Male Circumcision – To do or Not to do

Male circumcision is the removal of the foreskin from the human penis. The word circumcision is from Latin circumcidere, meaning “to cut around”. The foreskin extends out from the base of the glans and covers the glans when the penis is flaccid. Proposed theories for the purpose of the foreskin are that it serves to protect the penis as the fetus develops in the mother’s womb, that it helps to preserve moisture in the glans, and that it improves sexual pleasure. The foreskin may also be a pathway of infection for certain diseases. Circumcision removes the foreskin at its attachment to the base of the glans.

The procedure is most often an elective surgery performed on babies and children for religious or cultural reasons. In other cases it may be done as a treatment for certain medical conditions or for preventative reasons.

Religious Aspects for Circumcision

Neonatal circumcision is usually elected by the parents for non-medical reasons, such as religious beliefs or personal preferences, possibly driven by societal norms.

1. May have originated as a religious sacrifice and as a rite of passage marking a boy’s entrance into adulthood.
2. It is part of religious law in Judaism
3. Is an established practice in Islam, Coptic Christianity, and the Ethiopian Orthodox Church.
4. For muslims circumcision is a matter of cleanliness,purification and control over ones ‘nafs’

Medical indications

Medically it is a treatment option for problematic cases of phimosis, balanoposthitis that does not resolve with other treatments, and chronic urinary tract infections (UTIs). It is contraindicated in cases of certain genital structure abnormalities or poor general health.

1. Phimosis is the inability to retract the foreskin over the glans penis. At birth, the foreskin cannot be retracted due to adhesions between the foreskin and glans, and this is considered normal (physiological phimosis). Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three. Less than one percent are still having problems at age 18. If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option.
2. An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called balanitis. Most cases of these conditions occur in uncircumcised males. The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection and are rarely identified in samples taken from circumcised males.

Circumcision Procedure:

It may be performed under topical anaesthesia ,local anaesthesia or general anaesthesia.First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated.The hospital stay after circumcision is only for a few hours for both children and adults.Children are back to normal in about 24 to 48 hours.Adults require about a week before they resume normal activity. The procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, so the use of analgesia is advocated.Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective.The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo.Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.

• The World Health Organization promotes circumcision to prevent female-to-male HIV transmission in countries with high rates of HIV. There is strong evidence that circumcision reduces the risk of men acquiring HIV infection in areas of the world with high rates of HIV. The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells. When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission.
• The International Antiviral Society-USA also suggests circumcision be discussed with men who have sex with men, who engage in primarily insertive anal sex, especially in areas where HIV is common.
• When an uncircumcised penis is flaccid, the pocket between the inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival; circumcision eliminates this pocket.
• Circumcision is associated with a reduced prevalence of oncogenic types of HPV infection.
• Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men.

Complications that may arise out of Circumcision:

Neonatal circumcision is generally safe when done by an experienced practitioner. The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin. Severe complications are rare. Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.

Other possible complications include buried penis, chordee, phimosis, skin bridges, urethral fistulas, and meatal stenosis. These complications may be avoided with proper technique, and are most often treatable without requiring a hospital visit.

There highest quality evidence indicates that circumcision does not decrease the sensitivity of the penis, harm sexual function or reduce sexual satisfaction.