Circumcision

Globally, an estimated 39% of males have been circumcised.¹ There are an estimated 30,000 ritual circumcisions performed in England each year.² The number of operations has fallen from 80% to approximately 56% in the USA in recent years and similar falls have been seen in England and Northern Ireland.^{3 4}

Background

Circumcision of males involves removal of the fold of skin which covers the glans penis. It has become more controversial and more scrutinised because of the potential risks to the child's well-being. Male circumcision is a painful procedure and it is frequently performed with inappropriate and inadequate analgesia.⁵

American physicians are advised to provide appropriate counselling and informed choice before circumcision is undertaken.⁶ A rigid ban on circumcision for non-medical reasons is likely to drive the practice underground, leading to an increase in complications.⁷

Indications for circumcision

The most common reason given for circumcision is to fulfil ritual/religious requirements although it is being increasingly performed to prevent the acquisition of HIV in areas where that disease is rife, such as East and Southern Africa.⁸ Strict medical reasons for circumcision include:⁹

• Phimosis: when the distal prepuce cannot be retracted over the glans penis, it is known as phimosis. In preschool children it is not unusual for there to be thin adhesions to the glans. This physiological phimosis is quite normal. At age 3 years about 10% of boys are unable to retract the foreskin but, by adolescence, 99% of boys achieve retraction. Severe phimosis is quite rare in young children and can be demonstrated by bulging of the foreskin during micturition. It should be remembered that circumcision is not the only option and preputioplasty can also be performed (this preserves the prepuce). Acquired phimosis occurs because of:
  

  • Poor hygiene.

  • Chronic balanitis.

  • Repetitive forceful retraction of foreskin.

  
  Phimosis does not obstruct the flow of urine but it can lead to infections, paraphimosis and interference with normal sexual activity.

• Paraphimosis: this is the inability to pull the foreskin from the retracted state back over the glans. It is a urological emergency which can lead to ischaemia of the glans if left untreated. This can arise, for example, after retraction of the foreskin for catheterisation. If it cannot be reduced, a dorsal incision may be required, followed by circumcision electively.

• Recurrent balanitis: balanitis is infection of the glans (posthitis is infection of the foreskin). Balanitis and posthitis respond to antibiotics and warm baths. Both may be caused by poor hygiene.

• Lichen sclerosus (balanitis xerotica obliterans): a chronic, progressive, scarring, inflammatory skin condition.¹⁰

Circumcision has other suggested benefits and indications:

• Recurrent urinary tract infection (UTI). An American meta-analysis reported that uncircumcised males were 23.3% more likely to develop a UTI in their lifetime compared to circumcised males.¹¹ However, a Cochrane review recommended further research before routine circumcision could be recommended for the prevention of UTIs in all males.¹² Even in children who have complex renal problems, such as uretero-vesicular reflux, the situation is far from clear and decisions have to be taken based on the risks and benefits for individual patients.¹³

• Prevention of penile cancer. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer.¹⁴

• Reduction in the risk of sexually transmitted infection (STI). Trials report that circumcision reduces HIV acquisition by 53-60%, herpes simplex virus type 2 acquisition by 28-34% and human papillomavirus prevalence by 32-35% in men. Bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48% in the female partners of circumcised men.^{15 16} However, the result of a meta-analysis of studies of the evidence-base supporting circumcision for the prevention of syphilis and other STIs was equivocal.¹⁷

Assessment prior to circumcision

Assessment should:

• Estimate how much foreskin should be removed.

• Exclude hypospadias, epispadias, chordee and other relevant conditions.

In phimosis, circumcision may be avoided by daily cleaning (without forceful retraction) when this is uncomplicated (no urinary obstruction or pain). Topical steroid may be used to separate adhesions between foreskin and glans (applied daily for four weeks).

Performing circumcision

This should be performed by an experienced person using the correct, sterile equipment in an aseptic environment.

The penis should be anaesthetised with either a nerve block (local or regional anaesthesia) or anaesthetic cream.¹⁸ However, swelling after use of local anaesthetic cream, causing loss of anatomical landmarks has been reported.¹⁹

General anaesthesia can also be used, particularly in adults. The patient should be given analgesics afterwards (paracetamol or ibuprofen usually or, with adults, oral narcotics). Full recovery requires 4-6 weeks of complete sexual abstinence with loose-fitting briefs and instructions to shower and gently wash around the incision site.

In infants various devices are used. The Gomco® clamp and the Mogen® clamp are useful in infants but not toddlers (increased risk of bleeding). The Plastibell® technique can be used in toddlers up to 10 kg. The Shang Ring® can be used in males of all ages - from neonates to adults. When used in children, adequate analgesia is essential.²⁰

Contra-indications to circumcision

Small penis, buried penis, hypospadias, chordee (ventral penile curvature) without hypospadias, deformity of dorsal hood, penile webbing, epispadias, ambiguous genitalia, and bleeding diatheses (relative contra-indication).

Complications of circumcision²¹

Complications are common. There is a higher complication rate in adolescents and adults than in neonates and children.²²

Minor complications include:

• Haemorrhage.

• Local infection.

• Meatal stenosis.

• Secondary phimosis (especially in babies with a hernia or large hydrocele).

• Adhesions or skin bridge joining the penile shaft and glans.

More severe complications include:

• Septicaemia.

• Removal of the end of the penis.

• Removal of too much foreskin.

• Urethrocutaneous fistula.

Problems with sexual function have been reported,and a large Belgian study reported that circumcised men had more pain, discomfort or unusual sensations than uncircumcised men.²³