Circumcision

Definition

The surgical removal of the foreskin of the penis or prepuce.

(Fig 3.20a; Fig 3.20b.)
A typical circumcision procedure involves the following steps: Figure A: The surgeonmakes an incision around the foreskin. Figure B: The foreskin is then freed from the skin covering the penile shaft. Figure C: The surgeon cuts the foreskin to the initial incision, lifting the foreskin from the mucous membrane. Figure D: The surgeon sutures the top edge of the skin that covers the penile shaft and the mucous membrane.



Purpose

In the United States, circumcision in infant boys is performed for social, medical, or cultural/religious reasons. Once a routine operation urged by pediatricians and obstetricians for newborns in the middle of the twentieth century, circumcision has become an elective option that parents make for their sons on an individual basis. Families who practice Judaism or Islam may select to have their sons circumcised as a religious practice. Others choose circumcision for medical benefits.

Female circumcision (also known as female genital mutilation) is usually performed for cultural and social reasons by family members and others who are not members of the medical profession, with no anesthesia. Not only is the prepuce removed but often the vaginal opening is sewn to make it smaller. This practice is supposed to ensure the virginity of a bride on her wedding day. It also prevents the woman from achieving sexual pleasure during coitus. This practice is not universally approved by the medical profession and is considered by some as a human rights violation.

Though the incidence of male circumcision has decreased from 90% in 1979 to 60% in 1996, it is still the most common surgical operation in the United States. Circumcision rates are much lower for the rest of the industrialized world. In Britain, it is only done for religious practices or to correct a specific medical condition of the penis.

Some of the medical reasons parents choose circumcision are to protect against infections of the urinary tract and the foreskin, prevent cancer, lower the risk of getting sexually transmitted diseases, and prevent phimosis (a tightening of the foreskin that may close the opening of the penis). Though studies indicate that uncircumcised boys under the age of five are 20 times more likely than circumcised boys to have urinary tract infections (UTIs), the rate of incidence of UTIs is quite low. There are also indications that circumcised men are less likely to suffer from penile cancer, inflammation of the penis, or have many sexually transmitted diseases. Here again, the rate of incidence is low. Good hygiene usually prevents most infections of the penis. Phimosis and penile cancer are very rare, even in men who have not been circumcised. Education and good safe sex practices can prevent sexually transmitted diseases in ways that a surgical procedure cannot because these are diseases acquired through risky behaviors.

With these factors in mind, the American Academy of Pediatrics has issued a policy statement that states though there is existing scientific evidence that indicates the medical benefits of circumcision, the benefits are not strong enough to recommended circumcision as a routine practice.



Precautions

Circumcision should not be performed on infants with certain deformities of the penis that may require a portion of the foreskin for repair. The most common condition for surgery using the foreskin is hypospadias, a congenital deformity of the penis where the urinary tract opening is not at the tip of the glans. Also, infants with a large hydrocoele or hernia may suffer important complications through circumcision. Premature infants and infants with serious infections are also poor candidates to be circumcised, as are infants with hemophilia, other bleeding disorders, or whose mothers had taken anticoagulant drugs. In older boys or men, circumcision is a minor procedure. Therefore, it can be performed in virtually anyone without a serious illness or unusual deformity.

Description

The foreskin of the penis protects the sensitivity of the glans and shields it from irritation by urine, feces, and foreign materials. It also protects the urinary opening against infection and incidental injury.

In circumcision of infants, the foreskin is pulled tightly into a specially designed clamp, and the foreskin pulls away from the broadened tip of the penis. Pressure from the clamp stops bleeding from blood vessels that supplied the foreskin. In older boys or adults, an incision is made around the base of the foreskin, the foreskin is pulled back, and then it is cut away from the tip of the penis. Stitches are usually used to close the skin edges.

Preparation

Despite a long-standing belief that infants do not experience serious pain from circumcision, most authorities now believe that some form of local anesthesia is necessary. The physician injects local anesthesia at the base of the penis or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves. EMLA cream, a topical formula of several anesthetics, can also be used.

Aftercare

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring will usually fall off in five to eight days. The penis will heal in seven to 10 days.

Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally these go away within a day. In older boys, the penis may be painful, but this will go away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a "bruise" on the penis, which typically goes away with no particular attention.

Risks

Complications following newborn circumcision appear in one out of every 500 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and present with fever and signs of inflammation.

There may be injuries to the penis itself, and these may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit their infant patients.