Circumcision

Circumcision is the surgical removal of the foreskin. It may be performed for medical, cultural or religious reasons. Circumcision performed for a medical indication is relatively uncontroversial, but the routine circumcision of male infants is often a hotly debated topic. Jews, Muslims and some Western societies practise routine neonatal (new-born) circumcision. The Xhosa practise adult ritual circumcision as part of the initiation into manhood.  New research has shown that it reduces the risk of HIV transmission. Therefore circumcision is becoming fashionable in countries with high incidence of HIV.

Circumcision on the whole is a relatively minor and safe procedure. While there does appear to be some proven medical benefits to circumcision, these are at best quite modest. Only a small percentage of patients suffer complications, which are usually minor and self-limiting, but isolated cases of severe and debilitating complications do occur. The latter scenario is fortunately exceedingly rare.

It is a moot point whether the benefits of routine neonatal circumcision outweigh the risks. Current medical opinion does not appear to favour routine neonatal circumcision. In 1971 the American Academy of Paediatrics stated that “there is no absolute medical indication for routine circumcision of the newborn”. The Academy has since softened its stance somewhat and in 1989 the American Academy of Paediatrics Task Force on Circumcision concluded that “Newborn circumcision has potential medical benefits and advantages, as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.”

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Procedure

In neonates, circumcision is usually performed with either local anaesthetic, or no anaesthetic at all. In young children, a general anaesthetic is usually used in order to minimize the potential for psychological trauma. In adults it is almost always possible to perform a circumcision using a local anaesthetic, but regional or general anaesthetic can be used if preferred.

After appropriate anaesthesia has been achieved, incision lines are marked and the excess skin is excised with a scalpel or scissors. The bleeding points are sealed off with cautery (where an electric current generates heat used to seal the blood vessels) or ligated (tied) with surgical ties. The skin edges are then sutured together with absorbable sutures. The main advantage of these is that they do not need to be removed later. A non-stick dressing is applied and the patient can usually go home shortly after the procedure. Suturing can be replaced by glue application to stick the skin edges together.

There are many variations on the actual technique of circumcision. The safest techniques are those in which the glans (head of the penis) is in full view when all incisions are made. This is not the case during the guillotine type of circumcision where the foreskin is pulled forward and chopped off. Ritual adult circumcision as practised in traditional Xhosa culture is usually of the guillotine type.

A variety of devices are available to aid with circumcision and protect the glans from inadvertent injury. Examples include the Plastibel device and the Gomco clamp. These devices are popular for circumcision performed on small babies. The Gomco clamp is dangerous if it is used in conjunction with diathermy (cautery), however. Another disadvantage of these devices is that the glans is obscured once the device has been applied.

Circumcision can usually be performed as a day case procedure. About 1% of patients end up being readmitted to hospital, usually due to bleeding, wound infection or the inability to pass urine.

Indications

Circumcision may be performed in the following circumstances:

• Medical
  • Phimosis (a tight foreskin that cannot be retracted)
  • Paraphimosis (a tight retracted foreskin constricting the penis)
  • Recurrent balanitis (inflammation of the foreskin)
  • Recurrent posthitis (inflammation of the glans of the penis)
  • Genital warts confined to the foreskin
  • Penile cancer confined to the foreskin
  • Reducing the risk of HIV infection
• Religious
  • Muslims
  • Jews
• Cultural
  • Xhosas
  • Many American and other Western infants

The medical indications for circumcision are relatively clear-cut. Phimosis is a condition where the foreskin cannot be retracted over the glans (head) of the penis. In babies this is a normal state, since the foreskin is adherent to the underlying glans. By the age of six years the foreskin has usually separated from the glans and can be retracted in the vast majority of boys, thus the inability to retract the foreskin of a young boy under age six is not an indication for circumcision. There is also no benefit in repeated attempts to stretch or forcibly retract the foreskin. True phimosis should probably not be diagnosed before age six. True phimosis can be congenital (born with), or may develop after episodes of recurrent infection of the foreskin and glans (balanitis and balanoposthitis).

Paraphimosis is a painful, emergency medical condition in which a tight foreskin has been retracted over the glans and cannot be reduced. The tight retracted foreskin forms a ring around the penis that can impair blood flow and lead to extensive swelling of the glans. Paraphimosis can usually be reduced by pulling the foreskin back into its normal position. If paraphimosis can be reduced, then circumcision can be performed later at a convenient date. If paraphimosis cannot be reduced, an immediate circumcision or dorsal slit must be performed.

Balanitis and balanoposthitis are infections or inflammations of the foreskin and glans of the penis. These conditions are much more common in diabetics than non-diabetics. Recurrent balanitis can lead to scarring and true phimosis of the foreskin.

Genital warts are caused by the human papilloma virus. The majority of these warts are often confined to the slightly damp areas under the foreskin. An uncircumcised male with genital warts on or under the foreskin should undergo circumcision. Penile cancer often originates on the foreskin, and circumcision can be curative for early superficial penile cancer that is confined to the foreskin. 

Jews and Muslims are the main cultures who practise routine neonatal circumcision; many American boys are circumcised for cultural reasons and the Xhosa people in South Africa practise circumcision as part of initiation into manhood. This initiation takes place around age 18.

Contraindications

Circumcision should be avoided in cases of:

• Hypospadias
• Bleeding tendency

Hypospadias is a congenital condition where the opening of the urethra (tube that carries urine from the bladder) is not in the normal position on the tip of the penis, but somewhere on the underside of the penis. Other associated features of hypospadias include an abnormal foreskin and curvature of the penis. The foreskin is usually deficient on the underside, giving it an abnormal appearance. In medical terms this abnormality is referred to as a dorsal hood of the foreskin. Babies with hypospadias should not undergo routine circumcision, because the foreskin is usually utilised in the eventual repair of the condition.

Patients with a bleeding tendency are fortunately quite rare. In those with a known bleeding tendency, circumcision should either be avoided, or the bleeding tendency should be corrected prior to surgery.

Advantages

• Reduced incidence of urinary tract infection in male infants. The incidence of urinary tract infections is lower for male babies who are circumcised, compared to those who are not. The actual incidence of serious urinary tract infections is very low for all male infants, but circumcision reduces this low risk even further.
• Reduced risk of penile carcinoma (tumour). The development of penile carcinoma is related to long-term penile hygiene. In cultures where neonatal circumcision is routine, such as Muslim and Jewish communities, penile carcinoma is almost non-existent. Penile carcinoma is much more common in the developing world. Uncircumcised men who practise good penile hygiene are also very unlikely to develop penile carcinoma. In the Scandinavian countries most men are uncircumcised, but penile carcinoma is very rare.
• Possible reduced risk of sexually transmitted diseases. Several recent studies indicate that circumcision may help protect men from contracting sexually transmitted diseases. This appears to include reducing the risk of HIV transmission to the male. It also appears that female partners of circumcised males are less likely to develop cervical carcinoma, probably due to a lower rate of transmission of human papilloma virus infection. Not all studies have confirmed the above findings, however.
• Improved hygiene
• Reduced transmission of HIV infection

Disadvantages/complications

• Infection in less than 1% of medically supervised circumcisions
• Bleeding in 0.2%
• Injury to the penis or urethra in 0.2%
• Removal of excessive skin
• Reduced sexual sensation
• Penile gangrene (very, very rare)

Overall, circumcision is a very safe procedure with a complication rate of around 1%. Most complications are minor problems related to the wound and are self- limiting. However, isolated cases of serious complications have been described in medical literature. The most serious of these include loss of all, or part of the penis due to necrosis (tissue death) caused by inadequate penile blood supply. The most common causes of impairment of penile blood supply are thrombosis (clotting) of the blood vessels due to diathermy (cautery) or overly tight bandages.

Some authors believe that the nerves supplying the glans of the penis with sensation can be damaged during circumcision. While most circumcised men are happy with the function of their organ, there have been lawsuits in the USA where patients have sued their doctor or parents for damages due to the “mutilation” of neonatal circumcision. The operation for reversal of circumcision has its proponents, but it is not very successful.

Ritual adult circumcision, performed as part of the traditional initiation into manhood in some cultures, is certainly not free of complications, but the overall complication rate is probably quite low. Due to the high level of secrecy surrounding the process, as well as a reluctance to seek conventional medical assistance should problems arise, it is difficult to ascertain the true extent of complications. State hospitals in the Eastern and Western Cape regions of South Africa see numerous young men with complications from ritual circumcisions. The most common complication is wound infection, which can usually be resolved with standard medical care. Unfortunately some patients only attend hospital once they are in serious trouble and every year a few young men lose part or all of their penises, and some even lose their lives.

Alternatives

Dorsal slit

In a dorsal slit, the foreskin is split at the top to expose the glans, but no skin is removed. This is often performed as an emergency procedure in cases of paraphimosis that cannot be reduced. It does not generally provide a satisfactory long-term cosmetic result.

Z-plasty of foreskin

Z-plasty is a technique often used in plastic surgery to move skin flaps from one place to another. Z-shaped cuts can be made on each side of the foreskin and re-sutured in such a fashion that the foreskin becomes shorter and wider, without the need to remove any skin. It is a procedure that can be considered for a patient with true phimosis who does not want a routine circumcision.

Reviewed by Dr Pieter J le Roux MBChB, FRCS(Eng), FRCSI, FCS(SA)Urol.