Male circumcision is the surgical removal of the penile prepuce or foreskin, as commonly called. The earliest known circumcision dates back to the prehistoric era. Circumcision is frequently performed globally on children as part of religious requirements like Judaism and Islam. 30% of the remaining circumcision is performed for sociocultural practices and non-religious reasons.
The most common reasons for circumcision in adults are phimosis, balanitis/balanoposthitis or dyspareunia (painful intercourse). There are significant variations in rates of circumcision globally. The circumcision rate in the United States is as high as 80%, while other countries report a circumcision rate of 0.1 %. The high rates of circumcision can be due to historical and sociocultural reasons. Aesthetics and cosmesis are popular reasons for adult circumcision in specific communities.
There are conflicting researches showing circumcision may help prevent penile cancer. The rationale for this research is due to the observation that penile cancer occurs exclusively in uncircumcised men. However, the in-depth analysis revealed that circumcision is only helpful if performed early in life.
Several high-quality studies have shown circumcision reduces the risk of HIV infection by 60% and helps reduce the transmission of some sexually transmitted infections (STIs). As a result, global guidelines recommend circumcision in countries with high incidences of HIV. It is important to remember that circumcision alone is not effective in reducing HIV infections and needs to be complemented with education, protective measure and avoiding high-risk behaviours.
To better understand medical circumcision, we rewind to the early days of a baby boy. Circumcision, for religious reasons, is usually performed early in a baby’s life. Circumcision is commonly performed in the first week of life, early childhood, or the prepubertal period. For this article, we will cover only medically indicated circumcision.
Only 4% of babies have a retractable foreskin. This number increases to 50% by the first year of life and 89% by three years old. Up to 10% of the young male population may have foreskin issues. Non-retractile prepuce must be considered if there are no other urinary symptoms like pain or swelling. Preputial adhesion can also prevent the foreskin from being retracted. As the child grows, the adhesion separates the inner foreskin from the glans (head) of the penis.
If you think you need Circumcision, schedule a consult as soon as possible.
Epithelial debris, which is dead skin cells, is called smegma and can accumulate within the foreskin. Together with penile erection, they help encourage adhesion to separate in a growing child. Increased smegma production coincides with puberty when most boys can retract their foreskin.
Occasionally smegma collection occurs in a nodule form and can be mistaken for a cyst. Smegma can be mixed with urine leading to a purulent-like discharge which can be confused with an inflammatory condition called balanitis.
Parents must understand that children may have a non-retractable foreskin, a normal phenomenon. Forceful retractable of the foreskin in young children for cleaning purposes is often unnecessary and causes pain. Force retraction of the foreskin can cause scar formation and form secondary phimosis.
Phimosis is the inability to retract the foreskin below the glans of the penis and is commonly due to a narrow ring along the foreskin. Phimosis is estimated to occur in 9 – 20% of the 5-13 age group. It is important to differentiate between phimosis (mechanical tightening) and preputial adhesion in the non-retractile foreskin, which can be tricky. Ballooning of the penis can occur during voiding due to adhesion or phimosis and may be physiological (normal development), and is not a recognised indication for circumcision.
We move on to the medical conditions and where circumcision may be required. Phimosis can lead to paraphimosis when the retracted foreskin cannot be replaced back up. The narrow ring of the foreskin can constrict the blood flow in the penis leading to pain, discomfort and potential organ damage. Paraphimosis is a medical emergency and should be attended to immediately.
Balanitis/Balanoposthitis is the infection of the glans and foreskin, respectively. These are two conditions parents of young boys need to be aware of as they may complain of pain with swelling around the penis, which can occur with pus. Balanitis/Balanoposthitis can be caused by exposure to an irritant like a new brand of soap or excessive cleaning. Non-specific balanitis/balanoposthitis can be treated with topical antibiotic ointment.
Balanitis Xerotica Obliterans (BXO) is a non-painful chronic inflammatory condition that affects the glans, foreskin, meatus and urethra. It is characterised by white atrophic plaques on the glans, which coalesce into a sclerotic lesion. Fortunately, it is uncommon in children and is more commonly found in adults.
Determining the cause of the narrow foreskin is crucial before deciding on the treatment course. It is important to understand that circumcision is not the only option for foreskin issues. The first-line treatment for phimosis is topical steroids. Research shows that topical steroid given twice daily for 4 to 8 weeks can improve phimosis up to 80% of the time. While effective, long-term administration of steroids is not recommended as it can result in skin thinning. As such, recurrence of phimosis occurs in 20% after the stoppage of steroids.
Circumcision may be necessary when phimosis does not respond to steroid treatment or repeated balanitis/balanoposthitis in children. Circumcision, in this instance, solves the issues once and for all. In paraphimosis, the foreskin should be replaced to its original position as soon as possible before circumcision. Early reduction of paraphimosis reduces discomfort. Reduced tissue swelling results in better cosmesis during circumcision.
In children with recurrent attacks of urinary tract infection or congenital urinary tract abnormalities, circumcision has been shown to help reduce bacterial colonisation of the glans with a resultant reduction in urinary tract infections.
There are many ways to perform circumcision. The techniques can be broadly classified into preputioplasty (partial removal of the foreskin) and circumcision. There are different ways of circumcision in children and adults, which we will not cover within the scope of this article. It is best to discuss the optimal way of performing circumcision with your urologist.
Finally, circumcision is contra-indicated (should not be performed) in foreskin, which is infected and for children with congenital abnormalities like hypospadias or curvature of the penis(chordee) as the foreskin can be used for reconstruction later in life.
Circumcision is a common procedure that is performed on both children and adults. Ultimately there are many reasons why circumcision may be performed. There are many reasons for circumcision which may be influenced by sociocultural, religious, personal preference, local expertise or medical indications. It is important to understand the indication for surgery and the potential complications that can occur with this surgery.
It is important to note that circumcision should be performed for clear indications as complications like bleeding, infection and wound dehiscence, while rare, can occur.
If you think you need Circumcision, schedule a consult as soon as possible.
Our friendly team is looking forward to serving you. For urgent enquiries and appointment requests, please call the clinic directly.
Dr Jay Lim is a urologist with a focus on providing personalised treatment plans specific to your unique urinary and reproductive health needs.
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