many different techniques to achieve the same effect, which is to remove the foreskin and suture the skin on the shaft of the penis to the remaining mucosal lining beneath the head of the penis. The sutures used are absorbable and do not need removal.

Complications of circumcision

Happily, complications of circumcision are relatively rare, although they may be under-reported following religious or cultural circumcision.

For this reason, figures on the rate of complications may not be reliable.

Complications include:

• swelling of the penis which may last a few days (common)
• bleeding, infection, reduced penile sensation (less common)
• tenderness in the scar, poor cosmetic outcome (rare).

Can circumcision be reversed?

Attempts have been made to restore the foreskin following circumcision since ancient times. Unfortunately, no procedure had satisfactory results.

Modern surgical procedures may have more success, but they are still experimental and the long-term results are unknown. If foreskin restoration is being considered, a urologist should be consulted.

Female circumcision is not required by any religious group and is a traditional practice prevalent in Africa, Southeast Asia and South America.

Example image circumcision with clamp tehnic:

The foreskin is a sleeve of tissue which covers the penis. At birth the foreskin is tightly attached. By mid-childhood it can be pulled over the penis when the penis is flaccid, or retracted back over the shaft of the penis during urination or erection.

The common indication for circumcision is cultural or religious desire for circumcision. Other indications (rare):

• treatment for inability to pull back the foreskin completely (phimosis)
• infection of the penis (balanitis)

Circumcision of a newborn boy is usually done before he leaves the hospital. A numbing medication (local anesthesia such as Xylocaine) is injected into the penis to reduce pain. Ring-type clamps are placed around the foreskin, tightened like a tourniquet to reduce bleeding, and the foreskin is removed below the clamp. Sometimes a plastic clamp is used (Plastibell). The Plastibell will fall off in 5 to 8 days, after the surgical site has healed.

For both newborns and older children, circumcision is considered a very safe procedure with complete healing expected. Healing time for newborns usually takes about 1 week. Apply petroleum jelly after diaper changes to protect the healing incision. Some initial swelling and yellow crust formation around the incision is normal. Healing time for older children and adolescents may take up to 3 weeks. In most instances, the child will be discharged from the hospital on the day of the surgery.

It's far more disfiguring, disabling and potentially dangerous than male circumcision so cannot be viewed in the same light. The original author fully supports the World Health Organisation's policy that this procedure should cease throughout the world.