THE CIRCUMCISION REFERENCE LIBRARY
From the Department of Paediatric Surgery, Adelaide Children's Hospital
The results of 200 circumcisions are presented, together with a discussion of the indications and subsequent complications.
A review of the literature suggests that many of the traditional indications remain unproven.
In the light of this study, and other surveys which indicate the hazards of the operation, it is suggested that circumcision should be confined to those with a genuine medical indication.
[CIRP historical note: This article played a part in turning Australia away from infant circumcision. The year after this article was published, the Australian College of Paediatrics issued a statement that baby boys should not be routinely circumcised.
This article disproved the medical myth (started by Abraham Wolbarst in 1932) that circumcision "prevented" penile cancer. Independently, Preston in the United States also disproved the Wolbarst myth in the same year.
The advice contained in this article from 1970 on the care of intact boys is not current advice, does not reflect the current state of medical knowledge. The intact foreskin should never be forcibly retracted; this can damage the penis and impede its development.]
Circumcision is a practice which originated in ancient Egypt (Bolande, 1969), since when the practice has spread to assume status as a ritualistic part of many religions. The original followers of those religions, Jews, Moslems, Australian Aborigines, all lived in hard dry arid conditions where the standard of personal hygiene was sub-optimal. Circumcision, therefore had appeal as a prophylactic measure against balanitis.
Nowadays, in Australia, despite a state of enlightened civilization that average Australians are thought to enjoy, circumcision is still the rule. The exposed glans is the fashion. The undressed penis stands as a social symbol, and the foreskin is still a schoolboy's curiosity, viewed secretly with wonder and awe. Circumcision now performed as a social ritual, and those in favour of the operation have justified its performance on medical grounds.
It has been said that circumcision is a simple operation with little associated morbidity and mortality, and that benefits include increased hygiene, and prophylaxis against malignancy.
Opinion against the performance of the operation of circumcision is just as certain that if the foreskin is subjected to adequate toilet, carcinoma is not a problem, neither is balinitis.
In the belief that the operation of circumcision is not without risk, it was decided to analyse some of the case records of circumcision performed at this Hospital to obtain statistics concerning the actual morbidity. Should a significant morbidity exist, then it seems obvious that there are no grounds for the present-day practice of social circumcision.
The case notes of 200 consecutive patients from the records of this hospital were studied to obtain such information as the indication, operation, method of controlling bleeding and the incidence of complications. The results were partially analysed by computer.
The mean age of the patients in this survey was 2 years 4 months, the mean stay in Hospital 2 days, and the mean time on the waiting list was 2.1 months.
While awaiting operation, 39 children developed some additional symptoms or sequelae. 10 developed ``difficulty in passing urine'' without ballooning the foreskin; in 5, the prepuce became non-retractile; 5 developed an attack of balanitis which settled with conservative measures; 3 developed urinary obstruction necessitating advancement of the operation; 2 developed frequency of micturition; 2 had an episode of paraphimosis, and in one the indication for the operation disappeared, i.e. the penis prepuce became retractile. 10 other children had other complications, e.g. ``nappy rash,'' and one developed a urinary tract infection. There was a significant age distribution in the 10 patients who developed urinary difficulty; one was less than 1 year of age, no one was between 1 and 2 years of age, and 9 were over the age of 2 years.
These were obtained from the Outpatient records, and have been divided into 2 categories; medical and social (Table I). The prepuce was supposedly non-retractable in 102 out of the 200, i.e. 51%
MEDICAL SOCIAL Phimosis alone 74 Familial 43 with balanitis 9 Mother 8 with obstruction 1 Father 4 Hypospadias 23 Family Doctor advised 2 Non-retractile 18 Religious 1 Balanitis 9 Paraphimosis 8 143 58
The Social Indications followed the pattern described in most reports on the subject. In most cases the operation was requested for reasons of conformity, supposed cleanliness, because it was more attractive, or because it was socially the ``done thing,'' In 2 cases the operation was advised by the family doctor because it was ``better to have it done now and got out of the way.'' One case was a Moslem child circumcised for religious reasons.
In 150 cases this was simple primary circumcision. In 19 (9.5%), the operation was performed because an earlier circumcision had failed or been followed by complications.; 14 were circumcised as an encore to another elective surgical procedure. In 12 cases circumcision was performed for minimal hypospadias; 2 cases had a dorsal preputial slit followed by a circumcision for true phimosis; 2 cases had freeing of congenital adhesions only, and in one case freeing of adhesions was performed before proceeding to circumcision.
From these figures it appears that only 5 of the 102 cases diagnosed as being non-retractable were in fact non-retractable.
Of those cases considered, before operation, to have phimosis or a non-retractable prepuce, 44 were more than 3 years of age and 23 of those were over 6 years old.
The incidence was rather high (Table II), and for convenience they have been analysed in 2 groups, early and late, according to whether they occurred before or after 2 weeks. Late complications occurred in 15 (7.5%). One of the 2 cases of meatal stenosis eventually required a meatotomy; in one healing was delayed for 5 1/2 weeks; and in 2, too little skin was removed at operation.
EARLY Haemorrhage 12 Infection 1 Meatal Ulcer 1 Meatal Stenosis 1 Other 1 16/200, (8%) LATE Haemorrhage 2 Meatal Ulcer 7 Meatal Stenosis 2 Recurrent Phimosis 1 Prolonged Healing 1 Other 2 15/200, (7.5%) Total Complications 31 (15.5%)
The total complication rate was 31 in 200 cases, i.e. 15.5%.
In an attempt to evaluate these complications, several aspects were analysed. The first of these was the experience of the operator; surgeons had a complication rate of 14.9%, surgical registrars 17.6% and resident medical officers 50%. Perhaps this would not suffer statistical scrutiny, but it probably reflects the residents' lack of experience.
Haemorrhage was the most common complication, and on clinical grounds was classified as mild, arterial or brisk venous haemorrhage as moderate, while clinical signs of blood loss and/or the need for transfusion were classified as severe. The procedures required to control this haemorrhage were also listed.
Haemorrhage (early or late occurred in 14 cases, 9 mild and 4 moderate; in one case the degree is not known, and there was no instance of severe hemorrhage.
In the 9 cases with mild hemorrhage, 3 ceased spontaneously, 3 required topical adrenaline, 3 were controlled by re-dressing and digital pressure, and in one case a dressing of tinc. benz. co. was applied. Of the 4 cases of moderate haemorrhage, 3 required ligation of persistent bleeding points under a second general anaethestic, and in one a persistent bleeder was ligated in the ward without anaesthesia.
Meatal ulcer was the second most common complication, and an attempt was made to correlate it with the type of dressing or any adjunct smeared on the glans after circumcision. It was assumed that management after circumcision was similar in most instances, and in fact the type of dressing used had no significant effect on the incidence of meatal ulcer.
No adjunct was used in 74 cases and 3 (4%) developed a meatal ulcer. With ``KY Jelly,'' 2 out of 82 (2.4% developed a meatal ulcer. The development of a meatal ulcer bore no significant relationship to the age of the patient.
Recircumcisions constituted 19 (8.5%) of the 200 operations. These were patients who had been circumcised in the neonatal period for social reasons mostly, as far as could be ascertained, in other hospitals. 11 were recircumcised for phimosis occurring after routine circumcision; 7 were recircumcised for other reasons - mostly because too little skin had been removed at the first operation - and in many cases, the appearances suggested that circumcision had never been performed. One child developed paraphimosis which required emergency circumcision, reduction being otherwise impossible.
Of 19 recircumcisions, 18 were simple circumcisions and in one a dorsal slit was followed by a circumcision. Complications followed in 3 patients, infection (one), meatal stenosis (one), and mild haemorrhage (one) a rate of 15.7% which is comparable to that of the series as a whole. Finally, analysis of the type of operation, and the month in which it was performed, showed that these had little effect on the complication rate.
A multiplicity of reasons have been proposed for the performance of circumcision, and the variety of these only reflects the uncertainty and the emotional undertones that surround the whole subject. The reasons proposed can be conveniently subdivided into 3 categories.
Increased incidence of carcinoma of the penis, the cervix uteri, and the prostate, have all been attributed to lack of circumcision. Plaut and Kohn-Speyer (1947), using cerumen as a control, introduced horse smegma into the a subcutaneous tube constructed on the back of several mice, and showed that smegma was weakly carcinogenic. Most other evidence on carcinoma is based on racial or ethnic difference.
In a series of prostatectomies for prostatomegaly, Ravich (1942) noted an incidence of malignancy of 1.7% in Jewish males ritually circumcised some 8 days after birth, compared with a rate of 20% for uncircumcised non-Jewish males. From this, it was deduced that circumcision decreases the incidence of prostatic carcinoma.
Elliot (1964) reported that the incidence of carcinoma of the cervix is one-fifth to one-six as great in Jewish women as in the general population. Being a disease which is associated with a lower socio-economic status, the incidence declined in a survey period from 1910 to 1954, during which time socio-economic status and standards of personal hygiene are two factors which have risen conspicuously.
Boldt (1959) and Hubert (1960) independently noted that the incidence of carcinoma of the cervix of women in Abyssinia was higher than, or comparable to, that in Europe and the U.S.A., even though 90% of Abyssinia males are ritually circumcised at birth.
Weiss (1964) found that the disease is associated with poor socio-economic circumstances, sexual promiscuity, and early-childbearing, but was not affected by the use of a condom, which would presumably have a similar effect to circumcision in preventing the contact of smegma and cervix.
Carcinoma of the cervix in India is most frequent in the Hindu women from Deccan (Khanolkar, 1950), and proportionally less in Moslem women. Circumcision before the age of 12 years is obligatory for Moslem males. In Hindu women from Gujarat, who enjoy a higher social standing and who are more fastidious about their personal hygience, the incidence is four-fifths that of Hindu women from Deccan.
In Moslem women the incidence is two-fifths that of the Hindus' from Deccan.
Carcinoma of the cervix seems to be associated with a multiplicity of aetiological factors, the most consistent being poor socio-economic circumstances and the related lack of personal hygiene.
Speert (1953) quoted the work of Wolbarst (1933) which showed that:
Moslems are circumcised between the ages of 4 and 12 years, and comparisons of the incidence in Moslems and Jews show a lower incidence in Jews, who are circumcised on the eight post-natal day. However, Jewish ritual demands the removal of more prepuce than the Moslem ritual.
Carcinoma of the penis in the Chinese accounts for 18.5% of all carcinomata, compared with 2% in the U.S.A. (Ngai, 1933) There are wide geographic variations, and the disease is associated with a congenitally, tight, or a long redundant foreskin. The disease is rarely seen among the more well-to-do, whose level of personal hygiene is higher.
Circumcision has been thought to provide complete protection from carcinoma of the penis, but recently 2 cases have been reported in Jews circumcised in infancy (Dean, 1936; Melmed and Pyne, 1964) and 5 cases of carcinoma of the penis in non-Jews circumcised in infancy. (Amclar, 1956; Kauffman and Sternberg, 1963; Ledlie and Smithers, 1956; Marshall, 1953); Pacquin and Pearce, 1955).
In Australia , between 1960, between 1960 and 1966, there were 78 deaths from carcinoma of the penis; in the same period that there were 2 recorded deaths from routine circumcision.
Carcinoma of the penis seems to be associated with lack of circumcision, which by no means affords absolute protection. Also associated are a long redundant, and a congenitally adherent foreskin, while good personal hygiene appears to decrease the incidence.
In these three malignancies, it appears that more factors than simple circumcision and noncircumcision are involved, and those, personal hygiene seems to be the most consistently relevant.
Bolande (1969) wrote that circumcision originated through imitation of the practices of a superior or revered individual in a society, and has now become established as a fashion perpetuated by the need to conform.
MacCarthy et al. (1952) reported that 24% of children in the United Kingdom had been circumcised by the age of 4 years and 3 months. Patel (1966) noted an incidence of 48% at Kingston General Hospital, Canada, and Wall (1968), reported an overall incidence in the United States of 69-97%, Fredman (1969) in a survey in Victoria, Australia, found an incidence of 70%, most of the operations having been performed for reasons of family uniformity, Australian custom, aethetics, and so on.
Two deaths from routine circumcision occurred in Australia during the period 1960-1966. Speert (1953) in a survey of the period 1939-1951 quoted one death in a series of 566,463 circumcisions, and 243 deaths from carcinoma of the penis during the same period.
In England and Wales, between 1942 and 1947, 16 children died annually as a result of routine circumcison (Begg, 1953, while Gairdner (1949) reported 16 deaths in a series of 90,000 circumcisions, high mortality figures for a simple operation.
Mortality aside, circumcision is accompanied by a considerable number of less serious complications (15.5%) including haemorrhage, meatal ulcer, meatal stenosis and infection in the series reported here. Other complications included laceration of the glans during operation, delayed wound healing, and ineffectual circumcision.
A less serious delayed complication of circumcision is ammoniacal dermatitis causing a meatal ulcer and stenosis, a sequel which only occurs in the circumcised.
Other less common but more serious complications not seen in this survey are urethral fistula, amputation of the glans, avulsion of the scrotum and septicaemia (Patel, 1966).
Severe haemorrhage, also absent from this series, may require tranfusion with its attendant occasional complications, or further surgical intervention with the possibility of an additional anaesthetic.
Meatal stenosis may require a meatotomy, and the rarer severe complications may require elaborate plastic surgical procedures. A second operation because of the failure or complication of the first is not unusual and constituted 9.5% of this series.
A circumcision, then, is an operation which is accompanied by a not inconsiderable risk which should be seriously considered when the operation is entertained.
The most common abnormality in this series seemed to be a non-retractable foreskin, and there seemed to be some uncertainty concerning this diagnosis.
At birth, separation of the prepuce from the glans has not occurred in some 90% of males. The epidermis of the prepuce and glans is adherent until separated by a process of desquamation and before this has occurred the prepuce cannot be separated without difficulty.
AT BIRTH: 4% Fully Retractable 54% Meatus can be exposed 42% Completely non-retractable. PREPUCE NON-RETRACTABLE 6/12 80% 1 yr. 50% 2 yrs. 20% 3 yrs. 10% 6-7 yrs. 8% 16-17 yrs. 1%
Gairdner (1949) studied retractability at different ages, and showed that only 4% of males have a fully retractable foreskin at birth, while at the age of 3 years it is fully retractable in all but 10%. Øster (1968) extended the study and found that 8% of boys at the age of 6 years and 1% at the age of 16 years, still have a non-retractable prepuce. Øster also found significant amounts of smegma in 1% of uncircumcised 6 year old boys, and that smegma tended to increase after 12 or 13 years, so that 8% of 16 year old boys had significant amounts.
A prepuce made fully retractable after age of 3 years by simple separation of adhesions with a blunt probe, not necessarily under anaesthesia, would assist hygiene, decrease balanitis and true phimosis, and prevent the accumulation of smegma, thus deceasing the risk of carcinoma of the penis, possibly to an almost neglible level.
Circumcision is still necessary to correct genuine phimosis, and occasionally to alleviate that uncommon condition, paraphimosis. In this series paraphimosis was usually caused by an overzealous mother forcibly retracting, in the bath, a still congenitally adherent foreskin in a child less than 3 years of age, on the mistaken advice of a doctor. Surely this shows the need for proper education of those members of the medical profession most closely associated with those problems.
With proper counseling, circumcision becomes an unnecessary operation, even more so when it is realized that the prepuce plays an important part in protecting the glans during the period of urinary incontinence in the first years of life.
A study of 200 consecutive cases of circumcision has shown that:
We would recommend that Hospital waiting lists be unburdened of unnecessary routine circumcisions, and that if parents request the operation as a social ritual, it should be done in private, not public beds.
My thanks to Mr. R. S. Douglas for his help in the preparation of this paper, to those Honoraries responsible for allowing me to include their cases and to the Commonwealth Statistician for supplying figures of the mortality of Carcinoma of the Penis and circumcision in Australia.
Amelar, R. D. (1956), Carcinoma of the penis due to trauma occurring in a male patient circumcised at birth. J. Urol., 75: 728-729
Bolande, R. P. (1969), Ritualistic surgery-circumcision and tonsillectomy. New Engl. J. Med., 280: 591-596.
Boldt, W. (1959), On first experiences with routine circumcision of newborn infants in Germany and thoughts on cancer prophylaxis. Geburtsh. H. Frauenhllk., 19: 624-626.
Dean, A. L. (1936), Epithelioma of the penis in a Jew circumcised in early infancy. Trans. Amer. Ass. Gen.-urin. Surg., 29: 493-499.
Elliot, R. I. (1964). On the prevention of carcinoma of the cervix. Lancet 1: 231-235.
Fredman, R. M. (1969). Neonatal circumcision-a general practitioner survey. Med. J. Aust, 1: 117-120.
Gairdner, D. (1949), The fate of the foreskin: a study of circumcision. Brit. Med. J., 2: 1433-1437.
Huber, A. (1960), Uteruskarzinom und Zirkumzision. Wein. Med. Wsehr., 110: 571-574.
Kaufman, J. J. and Sternberg, T. H. (1963) Carcinoma of the penis in a circumcised man. J. Urol., 90: 449-450.
Khanolkar, V. R. (1950) Cancer in India. Acta Un. Int. Cancr., 6: 881-890.
Ledlie, R. C. B. and Smithers, D. W. (1956) Carcinoma of the penis in a man circumcised in infancy. J. Urol., 76: 756-757.
MacCarthy, D., Douglas, J. W. B. and Mogford, C. (1952), Circumcision in a national sample of 4-year-old children. Brit. Med. J., 2: 755-756.
Marshall, V. F. (1953), Typical carcinoma of the penis in a Jew circumcised in infancy. Cancer, 6: 1044-1045.
Melmed, E. P. and Pyne, J. R. (1967), Carcinoma of the penis in a Jew circumcised in infancy. Brit. J. Surg., 54: 729-731.
Ngai, S. K. (1933), The aetiological and pathological aspects of squamous-cell carcinoma of the penis among the Chinese; and analytical study of 107 cases. Amer. J. Cancer., 19: 259-284.
Øster, J. (1968), Further fate of the foreskin. Incidence of preputial adhesions, phimosis and smegma amongst Danish schoolboys. Arch. Dis. Childh., 43: 200-203.
Paquin, A. J. Jr., and Pearce, J. M. (1955). Carcinoma of the penis in a man circumcised in infancy. J. Urol., 74: 626-627.
Patel, H. (1966). The problem of routine circumcision. Can. Med. Ass. J., 95: 576-581.
Plaut, A. and Kunh-Speyer, A.C. (1947). The carcinogenic action of Smegma. Science. 105: 391-392.
Ravich, A. (1942) The relationship of circumcision to cancer of the prostate. J. Urol., 48: 298-299.
Speert, H. (1953). Carcinoma of the newborn; an appraisal of the present status. Obstet. and Gynec., 2: 164-172.
Wall, R. L. Jr. (1968). Routine circumcision? Recent trends and concepts. N. C. med. J., 29: 103-107.
Weiss, C. (1964) Routine non-ritual circumcision in infancy. A new look at an old operation. Clin. Pediatr. (Phila.) 3: 560-563.
Wolbarst, A. L. (1932), Circumcision and penile cancer. Lancet, 1: 150-153.
Department of Paediatric Surgery,
Adelaide Children's Hospital
72 King William Road,
North Adelaide, 5006.
Return to CIRP library