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Circumcision - a patient's and caregiver’s guide.
Circumcision is a subject that is somewhat like religion or politics to discuss. People tend to have strong views on the subject from a predetermined position and no amount of evidence will change their positions. The consensus view of the Australasian College of Physcians is that “there is no medical indication for routine neonatal circumcision.” I have found that the best that I can do is to provide information and make people aware of some of the issues for consideration when considering circumcision.
The main reasons that I have encountered for circumcision in New Zealand are:
Babies
- Personal reasons of the parents, that circumcision is more hygienic
- Religious reasons, in particular Jews and Muslims
- Cultural reasons, particularly for Polynesians
Children
- Cultural reasons, particularly for Polynesians, Filipinos, and Fijians
- Medical reasons, usually recurrent infection of the foreskin and/or the head of the penis. By this age group phimosis can also be a problem.
Teenagers
- Cultural reasons, particularly for Polynesians, Filipinos, and Fijians
- Medical reasons, recurrent infections, phimosis
- Sexual reasons, they and/or their partner do not like the foreskin
- Hygiene reasons, they and/or their partner do not like the smell of the smegma that develops under the foreskin.
Adults
- Cultural reasons, (some have missed getting this done earlier)
- Medical reasons, recurrent infections, phimosis
- Sexual reasons, they and/or their partner do not like the foreskin
- Hygiene reasons, they and/or their partner do not like the smell of the smegma that develops under the foreskin.
The frequency of circumcision varies from country to country. In New Zealand and Australia the rate is approximately 10-20% of boys but as mentioned above there are significant cultural differences. Rates of circumcision, for comparison, are much higher in the USA - up to 60% -, 6% in the UK and in Europe the rate is lower at less than 2% in some countries.
Reasons for Circumcision
1. Hygiene
Some parents believe that it is more hygienic or at least it is easier to care for a boy's penis if it is circumcised.
Infection or inflammation of the foreskin affects 3%-4% of uncircumcised boys. This means that 96%-97% of all boys will not have any problems with infection of the foreskin - urinary tract infections occur in about 1-2 in 100 uncircumcised boys, and 1 in 500 in circumcised boys.
There is an increased risk of inflammation and infections of the foreskin and glans in uncircumcised males. However it will come down to personal opinion whether the increased risks are significant enough to warrant circumcision. As stated above it is the opinion of the medical fraterenity that routine circumcision is not medically justified.
2. Other infections
Uncircumcised adults have an additional increase in the risk of foreskin infection, such as candida (thrush) especially if they also have diabetes.
There have been studies that have shown that some sexually transmitted infections (STIs), particularly herpes, gonorrhea and syphilis, are less frequent in circumcised men. Other STIs such as - NSU and genital warts have similar rates in both groups, one recent study suggests NSU may be higher in circumcised men.
Studies from Africa have shown that circumcised men are at less risk of becoming HIV infected than uncircumcised men however this is not reproduced in USA studies. The suggestion has been put forward that the reason for this is that there is a different HIV subtype in Africa than in developed countries, which may account for the difference.
However circumcision cannot be promoted as a protection from contracting any STI including HIV.
3. Religious Reasons
Circumcisions for religious reasons date back to Biblical times and the story of Abraham circumcising himself and his sons as a sign of his devotion to God. Jews and Muslims continue this custom to this day and firmly believe that circumcision is an integral part of their religion.
Other religious groups also continue the practice of circumcision to a greater or lesser degree.
4. Cultural Reasons
Some cultures strongly believe in circumcision, and circumcision is an integral part of their culture. Notably the Pacific Islanders in New Zealand have an almost 100% circumcision rate. The Pacific Islanders traditionally choose to have circumcision performed in late childhood or early puberty as a rite of passage to manhood.
5. Medical Reasons
A small number of males will need to have circumcision for medical reasons because of recurrent inflammation and infection to the foreskin and glans. This can produce tightening of the foreskin (phimosis) that makes it difficult or impossible to retract the foreskin, which leads to poor hygiene and further infections.
Circumcision or dorsal slit (which is dividing the foreskin on the upper side of the penis to make the foreskin easier to retract) are the only solutions if the problem is not able to be resolved with medications.
6. Social/Sexual
Some men seek to have circumcision because they or their partners prefer to have a circumcised penis. Some of the reasons found for this request are that the foreskin is very tight with an erect penis but may not be a problem when the penis is not erect. In some cases the foreskin can tear with an erection.
Some couples complain of the smell of the smegma especially with oral sex (fellatio) before circumcision. Others state that they just prefer the appearance of a circumcised penis to a non-circumcised penis.
7. Cancer Risk
There is a 1 in 100,000 risk of getting cancer of the penis in uncircumcised men. This is not a high risk and I have not had anyone have a circumcision to prevent cancer as a reason.
The Circumcision Procedure
Circumcision can be performed under local anaesthetic (penile block) with or without sedation or general anaesthesia. It is not recommended that circumcision be done without anaesthetic because even newborns can feel the pain and have a measurable physiological response to the pain. In the age group from about 6 months to 10 years it is difficult to do the procedure under local anaesthetic because of the inability to convince the child to lie still while the injections are given; general anaesthesia is usually required in this age group. Local anaesthetic is probably the anaesthetic of choice in babies and is also equally successfully used in older boys and men.
There are a number of methods of actually performing the removal of the foreskin and each surgeon has their preferred technique, which sometimes is different in the different age groups. For babies I use a circumcision tool to minimise bleeding and protects the penis during the operation. In older children and adults the circumcision is performed with surgical scissors. Absorbable sutures are used.
Postoperative care involves giving pain relief, usually paracetamol is sufficient, and keeping the operation site clean. The penis will be swollen for a period of time postoperative but this settles over the first week.
Circumcision Risks
Complications of circumcision range from 2% to 10% The following are possible complications:
- Infection - this is easily treated with topical or oral antibiotic.
- Post operative persistent bleeding - this may need a suture or cautery to stop the bleeding.
- Meatal stenosis - where the opening of the urethra becomes narrowed which makes it hard to pass urine. This is rare and should not happen with good post-circumcision care.
- Excessive skin, skin bridging, stitch sinus are other rare problems that can occur and may need surgery to repair.
- Too much skin removed. This is caused by the procedure being performed by an inexperienced operator.
- Glanular ulceration. This can occur in association with post operative infection.
- Other inadvertent injury during surgery – to the urethra and to the penis.
- Anaesthetic complications; this is rare with local anaesthetic but there is a risk of allergy to local anaesthetic.
- Psychological trauma.
- Secondary phimosis if the foreskin grows back over the penis after circumcision. This is avoided by following the post circumcision cleaning instructions.
- Secondary chordee caused by scarring after circumcision.
How Do I Care For The Foreskin If Circumcision Is Not Done?
These are the cleaning instructions that I give to my patients. The foreskin should be cleaned each bath time, like any other part of the body, this should be done by gently pulling the foreskin back as far as it will go without any force (as this may cause the foreskin to tear) and any collection trapped in the foreskin gently cleaned. With time the foreskin will retract back further and further until completely free. Once the boy is old enough to wash himself he should be taught how to clean the foreskin daily himself. I also advise boys to get into the habit of pulling the foreskin back to urinate so that they do not urinate through the foreskin, as this helps to reduce foreskin irritation and infection, but they must remember to pull the foreskin forward again when finished.
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