To Cut Or Not To Cut

Antonio Catangui, MD, FPCS, FPSPS

Pediatric Surgeon

Lecture delivered during the

Annual Convention of Philippine Academy of Family Physicians, February 28, 2003

The objectives of the session for this afternoon are the following:

1. To discuss the pros and cons of doing circumcision

2. To suggest guidelines that may help parents and doctors in deciding for or against circumcision

Circumcision is widely practiced as a religious rite since ancient times, with earliest evidence dating from ancient Egypt. Some biblical passages even showed that Jesus, himself, underwent circumcision on his 8th day of life.

Circumcision is defined as removal of the sleeve of skin and mucosal tissue that normally covers the glans penis. In simple terms, it is the removal of the prepuce or foreskin.

Circumcision technique may vary from one surgeon to another, although some urologists do not consider dorsal slit as a form of circumcision.

Since circumcision is removing of the foreskin, the following questions may be asked:

1. Is the foreskin dispensable?

2. Does the foreskin serve any purpose?

The following are the mentioned functions of the foreskin:

1. Protective

2. Sensory

3. Sexual

During the diaper stage, the foreskin protects the glans penis against abrasions resulting from diaper rash, as a result of its exposure to stools and urine. Through a male’s life, the foreskin makes the glans moist and soft, characteristics found attractive to female partners. The foreskin covering the glans also serves as a protection against trauma and injury.

The mucosal and frenulum parts of the foreskin are very sensitive contributing to the sexual pleasure. The ridged part of the foreskin is as sensitive as the lips of the individual.

The foreskin also provides ample loose skin for the penis to occupy when it is in its erected state. The movable foreskin serves as a sheath during intercourse reducing chafing. The foreskin lessens the need for artificial lubricants. The extra foreskin allows it and the glans to naturally stimulate each other.

The foreskin, then, serves some functions to the males. Is it dispensable? Not to some individuals with abnormalities such as hypospadias and chordee where the foreskin is used to reconstruct the problem. How about to most normal individuals? Is the foreskin dispensable for them? Perhaps, examining the embryogenesis may help us decide.

. The proper development of the foreskin depends upon the presence of androgens and its receptors. The development of the foreskin starts at age of 3 months of gestation when the presence of the fold of skin at the base of glans is noted. This fold of skin extends distally with its dorsal portion growing more rapidly compared to its ventral component. The growth of the ventral component is completed by the 5^th month age of gestation when the glanular urethra closes. Then, the keratinization of the glans and the inner surface of the prepuce begins. Initially, the inner surface of the prepuce and the glans are fused. Lacunae begin to form in between the glans and the inner surface of the prepuce, resulting in the eventual separation of the glans and inner surface of the prepuce. However, at birth, the separation remains incomplete with retraction of the foreskin possible only in 5 % of newborns. 90% of kids aging 3 years or more can retract the foreskin away from the glans. The re is no need for forced retraction and cleaning during the time of incomplete separation of the foreskin and glans. While the foreskin is still not separated from the glans, the foreskin still serves its protective function on the glans and may not be deemed dispensable up to that stage.

In general, the reasons for doing circumcision may be religiously based or not religiously based. Non-religiously-based reasons include medical reasons and non-religious rituals.

Among the non-religious reasons are cultural reasons. Circumcision is common among black Africans, Australian aborigines and people of near east. Circumcision is not commonly practiced in Europe, china and South America. It is estimated that 1/6^th of the world’s male population is circumcised.

The medical reasons include:

1. Phimosis. This condition has to be differentiated from the natural delayed separation of the foreskin from the glans. The patient will manifest with inability to retract the foreskin with ballooning noted during urination.

3. Paraphimosis. This occurs when the corona is retracted behind the glans but one is unable to bring back the foreskin over the glans.

4. Severe infection or gangrene.

5. Balanitis or infection of the glans.

6. Phosthitis or infection of the foreskin.

7. Recurrent urinary tract infection.

While there is general agreement on therapeutic indications of circumcision, there is much disagreement with regards the indications for routine prophylactic circumcision, most especially in older patients.

Many arguments have been used to justify routine prophylactic circumcision.

Among the reasons included in the prophylactic indications include:

1. Reduced risk of urinary tract infection. The study of Wiswell in 1993 showed a 12-fold increase in urinary tract infection among uncircumcised males. However, the frequency of urinary tract infection among US males is only about 1% with more female kids developing UTI.

2. Reduced risk of penile cancer. This is an extremely rare form of cancer among males affecting both circumcised and uncircumcised males.

3. Reduced risk of cervical cancers in partners of uncircumcised males.This has been disproven by Stern in 1962.

4. Reduced risk of sexually transmitted diseases. It was however noted that behavioral factors are more important than the circumcision status. Emphasis should be given on fidelity, use of condoms and abstinence.

5. Circumcised males with cleaner penis compared to uncircumcised males. Smegma is more likely to accumulate in males with intact foreskin. Good general hygiene and common sense are the keys to prevention to disease and infection.

Among Filipinos, the main reason for undergoing circumcision is peer pressure. Children can be cruel and find things to pick on another child. As parents and doctors, we can help children feel good about their bodies and respect individual differences. We should emphasize to our patients and children that the prepuce is a healthy and natural part of the body.

Even the American Academy of Pediatrics changed its position with regards to circumcision several times. In 1975 and 1985, its stand was that there was no indication to do routine prophylactic circumcision. In 1989, it concluded that neonatal circumcision may have potential medical benefits and advantages. In latest circular about circumcision in 1999, it concluded that benefits are not significant enough to recommend circumcision as a routine procedure.

The present evidence indicate that circumcision can be done on those with medical indications. No solid evidence is available for us to do routine circumcision. However, we should also respect the freedom of the child to choose, the right of the child to preserve his ethnic, cultural or religious identity and the right of the parents to provide guidance to their children.

Our responsibility as doctors should include talking with the parents and children about the pros and cons of the circumcision. This should be done, every time they sought consult for circumcision. If the choice is for circumcision, the procedure should be done safely. Pain relief should also be adequate during and after the circumcision.

Complications are rare and mostly minor. Major complications do happen. Our responsibility as doctors is to do the procedure safely.