Circumcision
Definition
The surgical removal of the foreskin of the penis, or prepuce of the clitoris.
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 of the clitoris 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 many to be a human rights violation.
Some of the medical reasons parents of male infants 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
In 2002, however, new research indicated that circumcised men may be less at risk for contracting HIV infections than uncircumcised men, whose foreskins have higher concentrations of cells that are targeted specifically by HIV. Genital hygiene and safe sex practices are still crucial to preventing the spread of HIV.
Another study during that same year found that circumcised men who engaged in risky sexual behaviors were less likely to contract penile human papillomavirus (HPV), which has been implicated in the incidence of cervical cancer in women. There was little difference between circumcised and noncircumcised men's incidence of the virus if the men were in a monogomous relationship.
With these factors in mind, the American Academy of Pediatrics has issued a policy statement that maintains that 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.
Demographics
Though the incidence of male circumcision has decreased from 90% in 1979 to 60% in 1999, 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.
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, which forces the foreskin 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.
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 hydrocele, or hernia, may suffer 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 and can be performed on virtually anyone without a serious illness or unusual deformity.
Diagnosis/Preparation
Despite a long-standing belief that infants do not experience serious pain from circumcision, physicians now believe that some form of local anesthesia is necessary. Over 80% of pediatric residents, 80% of family practice residents, and 60% of obstetric/gynecological residents are routinely given instruction on pain control for circumcisions. Local anesthesia is often injected at the base of the penis (dorsal penile nerve block) or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves and provide significantly lowered perceived pain. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) 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 disappears with no particular attention.
Risks
Complications following newborn circumcision appear in between two and six of every 1,000 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and occur at the circumcision site, the opening to the bladder, or at the tip of the penis as a result of contact with urine or feces. Infections are indicated by fever and signs of inflammation, and are treatable with antibiotics.
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.
Normal results
When an infant or an adult is circumcised, the surgical wound should heal quickly, with normal urinary function resuming immediately. An infant or older child should have no complications and should be able to pass through adolescence and eventual sexual activity normally. After a period of recovery, an adult male should be able to resume sexual intercourse normally.
Morbidity and mortality rates
Complications as a result of circumcision are usually minor if the physician is experienced and makes sure the Mogen or Gomco clamps that are used are in good working order. Severe penile injuries are rare, but they are serious, and include penile amputation (partial or total), laceration, hemorrhage, and damage to the urinary tract. Other serious complications such as meningitis, penile necrosis, necrotizing faciitis, and sepsis can occur. Some of these, like meningitis and sepsis, can even cause death.
Hidden complications also occur. Subcutaneous masses have been detected under the skin of the penis. These masses usually have no symptoms, but, left untreated, could lead more serious outcomes. Physicians should examine the penis at every well-baby checkup during the first year. If a mass is detected, it can easily be removed under a local anesthesia and sent to a pathology lab.
Alternatives
The only alternative to this surgery is to make an informed decision not to have an infant circumcised. Some Jewish parents are even electing not to hold a Bris Milah , a religious circumcision, for their sons, and choosing instead to hold a Brit Shalom , a naming ceremony, similar to that given for their infant daughters.
Resources
BOOKS
Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000.
PERIODICALS
"Circumcision." Harvard Men's Health Watch 6, no. 3 (October 2001).
Imperio, Winnie Anne. "Circumcision Appears Safe, But Not Hugely Beneficial." OB GYN News 35, no. 7 (1 April 2000): 9.
"Link to Uncircumcised Males Found." Women's Health Weekly (May 9, 2002): 10.
Schmitt, B. D. "The Circumcision Descision: Pros and Cons." Clinical Reference Systems (2000): 1579.
OTHER
American Academy of Pediatrics. New AAP Circumcision Policy Released (Press Release). March 1, 1999. http://www.aap.org/advocacy/archives/marcircum.htm .
Janie F. Franz
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Medical circumcisions are performed in the hospital by a pediatrician for an infant or child. For an adult, a general surgeon or urologist may perform a circumcision, especially if there are other urinary tract repairs to be made.
A Jewish religious circumcision, a Bris Milah , is performed when an infant male is eight days old. It is conducted by a trained mohel , with family and friends present, in a nonmedical setting.
QUESTIONS TO ASK THE DOCTOR
- Is there a medical reason for performing a circumcision on my child?
- Is there new research about the benefits of circumcisions that I should be aware of?
- What kind of anesthesia will be used during the procedure?
- What should I be aware of when I go home with the baby?
- When should I call the doctor?
Thank you for answering,
Nick
I would like to share my following knowledge and experiences with you as a doctor who has performed more than 25.000 male circumcisions (MC) and who has a lot of information about world circumcision map of world.
Besides every people has their habits and truths, there are the medical truths. It is impossible to carry the all male circumcision operations in to operation rooms due to high quantity of operations. It will be meaningless if we say just the trained professional do the all male circumcisions. I would have used to get angry to mass circumcision sponsors specially municipality presidents and would say exactly like that to them: go ahead and serve to the people in different fields like communications, roads, water lines, etc. But I saw that it is not so easy to do as like as to say.
Although I know all circumcision techniques, I use the clamp technique and perform Modern Circumcision Surgery.
I am one of the doctors who knows best the male circumcision is very difficult in fact. Absolutely every method has advantages and disadvantages. I never used electro-cauter or thermo-cauter techniques. I have circumcised 5.000 kids between 1990-2002 years by Classic Circumcision Surgery which requires sutures. I met with Smartclamp named device in 2002 and I had a chance to introduce this device to the Turkey. I visited the Turkey step by step. I met with surgeons who make circumcisions in different countries. I circumcised people from different nationalities. I shared my experiences with most of well know people who assigned with circumcision in their countries or all world. I had the difficult experiences of many authors.
I am using the alisklamp disposable circumcision device which I had supported the developing period. I honestly believe that it will be a world brand and suggest to everyone who makes circumcisions to see this product. You will notice that how it approach to ideal circumcision when you see the results at www.alisklamp.com.
Dear friends, although I am you consider me as a clamp user, I also would like to share my opinions about which method is feasible while looking the world circumcision map.
1. The method should supply easiness to operator,
2. The method should be done fast,
3. The method should protect the operator and the people who will get circumcised,
4. The method should not to cause any cosmetic defect,
5. The method should not be a reason for sexual function problems,
6. The method should be applicable easily,
7. The method should easy to learn and to teach,
8. The method should not require to suturing on penis,
9. The method should not require too much surgical instruments,
10. The method and tools should not cause unknown infections like the Catguts,
11. The required tools should be disposable,
12. The method should not require bed resting during the healing period,
13. The method should not require additional antibiotic medicines nor wound dressing
14. The method and tools should not cause glans penis amputations,
15. The method should be a standard method,
16. Post operative bleeding should not be even in case of bleeding anomalies,
17. The method should supply standardization in all conditions.
I suggest to everyone to perform and advice the method which covers the most of above features in male circumcision practices.
I wish the success to all doctors who contribute to developments in circumcision techniques and technologies.
Dr. Mustafa Demirelli.