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Circumcision

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Circumcision

Written by Dr John Dean, specialist in sexual medicine

What is circumcision?

Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. The first evidence of circumcision comes from early Egyptian wall paintings that are more than 5000 years old.

How common is circumcision?

About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty.

Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.

At present, around 80 per cent of US males have been circumcised, mostly for non-religious reasons. The frequency of newborn circumcision has fallen in the USA from 90 per cent in the 1950s to around 60 per cent today.

In Korea, more than 90 per cent of men have been circumcised, usually in their teens and twenties.

In the UK in 1948, around 20 per cent of boys were circumcised shortly after birth, more commonly among middle class families and those living in the south of England. Then, 50 per cent of grammar school boys, 84 per cent of public school boys and 60 per cent of graduates were circumcised. By 1975, only 6 per cent of boys born in the UK were circumcised.

Why circumcise?

Reasons for circumcision fall into three broad groups:

for an immediate medical indication

to prevent future disease

as an act of religious dedication.

Circumcision for an immediate medical reason

Non-retractable foreskin in children Contrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies. Well-meaning parents do not need to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.

About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds.

The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below), but this persistence is not a reason for circumcision.

Phimosis

In phimosis (foreskin contraction), the opening of the foreskin is narrowed, preventing retraction. Provided that the skin of the foreskin is normal and inability to retract it does not cause problems with intercourse or recurrent infections, no action is necessary.

Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted. Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old. Symptoms can include

irritation or bleeding from the edge of the foreskin

stinging or pain on passing urine (dysuria)

inability to pass urine (acute or, rarely, chronic urinary retention).

The changes in the prepuce are known as balanitis xerotica obliterans, which can become cancerous if left untreated. Circumcision is advisable in most cases.

Acute balanoposthitis

This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans.

Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined.

Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention. Circumcision is only done for recurrent and troublesome cases.

Paraphimosis

This condition is caused by forcibly pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement.

The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again.

If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic. Circumcision is only very rarely necessary.

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