IRISH MEDICAL JOURNAL, Volume 74, Number 2: Pages 55-56,
February 1981.

Circumcision — It is ever Necessary?


Dr. Steevens’ Hospital
Our Lady’s Hospital for Sick Children
St. Anne's Skin and Cancer Hospital

The surgery of the penis and scrotum antedates recorded history, for the earliest cave paintings provide evidence of mutilation of this and other extremities. We know from the Australian aboriginal practices of Arinths and Tokalosie that subincision of the urethra again and again could mark a man’s advancement in the tribal hierarchy just as his circumcision denoted his initiation to the totem.

There are many reasons advanced in favour of circumcision, most of which are unconvincing when critically examined.

Circumcision in the Newborn
The foreskins of 96 per cent of newborn infants cannot be fully retracted and, hence, “Phimosis” is physiologic in the newborn. The inner surface of the prepuce and the glans share a common epithelium, erroneously termed “adhesions”, which separates around the timer of birth, or much later. It is impossible to say at birth which children will subsequently develop clinically significant phimosis.

In the majority of boys, in the age group, five to thirteen years, non-retractibility of the foreskin depends on the persistence of a few strands of tissue between prepuce and glans, that minimal force is required to achieve retractibility. In this age group, however, retraction of the hitherto unretracted prepuce reveals inpissated smegma which, in contrast to that found in the younger child is in most cases malodorous. This, together with the fact discussed under penile cancer, indicates that a different view be taken of the unretracted prepuce in the child over about five years, and that, whereas an unretractable prepuce in the young child should be accepted with equanimity as normal, after about three years of age steps should be taken to render the prepuce of all boys retractible and capable of being kept clean.

[CIRP Note: The previous paragraph does not contain current recommendations for the care of an intact boy's penis. The current recommendation is that the foreskin be left undisturbed until the boy retracts the foreskin for himself.]

Circumcision and Cervical Cancer
Circumcision is only one of a large number of variables, many of them interrelated, which cannot be considered separately in epidemiologic studies of the etiology of cancer of the cervix. Factors shown to be associated with a high risk of cervical cancer include low socioeconomic status, early marriage, multiple marriages, extra marital relations, coitus at an early age, frequent coitus, non-use of contraceptives, syphilis and mulitparity.

Boyd and Doll (1964) found the discovery rate of cancer of the cervix among non-Jewish women whole marital partners were circumcised to be no different from the rate among non-Jewish women with uncircumcised husbands. Jones et al. (1958) found the incidence of cancer of the cervix not to be related to the absence of circumcision in the spouse or other sexual partners. Circumcision was as common among the partners of a group of women with cervical cancer as among husbands of a control group of women. Khanolkar (1950) found the cervix to be site of origin of cancer more frequently in Moslem than Parsee women with cancer, although the husbands of the former are circumcised and those of the latter are not. The Parsee, on the other hand, attach greater importance to cleanliness. Elliot (1964) found English wives at the lower end of the socioeconomic scale to have a liability to cancer more than ten times greater than those at the top.

Circumcision and Cancer of the Penis
Apt (1960) found only 15 cases of cancer of the penis, scrotum and other male genital organs (excluding cancer of the prostate and testis) in Sweden; virtually none of Sweden’s 3.7 million males are circumcised.

Anna Munthodo (1961) recorded the incidence of carcinoma of the penis among Jamaicans and observed that over 50% of them had gonococcal infection, 55% had positive blood Wasserman reactions and 50% had positive complement-fixation tests for granuloma inguinale.

The Javanese, like the Jews, regularly perform ritual circumcision, but Sampoerno, in a study referred to by Herskowitz, (1964) found seven carcinomas of the penis among 78 carcinomas of Javanese men.

All 163 cases with cancer of the penis in Reddy’s (1963) series of Indian men belonged to the low income group usually credited with low personal and genital hygiene Dodge and Kaviti (1965) among the rate of carcinoma of the penis among uncircumcised East African tribes to vary considerably and conceded that unexplored differences in personal hygiene may be responsible. Lenowitz and Graham (1946) found that cancer of the penis was five times more common in American Negroes than in American Whites, but skin cancer was seven times more common in whites.

Carcinoma of the penis us uncommon in uncircumcised men with a high standard of hygiene, as in Sweden, but circumcision affords little protection in populations where personal hygiene may be minimal. In cases of penile carcinoma, lack of hygiene is always striking. If the uncircumcised male has a foreskin which he can retract and which he keeps clean, the risk of this cancer is removed.

According to Burger and Guthrie (1977), the risk of developing carcinoma of the penis is probably no greater than the risk of a major complication of circumcision.

Circumcision and Infection
Although there is a common belief that the circumcised man runs a lessened risk of venereal infection, particularly syphilitic, there are few figures to support this. Lloyd and Lloyd (1934), who reviewed the published evidence and analyzed their own figures, concluded that circumcision did not diminish the chance of syphilitic chancre. Schrek and Lenowitz (1947) found that hospital patients gave a history of venereal disease equally often whether circumcised or not.

Complications of Circumcision
Circumcision, like any other operation, is subject to the risk of hemorrhage and sepsis and where a general anaesthetic is used, to the risk of anaesthetic death. Haemorrhage is the most common immediate complication. It may be caused by inadequate haemostasis, blood coagulopathies, or the existence of anomalous vessels. Patel (1966) studied 100 consecutive male infants who were circumcised at birth and who were revaluated 6 to 18 months later. He found 35 instances of haemorrhage, of which four required sutures.

Infection is also fairly common. Occasionally, infection may lead to more serious complications such as partial necrosis of the penis, or it may be a source of septicemia. Shulman et al. (1964) have recorded a case of staphylococcal septicemia giving rise to osteomylitis of the femur, and a fatal case of septicemia and pulmonary abscesses, both of which ascribed to infection of circumcision wounds.

A common complication of circumcision is loss of penile skin. This can result from pulling too much of the skin from the shaft up over the glans during the operation. The remaining skin slides back, leaving a denuded penile shaft. Major losses of penile skin using occur, however, because of a complicating infection, the use of the electrocautery, or improper surgical technique.

Additional complications include accidental lacerations of penile or scrotal skin, or both, incomplete circumcision with formation of adhesions and secondary penile deformity, accidental amputation of the glans with secondary post-operative haemorrhage, and retraction of the penis into a subcutaneous position by contraction, healing and fibrosis of the circular wound.

Delayed complications of circumcisions are related to the newly circumcised penis being in frequent and prolonged contact with faeces and ammoniacal urine. Meatal stenosis, and its symptoms of dysuria, increased urinary frequently and enuresis, is a late complication. The appearance of this condition indicates the fallacy of the argument that boys should be circumcised at birth so they will have “no trouble in later life”. In Patel’s series of 100 newborn circumcised bys who were examined at 6 to 18 months later, 31 developed meatal ulcers, 8 had meatal stenosis and 8 had developed infections.

Functions of the Prepuce
It is often stated that the prepuce is a vestigal structure devoid of function. However, it seems no accident that during the years when the child is incontinent, the glans is completely clothed by the prepuce, for, deprived of this protection, the glans becomes susceptible to injury from contact with sodden clothes or nappy.

Meatal ulcer is almost confined to circumcised male infants and is only occasionally seen in the uncircumcised child when the prepuce is unusually lax and the glans consequently is exposed. (Freud, 1947).

In the adult, the function of the prepuce is to protect the glans, the latter being almost insensitive to ordinary tactile and thermal stimuli. It has however, specific receptors to other pleasurable sensations. Removal of the prepuce exposes the glans to foreign stimuli which dull those special receptors.

Alternative to Circumcision
In cases of true phimosis, a simple dorsal slit of the foreskin would seem to permit the advantages of circumcision while avoiding many of the potential problems. Aesthetically, this gives a very satisfactory result.

[CIRP Note: Phimosis now is being treated medically with topical steroid ointment. The surgical alternative is the limited dorsal slit with tranverse closure. Circumcision is contraindicated due to pain, trauma, risks, and loss of sexual and erogenous functions.]

An attempt is made to retract the prepuce and clean the corona. If this is not possible after adhesions have been broken down it may be necessary to perform the dorsal slit in the first instance. The slit is carried back far enough to allow easy retraction. Haemostatis is secured and a fine cat gut suture is used to approximate the skin and mucosa. An oplle dressing is applied and the mother is instructed to retract the foreskin daily for about two weeks and at frequent intervals afterwards.

It has been shown that since during the first few years of life the prepuce is still in the process of developing, it is impossible to determine in which infants it will attain normal retractibility. In fact, only about 10% fail to attain this by three years. Of these, it will be found a simple matter to render the prepuce retractable by completing the separation from the glans by gentle manipulation. In a very few this may prove to be impossible, usually because of phimosis, and a dorsal slit is then indicated.

[CIRP Note: The previous paragraph does not contain current recommendations for the care of an intact boy's penis. The current recommendation is that the foreskin be left undisturbed until the boy retracts the foreskin for himself.]

The prepuce of the young infant should therefore be left in its natural state. As soon as it becomes retractable, which will generally occur sometime between nine months and three years, its toilet should be included in the routine of bath time and soap and water applied to it in the same fashion as to other structures such as the ears, which are customarily treated with special assiduousness on account of their propensity to retain dirt. As the boy grows up, he should be taught to keep his prepuce clean himself just as he is taught to wash his ears. If such a procedure became customary, the circumcision of children would become an uncommon operation.

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