So you think you need . . . Circumcision

What is circumcision?
Circumcision is the removal of the loose fold of skin, the prepuce or foreskin, at the head of the penis. Many cultures remove the foreskin for religious reasons, but at least 10 per cent of operations are for so-called medical reasons.

Why is it done?
The main reasons for circumcision are:

* Carcinoma. Circumcision is said to remove the risk of cancer, although the research that forms the basis for this theory was carried out in 1932. Penile carcinoma accounts for less than 2 per cent of all male malignancies.

In fact, the incidence of penile cancer tends to be higher in countries where men are routinely circumcised, for example, in the US, where the rate is up to 2.1 per 100,000 men compared with Denmark and Japan, where the rates are 1.1 and 0.3 per 100 000 men, respectively.

* Balanitis, or inflammation of the head of the penis. This may be due to either poor hygiene or overzealous cleanliness, but it can also be caused by trauma (zipper entrapment) or an infection such as herpes. Repeated balanitis may also be related to diabetes, as sugar in the urine leads to overgrowth of yeasts and bacteria. Treating the underlying disease in this case is a far more effective cure than circumcision.

* Trauma. The invention of the zipper brought with it a cause of medical trauma that is sufficiently common as to have its own name – ’penile zipper-entrapment syndrome’. Incredibly, surgery is sometimes used as a solution, although there are far more simple and effective methods of rectifying such a situation (see box below).

* Hygiene. Dirt can accumulate under the foreskin and cause infection, but this problem can easily be solved by learning good hygiene.

* Phimosis, or a constricted foreskin. This is by far the most common reason for circumcision. Yet, studies show that the incidence of true phimosis is very rare – it is seen in only 1 to 2 per cent of boys. Interestingly, this same incidence is also found among those who have been circumcised.

At birth, only 4 per cent of all baby boys have a foreskin that is retractable, and it can remain tight until after puberty. A tight foreskin is evidently a natural part of development and a condition that generally corrects itself by the age of 18, when 98-99 per cent of boys will have a retractable foreskin (BMJ, 1993; 306: 1-2).

Yet, despite such a low occurrence of true phimosis in the male population, the current rate of circumcision carried out to correct so-called phimosis in the UK is around 7 per cent – considerably more than should be necessary.

Worryingly, at least five studies suggest that many medical personnel can’t tell the difference between true phimosis and a tight foreskin (BMJ, 1993; 306: 1-2). Such misdiagnosis can lead to many unnecessary circumcisions.

Well-meaning doctors or nurses may even try to force the foreskin back. This can lead to a condition known as ‘paraphimosis’, in which the foreskin remains permanently retracted.

What doctors don’t tell you
The assumption is that the risks of medical circumcision are low, yet numerous complications can occur and, on rare occasions, can even include death of the child (Br J Surg, 1993; 80: 1231-6).

Circumcision can be broadly grouped into four different types of procedure – dorsal slit, shield, clamp and excision – with complication rates varying from 0.06 to 55 per cent be-cause of:

* haemorrhage, the most common complication. Bandaging that is too tight can cause urinary retention that, in turn, leads to urinary tract infection, bladder rupture and, in rare cases, local vein compression. It can also cause necrosis (dead tissue) at the tip of the penis as a result of the tourniquet action of the dressing. Sutures are used to stop the bleeding, but it is not uncommon for a stitch to inadvertently be made in the urethra, resulting in a fistula (a passage where there should be none). Diathermy, where an electric current is used to coagulate blood, has also been known to result in injury, ranging from minor skin burns to complete loss of the penis

* removal of an insufficient amount of skin, leading to the development of a fibrous ring that can result in true phimosis and urinary obstruction, requiring a repeat operation

* removal of too much skin, requiring a corrective skin graft

* laceration of the penile skin or shaft, sometimes resulting in partial amputation

* ulceration of the glans. If the child is still in nappies, the ammonia-based compounds in urine can cause irritation, as the glans is no longer protected by the foreskin

* accidental amputation of the glans, the tip of the penis

* an unsatisfactory cosmetic result

* pain-induced trauma. In one case, changing the dressing of a circumcised infant triggered caused the child to cry with such force as to rupture the chest cavity – which induced a pneumothorax (accumulation of air or liquid in the lung space)

* infection. Ten per cent of patients will develop sepsis after circumcision. Although it is usually mild, it can have more serious consequences. Reports include gangrene, bacterial contamination of cerebrospinal fluid, impetigo (contagious pus-forming skin ulceration), staphylococcal scalded skin syndrome, diphtheria and the presence of Mycobacterium tuberculosis, the bacteria that causes tuberculosis

* psychological trauma. Research shows that children suffer from prolonged crying and wakefulness with poor-quality sleep in the immediate aftermath of circumcision. Children were found to react to circumcision as an episode of stress, the long-term consequences of which include behavioural changes (Develop Psychobiol, 1976; 9: 89-95) and increased sensitivity to pain. The loss of a body part can induce feelings of grief that need to be acknowledged and dealt with appropriately, particularly in children (BMJ, 1998; 316 [7137]).

Although the male foreskin is considered redundant in many cultures, it contains numerous nerve endings and plays an important role in sexual pleasure. It also contains glands that produce lubrication, which protects the female partner’s vaginal mucosa during sexual intercourse as well as the sensitive glans area of the penis. For these reasons, it would appear to be prudent to maintain the foreskin wherever possible.

Michelle Clare