PEDIATRIC SURGERY INTERNATIONAL 1989, Volume 4: Pages 227-228.

Circumcision in Germany

Editorial comments

S. Hoffman-von Kap-herr

Klinik- u. Poliklinik für Kinderchirugie, Mainz, Federal Republic of Germany

Phimosis has long been a subject of controversy, as it is a point where medical and ritualistic schools of thought intermingle and lead to deliberation as to whether, when, and how circumcision should be performed in boys. It is thus understandable that there is no uniform opinion in the German-speaking countries.

Only the medical indications for circumcision need concern the physician, of course, since this is a surgical procedure that like any other operation is legally regarded as bodily injury and requires the parents' consent.

The majority of pediatric surgeons in our area, while not doubting the existence of true medical indications, reject the routine practice of circumcision in newborns despite cognizance of the apparently weighty arguments such as the allegedly higher incidence of penile and cervical carcinomas associated with uncircumcised men. These arguments are essentially thinly-veiled justifications for prophylactic circumcision, however, and are not accepted by most of us. The correctness of this silent opposition is being confirmed by the slow but increasing changes in practice in the United States, where for decades circumcision was carried out totally uncritically as a "cultural ritual;" currently efforts are underway to do away with this nonsense (e.g. Brown, MS, Brown CA (1987), Pediatrics 80: 215-219).

The problem of circumcision in the newborn period or at any other set time is thus obviated; when medical indications are present, the procedure will be performed regardless of age, assuming that the physiologic adhesion of the prepuce in newborns and infants is understood. Manipulation of the prepuce in this age group to free it and ostensibly allow cleansing of the glans inevitably leads to fine fissures in the delicate membranes with subsequent circular scarring that may later necessitate operation. As the foreskin slowly becomes spontaneously detached around the 3rd to 4th year of life, only at this time can the rare congenital phimosis or that due to retraction or inflammation be diagnosed. Both, of course, represent true medical indications for circumcision and require surgical correction.

[CIRP Note: When Dr. Hofmann-von Kap-herr prepared this comment, he lacked access to later research into the normal development of the prepuce. We now understand from the research of Kayaba et al. that the growth and development of the prepuce continues into adult life. Consequently, phimosis cannot be diagnosed until well after puberty.]

Recurrent balanitis, voiding problems (distension of the prepuce during micturition in infants), or paraphimosis are the most important findings in setting the indication for surgery. This may occur long before the 3rd year of life, or later during school age..

[CIRP Note: Dr. Hofmann-von Kap-herr considered distention of the prepuce (ballooning) to be a medical indication for circumcision. We now know, however, that this is a normal developmental transient condition. It occurs after the prepuce separates from the glans and before the opening of the prepuce has grown larger. It no longer is regarded as in indication for circumcision. Similarly, paraphimosis does not require circumcision, only that the prepuce be returned to its normal position. Balanitis is properly treated by accurate diagnosis of the cause with smear and culture and/or biopsy followed by the treatment indicated by the diagnosed cause.]

Although these considerations are more or less accepted by most pediatric surgeons in central Europe, the surgical method of choice remains controversial. The classical technique of circumcision, with or without aids such as the plastic bell, etc., is preferred by more urologically oriented pediatric surgeons and adult-urologists who also operate on children. The remaining pediatric surgeons resect only as much of the foreskin as is necessary to prevent recurrence of the phimosis. In this method, which is also favored in my clinic, the inner preputial membrane along with any scar tissue is resected at its junction with the outer membrane, and the latter is then fixed to the corona glandis. There is usually sufficient foreskin remaining to cover three-fourths to all of the glans postoperatively, but good retractability must always be achieved..

Although we are aware that the philosophy of this method is just as open to criticism as the reasoning behind total circumcision, we feel more at ease with a glans penis that is surgically "protected" rather than "stark naked" postoperatively..

Interestingly enough, mothers tend to request total circumcision only when the child's father is totally circumcised; otherwise they feel it is important that as little skin as possible be removed. Occasionally parents whose son had total circumcision have sought cosmetic surgery to reconstruct the original condition, which is unfortunately impossible..

Decreased sensitivity and injuries to the vaginal mucosa due to coarseness of the glans have actually been described following total circumcision. The partially resected prepuce does require higher hygienic standards, but offers a better cosmetic appearance, at least from the viewpoint of our society.

Be that as it may: phimosis is a popular bone of contention at pediatric surgical meetings and is likely to remain so. As is true in many fields, the controversy revolves around a paltry few millimeters!.

In summary, it is certain that prophylactic circumcision is unnecessary in our climatic zones if training in normal genital hygiene is carried out. Inflammatory scarring and genuine congenital phimosis, however, are always indications for operation. Both mother and child are most satisfied when the prepuce still adequately covers the glans. In this regard, perhaps it is appropriate to speak of a fashion?!.

(File prepared 2 October 2006)